Physical Therapists in Private Practice
A. Private Practice
Section 42 CFR 410.60(c)(ii), (iii), and (iv) state that a physical therapist in private practice must:
(1) Engage in the private practice of physical therapy on a regular basis as an individual, in one of the following practice types:
(a) An unincorporated solo practice.
(b) A partnership or unincorporated group practice.
(c) An unincorporated solo practice, partnership, or group practice, or a professional corporation or other incorporated physical therapy practice.
(d) An employee of a physician group.
(e) An employee of a group that is not a professional corporation
AND
(2) Bill Medicare only for services furnished in his or her private practice office space, or in the patient's home.
(a) 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.
(b) A patient's home does not include any institution that is a hospital, a CAH, or a SNF.
AND
(3) Treat individuals who are patients of the practice and for whom the practice collects fees for the services furnished.
B. Regulatory Definition
Section 42 CFR § 484.4 defines a physical therapist as a person who is licensed, if applicable, by the state in which practicing (unless licensure does not apply) and who meets one of the following requirements:
(1)(a) Graduated after successful completion of a physical therapist education program approved by one of the following:
(i) The Commission on Accreditation in Physical Therapy Education (CAPTE).
(ii) Successor organizations of CAPTE.
(iii) An education program outside the United States determined to be substantially equivalent to physical therapist entry-level education in the United States by a credentials evaluation organization approved by the American Physical Therapy Association or an organization identified in 8 CFR § 212.15(e) as it relates to physical therapists; and
(b) Passed an examination for physical therapists approved by the state in which physical therapy services are provided.
OR
(2) On or before December 31, 2009--
(a) Graduated after successful completion of a physical therapy curriculum approved by the Commission on Accreditation in Physical Therapy Education (CAPTE); or
(b) Meets both of the following:
(i) Graduated after successful completion of an education program determined to be substantially equivalent to physical therapist entry level education in the United States by a
credentialed evaluation organization approved by the American Physical Therapy Association or identified in 8 CFR § 212.15(e) as it relates to physical therapists.
(ii) Passed an examination for physical therapists approved by the state in which physical therapy services are provided.
OR
(3) Before January 1, 2008--
(a) Graduated from a physical therapy curriculum approved by one of the following:
(i) The American Physical Therapy Association.
(ii) The Committee on Allied Health Education and Accreditation of the American Medical Association.
(iii) The Council on Medical Education of the American Medical Association and the American Physical Therapy Association.
OR
(4) On or before December 31, 1977 was licensed or qualified as a physical therapist and meets both of the following:
(1) Has 2 years of appropriate experience as a physical therapist.
(2) Has achieved a satisfactory grade on a proficiency examination conducted, approved, or sponsored by the U.S. Public Health Service.
OR
(5) Before January 1, 1966--
(1) Was admitted to membership by the American Physical Therapy Association; or
(2) Was admitted to registration by the American Registry of Physical Therapists; or
(3) Has graduated from a physical therapy curriculum in a 4-year college or university approved by a state department of education.
OR
(6) Before January 1, 1966 was licensed or registered, and before January 1, 1970, had 15 years of full-time experience in the treatment of illness or injury through the practice of physical therapy in which services were rendered under the order and direction of attending and referring doctors of medicine or osteopathy.
C. Training Outside the United States
Section 42 CFR § 484.4 states that if the physical therapist was trained outside the United States before January 1, 2008, he or she must meet the following requirements:
(1) Was graduated since 1928 from a physical therapy curriculum approved in the country in which the curriculum was located and in which there is a member organization of the World Confederation for Physical Therapy.
(2) Meets the requirements for membership in a member organization of the World Confederation for Physical Therapy.
D. Additional References
See Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15:
• Section 230.2(B) for more detailed information regarding the required qualifications of physical therapists.
• 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).)
Subject to subsection F below, site visits will be performed in accordance with the following:
• Initial application – If a physical therapist (PT) or PT group submits an initial application for private practice, the contractor shall order a site visit through the Provider Enrollment, Chain and Ownership System (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 section 15.19.2.2(B) of this Chapter.
The National Site Visit Contractor (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.
• Revalidation – If a private practice PT or PT 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 section 15.19.2.2(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.
• New/changed location – Unless CMS has directed otherwise, if a private practice PT or PT 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 is in compliance with CMS’s enrollment requirements. The scope of the site visit will be consistent with section 15.19.2.2(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.
F. Additional Site Visit Information
NOTE: The contractor shall also view the following:
• In section 2A of the Form CMS-855B application, physical and occupational therapy groups are denoted as “Physical/Occupational Therapy Group(s) in Private Practice.” If a supplier that checks this box in section 2A 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, 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, not a physical therapy group in private practice.
• If a newly-enrolling private practice physical therapist lists several practice locations, the enrollment contractor has the discretion to determine the location at which the NSVC will perform the required site visit.
• 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 and Form CMS-855R). However, a site visit is not required for an enrolled private practice physical therapist who is reassigning his or her benefits only (Form CMS-855R).
• If the private practice physical therapist’s practice location is his or her home address and it exclusively performs services in patients’ homes, nursing homes, etc., no site visit is necessary.
