Oversight Overview: The Rules of Supervision for Rehab Therapy Techs, Assistants, and Students

Therapist assistants (PTAs, OTAs, and SLPAs) and techs—as well as therapy students—can be a big help to therapy practices. But, per state and Medicare law, not all titles are created—or treated—equally. Read on to learn how you can incorporate the services of assistants, technicians, and students into your practice—and still get paid.

Therapist Assistants

According to the APTA, under Medicare, therapist assistants can provide therapy services in an outpatient private practice setting—as long as those services are performed under the direct supervision of a licensed therapist. Generally speaking, direct supervision means that the supervising therapist is physically present in the office—but not necessarily in the same room—and available to intervene if necessary at the time the assistant performs the services. In other settings, the requirements may not be as stringent. For example—unless a state practice act says otherwise—therapist assistants may provide services in a skilled nursing facility or on behalf of a home health agency under the “general” supervision of skilled therapist. General supervision means that the supervisor must provide initial direction and periodic inspection of the activity, but he or she does not necessarily need to be on the premises during every treatment. According to the APTA, the rules regarding supervision in an outpatient hospital setting are a little less clear, which is why the association recommends deferring to your state practice act to ensure compliance with all rules and regulations. Additionally, according to this CMS document, you may want to review your hospital’s by-laws.

In some cases, state practice act supervision requirements may actually be more stringent than Medicare rules. If that’s the case, always follow the rules of your state practice act. Additionally, if a patient’s condition is so medically complex that he or she requires the skill of a therapist to analyze the impact of these complexities, develop a plan of care (POC), and safely provide care, then assistants may not provide these services—regardless of the setting.

Billing

Per Medicare, to bill for assistant-provided outpatient services in a non-institutional setting, the following conditions must be met:

• A licensed therapist performs the initial evaluation and establishes the POC.
• The assistant provides medically necessary services.
• The supervising therapist provides direct onsite supervision (i.e., he or she is in the same facility, but not necessarily in the same room).
• The supervising therapist is immediately available to intervene, if necessary.
• The supervising therapist has active, ongoing involvement in the management of the patient's condition.
• If the patient presents with a new condition, the supervising therapist sees the patient.
• The assistant is an employee or an independent contractor of the practice.

In addition to ensuring that all of these conditions are met, you must also document that you’ve met them. Here are four tips to help you do just that:

1. State that you’ve reviewed your POC with the assistant who’s providing the services under your direction.
2. Document regular patient progress review meetings with the assistant.
3. Note when the treatment has advanced to the next more complex task.
4. Cosign the daily note and have the assistant document that he or she “provided services under the direct supervision of (name of the supervising therapist).”

Curious about how to bill for therapist assistant-provided outpatient services within WebPT? Check out this blog post.

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Therapist Technicians

Technicians—a.k.a. aides—may help a licensed therapist or therapist assistant perform a specific service. However, according to this APTA document, the technician may never perform services that “require the clinical decision-making of the...therapist or the clinical problem solving of the...therapist assistant.” To learn more about the differences between a therapist assistant and a technician—including job responsibilities, education requirements, and salary information—check out this post.

Billing

In this Medicare-focused webinar, compliance expert Tom Ambury and WebPT President Heidi Jannenga explained that Medicare won’t reimburse for services that a technician provides—regardless of the level of supervision. “That’s because all therapy services—beginning with a patient’s first visit—must be skilled, reasonable, and medically necessary. They also must be provided by a licensed provider (i.e., a PT/PTA, OT/COTA, or SLP/SLPA).”

Therapy Students

Similar to what we mentioned above regarding therapist technicians, Medicare Part B will not provide payment for services that a therapy student provides, because therapy students aren’t licensed providers. So, even if the therapist is in the room with the student while the student provides the services, only the services of the licensed therapist are billable. Now, there are some exceptions to that rule, including the following:

• “The qualified practitioner is recognized by the Medicare Part B beneficiary as the responsible professional within any session when services are delivered.
• “The qualified practitioner is present and in the room for the entire session. The student participates in the delivery of services when the qualified practitioner is directing the service, making the skilled judgment, and is responsible for the assessment and treatment.
• "The qualified practitioner is present in the room guiding the student in service delivery when the student is participating in the provision of services, and the practitioner is not engaged in treating another patient or doing other tasks at the same time.
• "The qualified practitioner is responsible for the services and as such, signs all documentation."

Billing

So, if a licensed therapist provides services together with a student, the therapist may be able to bill for those services. However, the APTA offers the following tips on billing for student-performed services:

• Therapists should use their “professional judgement” to determine whether a service is billable, and they should always bill with integrity.
• Students may provide services to patients as long as it is allowable under state law. However, that does not necessarily mean that it is appropriate to bill for them.
• Because only services that the licensed physical therapist provides can be billed to Medicare, the therapist should consider whether he or she is essentially providing the service (with some involvement of the student). In other words, the therapist should think about how involved he or she was in the patient’s care while the student was participating. To bill, the therapist must be actively engaged in providing care for the patient, directing the service, making skilled judgments, and providing checks and balances for the student.
• Therapists should never bill beyond what they would normally bill in the absence of student assistance. Neither the therapist nor the practice should benefit financially from the student’s participation.

Still not sure how therapist assistants, technicians, and students can participate in patient care—and for what services you can bill? Check your individual state practice act. Then, double-check with your MAC as well as your commercial insurance carriers before submitting a claim. While many private payers adhere to Medicare’s guidelines, some may have specific requirements beyond what we’ve included here.