CMS Pub. 100-02, ch. 15, § 230.5

Pathology Services Provided Incident to the Services of Physicians and

Non-Physician Practitioners (NPP)

(Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14)

References: §1861(s)(2)(A) of the Act

42 CFR 410.10(b)

42 CFR 410.26

Pub. 100-02, ch. 15, §60.

The Benefit. Therapy services have their own benefit under §1861 of the Social Security

Act and shall be covered when provided according to the standards and conditions of the

benefit described in Medicare manuals. The statute 1862(a)(20) requires that payment be

made for a therapy service billed by a physician/NPP only if the service meets the

standards and conditions--other than licensing--that would apply to a therapist. (For

example, see coverage requirements in Pub. 100-08, chapter 13, §13.5.1(C), Pub. 100-04,

chapter 5, and also the requirements of this chapter, §220 and §230.

Incident to a Therapist. There is no coverage for services provided incident to the

services of a therapist. Although PTAs and OTAs work under the supervision of a

therapist and their services may be billed by the therapist, their services are covered

under the benefit for therapy services and not by the benefit for services incident to a

physician/NPP. The services furnished by PTAs and OTAs are not incident to the

therapist’s service.

Qualifications of Auxiliary Personnel. Therapy services appropriately billed incident to a

physician’s/NPP’s service shall be subject to the same requirements as therapy services

that would be furnished by a physical therapist, occupational therapist or speech-language

pathologist in any other outpatient setting with one exception. When therapy services are

performed incident to a physician’s/NPP’s service, the qualified personnel who perform

the service do not need to have a license to practice therapy, unless it is required by state

law. The qualified personnel must meet all the other requirements except licensure.

Qualifications for therapists are found in 42CFR484.4 and in section 230.1, 230.2, and

230.3 of this chapter. In effect, these rules require that the person who furnishes the

service to the patient must, at least, be a graduate of a program of training for one of the

therapy services as described above. Regardless of any state licensing that allows other

health professionals to provide therapy services, Medicare is authorized to pay only for

services provided by those trained specifically in physical therapy, occupational therapy

or speech-language pathology. That means that the services of athletic trainers, massage

therapists, recreation therapists, kinesiotherapists, low vision specialists or any other

profession may not be billed as therapy services.

The services of PTAs and OTAs also may not be billed incident to a physician’s/NPP’s

service. However, if a PT and PTA (or an OT and OTA) are both employed in a

physician’s office, the services of the PTA, when directly supervised by the PT or the

services of the OTA, when directly supervised by the OT may be billed by the physician

group as PT or OT services using the PIN/NPI of the enrolled PT (or OT). (See Section

230.4 for private practice rules on billing services performed in a physician’s office.) If

the PT or OT is not enrolled, Medicare shall not pay for the services of a PTA or OTA

billed incident to the physician’s service, because they do not meet the qualification

standards in 42CFR484.4.

Therapy services provided and billed incident to the services of a physician/NPP also

must meet all incident-to requirements in §60 of this chapter. Where the policies have

different requirements, the more stringent requirement shall be met.

For example, when therapy services are billed as incident to a physician/NPP services,

the requirement for direct supervision by the physician/NPP and other incident to

requirements must be met, even though the service is provided by a licensed therapist

who may perform the services unsupervised in other settings.

The mandatory assignment provision does not apply to therapy services furnished by a

physician/NPP or "incident to" a physician's/NPP’s service. However, when these

services are not furnished on an assignment-related basis; the limiting charge applies.

For emphasis, following are some of the standards that apply to therapy services billed

incident-to the services of a physician/NPP in the physician’s/NPP’s office or the

beneficiary’s residence.

A. Therapy services provided to the beneficiary must be covered and payable

outpatient rehabilitation services as described, for example, in this section as well

as Pub. 100-08, chapter 13, §13.5.1.

B. Therapy services must be provided by, or under the direct supervision of a

physician (a doctor of medicine or osteopathy; a doctor of podiatry or a doctor of

optometry when treating patients within the state scope of practice in the state in

which the services are provided) or NPP who is legally authorized to practice

therapy services by the state in which he or she performs such function or action.

Direct supervision requirements are the same as in 42CFR410.32(b)(3). The

supervisor must be present in the office suite and immediately available to furnish

assistance and direction throughout the performance of the procedure. It does not

mean that the physician/NPP must be present in the same room in the office

where the service is performed.

C. The services must be of a level of complexity that require that they be performed

by a therapist or under the direct supervision of the therapist, physician/NPP who

is licensed to perform them. Services that do not require the performance or

supervision of the therapist, physician/NPP, are not considered reasonable or

necessary therapy services even if they are performed or supervised by a

physician/NPP or other qualified professional.

D. Services must be furnished under a plan of treatment as in §220.1.2 of this

chapter. The services provided must relate directly to the physician/NPP service

to which it is incident.