CMS Pub. 100-08, ch. 10, § 10.2.3.10

A. Regulatory Requirements - Physical Therapist in Private Practice

Section 42 CFR § 410.60(c) states that to qualify under Medicare as a supplier of outpatient

physical therapy services, each individual physical therapist in private practice must meet the

following requirements:

1. Be legally authorized (if applicable, licensed, certified, or registered) to engage in the private

practice of physical therapy by the state in which the individual practices, and practice only

within the scope of the individual’s license, certification, or registration.

2. Engage in the private practice of physical therapy on a regular basis as an individual in

one of the following practice types: (i) a solo practice; (ii) a partnership; (iii) a group

practice; or (iv) as an employee of any of (i), (ii), or (iii).

3. Bill Medicare only for services furnished in the individual’s private practice office

space, or in the patient's home. A therapist's private practice office space refers to 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 practice at that location. When services are furnished in private practice office

space, such space must be owned, leased, or rented by the practice and used for the

exclusive purpose of operating the practice. A patient's home does not include any

institution that is a hospital, a CAH, or a SNF.

4. Treat individuals who are patients of the practice and for whom the practice collects fees

for the services furnished.

B. Qualified Physical Therapist Definition

Pub. 100-02, chapter 15, section 230.1 states that a qualified physical therapist is a person

who: (1) is licensed, if applicable, by the state in which the individual is practicing (unless

licensure does not apply); (2) has graduated from an accredited physical therapist education

program; and (3) passed an examination approved by the state in which physical therapy

services are provided. The phrase “by the state in which practicing” includes any

authorization to practice provided by the same state in which the service is provided,

including temporary licensure, regardless of the location of the entity billing the services.

The curriculum accreditation is provided by the Commission on Accreditation in Physical

Therapy Education (CAPTE) or, for those who graduated before CAPTE, curriculum

approval was provided by the American Physical Therapy Association (APTA). For

internationally educated physical therapists, curricula are approved by a credentials

evaluation organization either approved by the APTA or identified in 8 CFR 212.15(e) as it

relates to physical therapists. For example, in 2007, 8 CFR 212.15(e) approved the

credentials evaluation provided by the Federation of State Boards of Physical Therapy

(FSBPT) and the Foreign Credentialing Commission on Physical Therapy (FCCPT).

The requirements above do not apply to a physical therapist effective January 1, 2010, if

the individual has otherwise met the requirements outlined in Category #2, Category #3,

Category #4, or Category #5 below. (Category #1 is outlined in the previous paragraph.)

Category #2 – A physical therapist whose current license was obtained on or prior to December

31, 2009, qualifies to provide physical therapy services to Medicare beneficiaries if the

individual:

(a) Graduated from a CAPTE approved program in physical therapy on or before

December 31, 2009 (examination is not required); or

(b) Meets both of the following:

(i) Graduated on or before December 31, 2009, from a physical therapy program

outside the U.S. that is determined to be substantially equivalent to a U.S.

program by a credentialed evaluation organization approved by the APTA or

identified in 8 CFR § 212.15(e).

(ii) Passed an examination for physical therapists approved by the state in which the

individual is practicing.

Category #3 – A physical therapist whose current license was obtained before January 1, 2008,

may meet the requirements in place on that date (i.e., graduation from a curriculum approved by

either the APTA, the American Medical Association, or both).

Category #4 – A physical therapist meets the requirements if the individual (a) is currently

licensed as a physical therapist, (b) was licensed or qualified as a physical therapist on or before

December 31, 1977, (c) had 2 years of appropriate experience as a physical therapist, and (d)

passed a proficiency examination conducted, approved, or sponsored by the U.S. Public Health

Service.

Category #5 – A physical therapist meets the requirements if the individual is currently licensed

and before January 1, 1966, was:

• Admitted to membership by the APTA; or

• Admitted to registration by the American Registry of Physical Therapists; or

• Graduated from a 4-year physical therapist curriculum approved by a state Department of

Education; or

• Licensed or registered and prior to January 1, 1970, had 15 years of full-time experience

in physical therapy under the order and direction of attending and referring doctors of

medicine or osteopathy.

C. Physical Therapist Trained Outside the United States

Pub. 100-02, chapter 15, section 230.1(B) states that a physical therapist meets the

requirements if the individual: (a) is currently licensed; (b) was trained outside the U.S.

before January 1, 2008; (c) after 1928 graduated from a physical therapy curriculum

approved in the country in which the curriculum was located and that country had an

organization that was a member of the World Confederation for Physical Therapy; and (d)

qualified as a member of that organization.

