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Service-Specific Prepay Audit Being Conducted for Physical and Occupational Therapy Services Billed by Physicians

Sunday, May 6, 2012


INTERNET - 9/8/2011
National Government Services, Inc. is currently conducting a service-specific prepayment review for Physical Therapy and Occupational Therapy Services being performed by specialties other than Specialty 65 (Physical Therapist billing independent) and 67 (Occupational Therapist billing independent). This article includes some common errors the Medical Review Department has identified as a result of the audit and information to assist providers in correcting errors in their submission of claims to Medicare. 

The Medicare therapy benefit allows for physical and occupational therapy services to be provided by physicians, nonphysician practitioners (NPPs), or incident-to the services of physicians/NPPs when provided by physical or occupational therapists, or qualified auxiliary personnel, in the office or home. 

The Local Coverage Determination (LCD) for Outpatient Physical and Occupational Therapy Services (L26884) states that students, aides, athletic trainers, exercise physiologists, massage therapists, recreation therapists, kinesiotherapists, low vision specialists, lymph edema specialists, Pilates instructors, rehabilitation technicians and life skills trainers are not considered qualified therapy professionals. The services provided by these employees may not be billed to Medicare. 

According to the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-2, Medicare Benefit Policy Manual, Chapter 15, Sections 230.1 (1 MB), the services of a physical therapy assistant (PTA) cannot be billed as services incident to a physician/NPP’s service because they do not meet the qualifications of a therapist. However, if a physical therapist (PT) and PTA are both employed in a physician’s office, the services of the PTA when directly supervised by the PT may be billed by the physician group as PT services using the provider identification number (PIN) of the enrolled PT. The CMS IOM Publication 100-2, Medicare Benefit Policy Manual, Chapter 15, Sections 230.1 (1 MB) states that if the PT is not enrolled, Medicare will not pay for the services of a PTA billed incident to the physician’s service because they do not meet the qualification standards in 42 Code of Federal Regulations (CFR) 484.4


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