CMS Pub. 100-08, ch. 10, § 10.2.3.9

A. Regulatory Requirements - Occupational Therapist in Private Practice

Section 42 CFR § 410.59(c)(1)(i) through (iv) state that an occupational therapist in private

practice must meet all the following:

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

private practice of occupational therapy by the state in which the individual practices,

and practice only within the scope of the individual’s license, certification, or

registration.

(ii) Engage in the private practice of occupational therapy on a regular basis as an

individual, in one of the following practice types: (A) solo practice; (B) a partnership;

(C) group practice; or (D) as an employee of one of these.

(iii) 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 critical access hospital, or a SNF.))

(iv) Treat individuals who are patients of the practice and for whom the practice collects

fees for the services furnished.

B. Qualified Occupational Therapist Requirements

Pub. 100-02, chapter 15, section 230.2(B) states that a qualified occupational therapist is an

individual who meets the requirements in one of the four categories below:

Category #1 – The occupational therapist: (i) is licensed (if licensure applies) or otherwise

regulated (if applicable) as an occupational therapist by the state in which practicing; (ii)

graduated from an accredited education program for occupational therapists; and (iii) is eligible

to take or has passed the examination for occupational therapists administered by the National

Board for Certification in Occupational Therapy, Inc. (NBCOT). The phrase “by the state in

which practicing” includes any authorization to practice provided by the same state in which the

service is furnished (including temporary licensure), regardless of the location of the entity

billing the services. The education program for U.S. trained occupational therapists is accredited

by the Accreditation Council for Occupational Therapy Education (ACOTE).

The requirements above apply to all occupational therapists effective January 1, 2010 if the

occupational therapist has not met any of the following requirements prior to January 1, 2010.

Category #2 - On or before December 31, 2009, the individual --

(a) Is licensed or otherwise regulated as an occupational therapist in the state in which

practicing (regardless of the qualifications they met to obtain that licensure or regulation);

or

(b) When licensure or other regulation does not apply--

(i) Graduated from an occupational therapist education program accredited by

ACOTE; and

(ii) Is eligible to take, or has successfully completed, the NCBOT examination for

occupational therapists.

Category #3 - On or before January 1, 2008 (and if the individual met the Medicare

requirements for occupational therapists that were in 42 CFR § 484.4 prior to January 1,

2008), the individual--

(a) Graduated from an occupational therapy program approved jointly by the American

Medical Association and the American Occupational Therapy Association (AOTA);

or

(b) Is eligible for the National Registration Examination of AOTA or NBCOT.

Category #4 - On or before December 31, 1977, the individual--

(a) Had 2 years of appropriate experience as an occupational therapist; and

(b) Had achieved a satisfactory grade on an occupational therapist proficiency

examination conducted, approved, or sponsored by the U.S. Public Health Service.

C. Occupational Therapist Educated Outside the United States

Pub. 100-02, chapter 15, section 230.2(B) states that individuals educated outside the U.S. may

meet the same qualifications as domestic trained occupational therapists; for example, the

individual qualifies if licensed or otherwise regulated by the state in which practicing on or

before December 31, 2009. The individual also qualifies if the person:

• Graduated from an occupational therapy education program accredited as substantially

equivalent to a U.S. occupational therapy education program by ACOTE, the World

Federation of Occupational Therapists, or a credentialing body approved by AOTA;

• Passed the NBCOT examination for occupational therapists; and

• Effective January 1, 2010, is licensed or otherwise regulated, if applicable, as an

occupational therapy by the state in which practicing.

D. Occupational Therapists - Additional References

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

required qualifications of occupational therapists and section 230.4 for information

regarding the term “private practice.”

E. Other Enrollment Information - Form CMS-855 Completion

All occupational 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 occupational therapist:

(1) plans to provide services as a member of an established occupational therapist group, an

employee of a physician-directed group, or an employee of a non-professional corporation;

and (2) wishes to reassign benefits to that group.

If the occupational therapist checks that all services are furnished in patients' homes, the

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

individual can be contacted directly 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 4B 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 occupational

therapy 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.