D. Physical Therapists - Additional References

In Pub. 100-02, chapter 15, see section 230.2(B) for more information regarding the

required qualifications of physical therapists and section 230.4 for detailed information

regarding the term “private practice.”

E. Site Visits of Physical Therapists in Private Practice

(This site visit requirement is pursuant to 42 CFR § 424.518(b).)

Unless otherwise stated in this chapter or another CMS directive, site visits will be

performed in accordance with the following:

i. Initial application – If a physical therapist or physical therapist group submits an initial

application for private practice, the contractor shall order a site visit through PECOS. This

is to ensure that the supplier is in compliance with CMS’s enrollment requirements. The

scope of the site visit will be consistent with sections 10.6.20(A) and 10.6.20(B) of this

chapter. The NSVC will perform the site visit. The contractor shall not convey Medicare

billing privileges to the supplier prior to the completion of the NSVC’s site visit and the

contractor’s review of the results.

ii. Revalidation – If a private practice physical therapist or physical therapist group

submits a revalidation application, the contractor shall order a site visit through PECOS.

This is to ensure that the supplier is still in compliance with CMS’s enrollment

requirements. The scope of the site visit will be consistent with sections 10.6.20(A) and

10.6.20(B) of this chapter. The NSVC will perform the site visit. The contractor shall not

make a final decision regarding the revalidation application prior to the completion of the

NSVC’s site visit and the contractor’s review of the results.

iii. New/changed location – Unless CMS has directed otherwise, if a private practice

physical therapist or physical therapist group is (1) adding a new location or (2) changing

the physical location of an existing location, the contractor shall order a site visit of the

new/changed location through PECOS. This is to ensure that the new/changed location

complies with CMS’s enrollment requirements. The scope of the site visit will be

consistent with sections 10.6.20(A) and 10.6.20(B) of this chapter. The NSVC will

perform the site visit. The contractor shall not make a final decision regarding the

application prior to the completion of the NSVC’s site visit and the contractor’s review of

the results.

Note that if the PT (being a moderate-risk provider under § 424.518) has multiple practice

locations, the SVC will conduct a site visit of each location rather than simply one selected

location.

F. Physical Therapists: Additional Site Visit Information

The contractor is also advised of the following:

• In Section 2B of the Form CMS-855B application, physical and occupational therapy

groups are denoted as “Physical/Occupational Therapy Group in Private Practice.” If

a supplier that checks this box in Section 2B is exclusively an occupational therapy

group in private practice – that is, there are no physical therapists in the group – the

contractor shall process the application using the procedures in the “limited”

screening category. No site visit is necessary. If there is at least one physical

therapist in the group, however, the application shall be processed using the

procedures in the “moderate” screening category. A site visit by the NSVC is

required unless CMS has directed otherwise.

• If an entity is enrolled as a physician practice and employs a physical therapist

within the practice, the practice itself falls within the “limited” screening category.

This is because the entity is enrolled as a physician practice and not a physical

therapy group in private practice. However, this does not exempt the physical

therapist from the screening required at the “moderate” risk level.

• Unless CMS has directed otherwise, a site visit by the NSVC is required when a

physical therapist submits an application for private practice initial enrollment and

reassignment of benefits (Form CMS-855I). However, a site visit is not required

for an enrolled private practice physical therapist who is reassigning benefits only.

• If the private practice physical therapist’s practice location is the home address and

the individual exclusively performs services in patients’ homes, nursing homes,

etc., no site visit is necessary.

G. Other Enrollment Information

All physical therapists in private practice must respond to the questions in Section 2J of the

Form CMS-855I. However, Section 2J does not apply if the physical therapist: (1) plans to

provide services as a member of an established PT group, an employee of a physician-directed group, or an employee of a non-professional corporation; and (2) the person

wishes to reassign benefits to that group. Such information will be captured on the group’s

Form CMS-855B application.

If the physical therapist checks that the individual renders all services in patients' homes,

the contractor shall verify that the individual has an established private practice where at

which direct contact can be made and where the individual maintains patient records. (This

can be the person’s home address, though all Medicare rules and instructions regarding the

maintenance of patient records apply.) In addition, Section 4E of the Form CMS-855I

should indicate where services are rendered (e.g., county, state, city of the patients' homes).

Post office boxes are not acceptable.

If the individual answers “Yes” to question 2, 3, 4, or 5, the contractor shall request a copy

of the lease agreement giving the individual exclusive use of the facilities for physical

therapist services only if it has reason to question the accuracy of the individual’s response.

If the contractor makes this request and the supplier cannot furnish a copy of the lease, the

contractor shall deny the application.