A. Private Practice
Section 42 CFR 410.60(c)(ii), (iii), and (iv) state that a physical therapist in private practice must:
(1) Engage in the private practice of physical therapy on a regular basis as an individual, in one of the following practice types:
(a) An unincorporated solo practice.
(b) A partnership or unincorporated group practice.
(c) An unincorporated solo practice, partnership, or group practice, or a professional corporation or other incorporated physical therapy practice.
(d) An employee of a physician group.
(e) An employee of a group that is not a professional corporation
AND
(2) Bill Medicare only for services furnished in his or her private practice office space, or in the patient's home.
(a) 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.
(b) A patient's home does not include any institution that is a hospital, a CAH, or a SNF.
AND
(3) Treat individuals who are patients of the practice and for whom the practice collects fees for the services furnished.
B. Regulatory Definition
Section 42 CFR § 484.4 defines a physical therapist as a person who is licensed, if applicable, by the state in which practicing (unless licensure does not apply) and who meets one of the following requirements:
(1)(a) Graduated after successful completion of a physical therapist education program approved by one of the following:
(i) The Commission on Accreditation in Physical Therapy Education (CAPTE).
(ii) Successor organizations of CAPTE.
(iii) An education program outside the United States determined to be substantially equivalent to physical therapist entry-level education in the United States by a credentials evaluation organization approved by the American Physical Therapy Association or an organization identified in 8 CFR § 212.15(e) as it relates to physical therapists; and
(b) Passed an examination for physical therapists approved by the state in which physical therapy services are provided.
OR
(2) On or before December 31, 2009--
(a) Graduated after successful completion of a physical therapy curriculum approved by the Commission on Accreditation in Physical Therapy Education (CAPTE); or
(b) Meets both of the following:
(i) Graduated after successful completion of an education program determined to be substantially equivalent to physical therapist entry level education in the United States by a
credentialed evaluation organization approved by the American Physical Therapy Association or identified in 8 CFR § 212.15(e) as it relates to physical therapists.
(ii) Passed an examination for physical therapists approved by the state in which physical therapy services are provided.
OR
(3) Before January 1, 2008--
(a) Graduated from a physical therapy curriculum approved by one of the following:
(i) The American Physical Therapy Association.
(ii) The Committee on Allied Health Education and Accreditation of the American Medical Association.
(iii) The Council on Medical Education of the American Medical Association and the American Physical Therapy Association.
OR
(4) On or before December 31, 1977 was licensed or qualified as a physical therapist and meets both of the following:
(1) Has 2 years of appropriate experience as a physical therapist.
(2) Has achieved a satisfactory grade on a proficiency examination conducted, approved, or sponsored by the U.S. Public Health Service.
OR
(5) Before January 1, 1966--
(1) Was admitted to membership by the American Physical Therapy Association; or
(2) Was admitted to registration by the American Registry of Physical Therapists; or
(3) Has graduated from a physical therapy curriculum in a 4-year college or university approved by a state department of education.
OR
(6) Before January 1, 1966 was licensed or registered, and before January 1, 1970, had 15 years of full-time experience in the treatment of illness or injury through the practice of physical therapy in which services were rendered under the order and direction of attending and referring doctors of medicine or osteopathy.
C. Training Outside the United States
Section 42 CFR § 484.4 states that if the physical therapist was trained outside the United States before January 1, 2008, he or she must meet the following requirements:
(1) Was graduated since 1928 from a physical therapy curriculum approved in the country in which the curriculum was located and in which there is a member organization of the World Confederation for Physical Therapy.
(2) Meets the requirements for membership in a member organization of the World Confederation for Physical Therapy.
D. Additional References
See Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15:
• Section 230.2(B) for more detailed information regarding the required qualifications of physical therapists.
• 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).)
Subject to subsection F below, site visits will be performed in accordance with the following:
• Initial application – If a physical therapist (PT) or PT group submits an initial application for private practice, the contractor shall order a site visit through the Provider Enrollment, Chain and Ownership System (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 section 15.19.2.2(B) of this Chapter.
The National Site Visit Contractor (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.
• Revalidation – If a private practice PT or PT 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 section 15.19.2.2(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.
• New/changed location – Unless CMS has directed otherwise, if a private practice PT or PT 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 is in compliance with CMS’s enrollment requirements. The scope of the site visit will be consistent with section 15.19.2.2(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.
F. Additional Site Visit Information
NOTE: The contractor shall also view the following:
• In section 2A of the Form CMS-855B application, physical and occupational therapy groups are denoted as “Physical/Occupational Therapy Group(s) in Private Practice.” If a supplier that checks this box in section 2A 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, 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, not a physical therapy group in private practice.
• If a newly-enrolling private practice physical therapist lists several practice locations, the enrollment contractor has the discretion to determine the location at which the NSVC will perform the required site visit.
• 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 and Form CMS-855R). However, a site visit is not required for an enrolled private practice physical therapist who is reassigning his or her benefits only (Form CMS-855R).
• If the private practice physical therapist’s practice location is his or her home address and it exclusively performs services in patients’ homes, nursing homes, etc., no site visit is necessary.
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