Physical therapy services require specific authorization for payment. Determining who can legally submit a claim for these services is governed by a framework of federal and state regulations. The Centers for Medicare & Medicaid Services (CMS) sets national standards, particularly for Medicare beneficiaries, that dictate the qualifications of the provider and the setting where the care is delivered. These rules ensure that only qualified professionals are reimbursed.
The Primary Role of Licensed Physical Therapists
The licensed Physical Therapist (PT) acts as the primary provider and holds the fundamental authority to bill for physical therapy services. To bill under Medicare, a PT must possess a valid state license and enroll as a supplier, obtaining a unique National Provider Identifier (NPI). This individual NPI is the identifier used to submit claims and attest to the medical necessity of the services rendered.
The PT is solely responsible for performing the initial comprehensive evaluation, establishing the plan of care, and conducting re-assessments. These high-level services are non-delegable and must be performed by the licensed therapist to be billable. While many states permit direct access, Medicare requires a physician or non-physician practitioner (NPP) to certify the established plan of care for billing purposes.
Billing Authority in Different Practice Settings
The entity holding the billing authority, typically the tax ID, depends on the practice setting and determines if the service is billed as a professional or facility component. In a private practice or group setting, the PT or the group entity bills Medicare Part B directly for outpatient services using the PT’s NPI or the group’s tax ID. This represents the professional component, where the therapist is recognized as the supplier.
In institutional settings, such as hospitals or skilled nursing facilities (SNFs), the facility holds the billing authority. The facility employs the therapist and bills for the services, often bundling them into a facility rate covering both technical and professional components. Medicare Part B covers these services when furnished by a provider or under arrangements with the provider, as detailed in 42 CFR 410.60.
For facility services, the claim is submitted under the facility’s tax ID, not the individual therapist’s NPI. This contrasts with the private practice model and directs payment based on whether the service is a standalone professional service or part of a broader institutional stay.
Billing for Services Performed by Assistants
Physical Therapist Assistants (PTAs) are qualified to provide many components of the treatment plan but cannot bill for services independently. All services rendered by a PTA must be billed under the NPI of the supervising licensed PT or the facility’s tax ID. Services furnished by a PTA are also subject to a payment reduction.
Effective after January 1, 2022, claims for PTA services must include the CQ modifier and are paid at 85% of the applicable amount, per 42 CFR 410.60. This reduction applies when the PTA furnishes more than 10% of a time-based service unit separately from the PT. Supervision requirements are strictly enforced, requiring “direct supervision” (PT physically present) for PTAs in outpatient private practice.
Most other non-private practice settings generally require “general supervision,” where the PT is available by telecommunication. Physical therapy aides are auxiliary personnel who perform non-skilled tasks and cannot bill for any services. The PT must personally perform all skilled tasks, such as evaluations, and assume full responsibility for all care provided by the PTA.
Physicians and Other Non-PT Providers
In limited circumstances, non-physical therapy providers, such as Medical Doctors (MDs), Physician Assistants (PAs), or Nurse Practitioners (NPs), can bill for physical therapy-related services. This typically occurs in a physician’s office under the concept of “incident to” billing. The services must be an integral, though incidental, part of the physician’s professional service in the course of diagnosing or treating an illness.
For therapy services to be billed as “incident to,” they must be furnished in a non-institutional setting under the physician’s direct supervision, as defined in 42 CFR 410.26. The person providing the therapy, even if they are auxiliary personnel, must meet the standards for a qualified therapist. Strict adherence to supervision and documentation rules is required to meet the criteria for “incident to” billing.