CMS Pub. 100-02, ch. 15, § 230.4

A. General

See section 220 of this chapter for definitions. Therapist refers only to a qualified

physical therapist, occupational therapist or speech-language pathologist. TPP refers to

therapists in private practice (qualified physical therapists, occupational therapists and

speech-language pathologists).

In order to qualify to bill Medicare directly as a therapist, each individual must be

enrolled as a private practitioner and employed in one of the following practice types: an

unincorporated solo practice, unincorporated partnership, unincorporated group practice,

physician/NPP group or groups that are not professional corporations, if allowed by state

and local law. Physician/NPP group practices may employ TPP if state and local law

permits this employee relationship.

For purposes of this provision, a physician/NPP group practice is defined as one or more

physicians/NPPs enrolled with Medicare who may bill as one entity. For further details

on issues concerning enrollment, see the provider enrollment Web site at

www.cms.hhs.gov/MedicareProviderSupEnroll and Pub. 100-08, Medicare Program

Integrity Manual, chapter15, section 15.4.4.9.

Private practice also includes therapists who are practicing therapy as employees of

another supplier, of a professional corporation or other incorporated therapy practice.

Private practice does not include individuals when they are working as employees of an

institutional provider.

Services should be furnished in the therapist’s or group’s office or in the patient’s home.

The office is defined as the location(s) where the practice is operated, in the state(s)

where the therapist (and practice, if applicable) is legally authorized to furnish services,

during the hours that the therapist engages in the practice at that location. If services are

furnished in a private practice office space, that space shall be owned, leased, or rented

by the practice and used for the exclusive purpose of operating the practice. For

descriptions of aquatic therapy in a community center pool see section 220C of this

chapter.

Therapists in private practice must be approved as meeting certain requirements, but do

not execute a formal provider agreement with the Secretary.

If therapists who have their own Medicare National Provider Identifier (NPI) are

employed by therapist groups, physician/NPP groups, or groups that are not professional

organizations, the requirement that therapy space be owned, leased, or rented may be

satisfied by the group that employs the therapist. Each therapist employed by a group

should enroll as a TPP.

When therapists with a Medicare NPI provide services in the physician’s/NPP’s office in

which they are employed, and bill using their NPI for each therapy service, then the

direct supervision requirement for enrolled staff apply.

When the therapist who has a Medicare NPI is employed in a physician’s/NPP’s office

the services are ordinarily billed as services of the therapist, with the therapist identified

on the claim as the supplier of services. However, services of the therapist who has a

Medicare NPI may also be billed by the physician/NPP as services incident to the

physician’s/NPP’s service. (See §230.5 for rules related to therapy services incident to a

physician.) In that case, the physician/NPP is the supplier of service, the NPI of the

supervising physician/NPP is reported on the claim with the service and all the rules for

both therapy services and incident to services (§230.5) must be followed.

B. Private Practice Defined

Reference: Federal Register November, 1998, pages 58863-58869; 42CFR 410.38(b),

42CFR410.59, 42CFR410.60, 42CFR410.62

The contractor considers a therapist to be in private practice if the therapist maintains

office space at his or her own expense and furnishes services only in that space or the

patient’s home. Or, a therapist is employed by another supplier and furnishes services in

facilities provided at the expense of that supplier.

The therapist need not be in full-time private practice but must be engaged in private

practice on a regular basis; i.e., the therapist is recognized as a private practitioner and for

that purpose has access to the necessary equipment to provide an adequate program of

therapy.

The therapy services must be provided either by or under the direct supervision of the

TPP. Each TPP should be enrolled as a Medicare provider. If a therapist is not enrolled,

the services of that therapist must be directly supervised by an enrolled therapist. Direct

supervision requires that the supervising private practice therapist be present in the office

suite at the time the service is performed. These direct supervision requirements apply

only in the private practice setting and only for therapists and their assistants. In other

outpatient settings, supervision rules differ. The services of support personnel must be

included in the therapist’s bill. The supporting personnel, including other therapists,

must be W-2 or 1099 employees of the TPP or other qualified employer.

Coverage of outpatient therapy under Part B includes the services of a qualified TPP

when furnished in the therapist’s office or the beneficiary’s home. For this purpose,

“home” includes an institution that is used as a home, but not a hospital, CAH or SNF,

(Federal Register Nov. 2, 1998, pg 58869).

C. Assignment

Reference: Nov. 2, 1998 Federal Register, pg. 58863

See also Pub. 100-04 chapter 1, §30.2.

When physicians, NPPs, or TPPs obtain provider numbers, they have the option of

accepting assignment (participating) or not accepting assignment (nonparticipating). In

contrast, providers, such as outpatient hospitals, SNFs, rehabilitation agencies, and

CORFs, do not have the option. For these providers, assignment is mandatory.

If physicians/NPPs, or TPPs accept assignment (are participating), they must accept the

Medicare Physician Fee Schedule amount as payment. Medicare pays 80% and the

patient is responsible for 20%. In contrast, if they do not accept assignment, Medicare

will only pay 95% of the fee schedule amount. However, when these services are not

furnished on an assignment-related basis, the limiting charge applies. (See

§1848(g)(2)(c) of the Act.)

NOTE: Services furnished by a therapist in the therapist’s office under arrangements

with hospitals in rural communities and public health agencies (or services provided in

the beneficiary’s home under arrangements with a provider of outpatient physical or

occupational therapy services) are not covered under this provision. See section 230.6.