Medicare Physical Therapy Rules & Regulations

Medicare has two basic parts: Part A, which covers inpatient hospital costs; and Part B, which pays for physician services, medical supplies such as wheelchairs, and outpatient services. Part A covers physical therapy services provided to hospital and immediate care facility patients; Part B covers physical therapy services provided in other settings, like a doctor's office or the physical therapist's own place of business. Health insurance companies who contract with Medicare determine if the physical therapist's services meet the requirements of Medicare law and regulations.

Medicare Regulations Defining Physical Therapists

• The definition Medicare uses for a qualified physical therapist (PT) is in Title 42 (Public Health) of the Code of Federal Regulations (CFR), § 484. 4 and § 485.705. Beginning January 2010, Medicare rules consider a qualified physical therapist as one licensed to practice in the state where he practices--if the state licenses PTs, one who has graduated from a physical therapist education program accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE), and one who has passed a state-approved examination for the state where he's practicing. Prior to 2010, a PT who graduated from a U.S. school program accredited by CAPTE did not need to take the state-approved examination to bill Medicare. Prior to 2008, other organizations were accepted as accrediting in addition to CAPTE. Medicare qualifies PTs who graduated from programs outside the United States if the foreign school accreditation process meets the standards of the American Physical Therapy Association. They must pass the state-approved or nationally approved exam. Physical therapists trained outside the U.S. prior to 2008 needed to attend schools meeting accreditation from specific international organizations.

Covered Physical Therapy Services

• Physical therapy is a covered benefit under Section 1861 of the Social Security Act. Medicare only pays for services that are reasonable and necessary per the Social Security Act Section 1862(a)(1)(A). The provisions of the Act are described in Medicare Program and Integrity Manual §13.5.1 as safe, effective and not experimental services that are appropriate for the patient's needs and based on generally accepted medical practice and experience. Services must be authorized by a physician, a physician assistant or other qualified professional. The services must be necessary for the patient and not less beneficial than other available treatments. Chapter 15 of the Medicare Benefit Policy Manual available at cms.gov provides detailed information on covered services by physical therapists.

Rules for Physical Therapists In Private Practice

• Medicare Benefit Policy Manual Chapter 15 section 230.4 and Title 42 CFR §410.60 discuss Medicare requirements for independent physical therapists. Therapists can bill Medicare directly if they are enrolled as a private practitioner. They could be a private, unincorporated business or partnership, or part of an unincorporated medical group. Independent therapists furnish services in their own office or the patient's home. Independent therapists who have their own Medicare National Provider Identifier (NPI) sometimes also provide services in the doctor's office. Services must be ordered by a physician or other authorized professional such as a physician's assistant. The patient must be under a physician's care even if the services are not provided in the physician's office. The therapist must regularly document the patient's progress and the patient's statements. Services come under Part B of Medicare.