Private Practices and Rehabilitation Agencies, CMS Requirements


By Mary R. Daulong, PT, CHC, CHP

Do you know where to locate Medicare regulations that apply specifically to physical therapists in private practice? Many would say “no.” However, it is with little hesitation that I say that physical therapy practices, which are rehabilitation agencies, would definitely answer “yes” to locating Medicare regulations specific to them.

Physical therapists in private practice (independent practice), at one time, were governed by Medicare’s Conditions of Coverage, which included detailed Interpretative Guidelines. Those conditions spelled out requirements related to: personnel qualifications and licensure, supervision, plan of care and clinical record contents, coordination of services, treatment and procedure requirements, physical environment obligations—for instance fire, safety, sanitation, infection control, and equipment preventive maintenance and calibration.

With little notice or explanation from Centers for Medicare and Medicaid Services (CMS), these Conditions, along with their Interpretative Guidelines, were deleted in 1999 and Physical Therapists in Independent Practice (soon to be renamed private practice [PTPP]) were left wondering how they would dig through the mounds of paper manuals and update memorandums to find what rules applied to them. Alas, the age of the internet would come to their rescue; CMS retired its paper manuals and replaced them with “internet only” manuals and all the answers lay therein—but which manuals, which chapters, and which sections?

Rehabilitation agencies shared the same dilemma regarding the regulations in the manuals, but they had one distinct advantage, which was that as certified Rehabilitation Agencies, they continued to be governed by CMS Conditions of Participation and its Interpretative Guidelines. These agencies were, and continue to be, subject to initial certification surveys conducted by state agencies or deemed accrediting organizations per CMS requirements. For this reason, rehabilitation agencies seem to have the upper hand on PTPP when it comes to mastering regulatory compliance. Most would agree that we all prepare better when we know we are going to be tested (surveyed). But as an added bonus, CMS has given rehabilitation agencies the “rule book” (Conditions of Participation) including the survey document. The Conditions not only help prepare rehabilitation agencies for Medicare compliance, but also prepare them for compliance with other federal regulations generated by the Occupational Safety and Health Administration (OSHA) and Americans with Disabilities Act (ADA).

But to level the playing field a bit, l have listed the manuals and rule locations that PTPP and rehabilitation agencies are mutually governed by. They are

  • Benefits Policy Manual: Chapter 15, Section 220-233
  • Claims Processing Manual: Chapter 5
  • Program Integrity Manual: Chapter 15

To answer some of the lingering questions, I have provided a table with a list of conditions that PTPPs often inquire about as they relate to Medicare compliance. There is also a bonus section to assist you if you are considering a move to or from Medicare Part A (Rehabilitation Agency [RA]) or Part B (Physical Therapist in Private Practice).

Click Here To View Table


1. Medicare’s Benefit Policy Manual: Chapter 15, Section 220-233

2. Medicare’s Claims Processing Manual: Chapter 5

3. Medicare’s Program Integrity Manual: Chapter 15

4. Conditions of Participation: Survey Form CMS 1893: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS012226.html

5. State Operations Manual: Guidance to Surveyors for Rehabilitation Agencies (Outpatient Physical Therapy or Speech Pathology Services 7-25-14 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_e_opt.pdf

Brandon Moser is the president and chief executive officer of HowlandMoser Advertising. He can be reached at HowlandMoser.com.