Supervision of Students Under Medicare - American Physical Therapy Association (APTA)

Practice Setting PT Student PT Student PTA Student PTA Student
  Part A Part B Part A Part B
PT in Private Practice N/A X1 N/A X1
Certified Rehabilitation Agency N/A X1 N/A X1
Comprehensive Outpatient Rehabilitation Facility N/A X1 N/A X1
Skilled Nursing Facility Y1 X1 Y2 X1
Hospital Y3 X1 Y3 X1
Home Health Agency NAR X1 NAR X1
Inpatient Rehabilitation Agency Y4 N/A Y4 N/A

Key
Y: Reimbursable
X: Not Reimbursable
N/A: Not Applicable
NAR: Not Addressed in Regulation. Please defer to state law.

Y1: Reimbursable: Therapy students are not required to be in line-of-sight of the professional supervising therapist/assistant (Federal Register, August 8, 2011). Within individual facilities, supervising therapists/assistants must make the determination as to whether or not a student is ready to treat patients without line-of-sight supervision. Additionally, all state and professional practice guidelines for student supervision must be followed. Time may be coded on the MDS when the therapist provides skilled services and direction to a student who is participating in the provision of therapy. All time that the student spends with patients should be documented.
 
Medicare Part B—The following criteria must be met in order for services provided by a student to be billed by the long-term care facility:
  • The qualified professional is present and in the room for the entire session. The student participates in the delivery of services when the qualified practitioner is directing the service, making the skilled judgment, and is responsible for the assessment and treatment.
  • The practitioner is not engaged in treating another patient or doing other tasks at the same time.
  • The qualified professional is the person responsible for the services and, as such, signs all documentation. (A student may, of course, also sign but it is not necessary because the Part B payment is for the clinician’s service, not for the student’s services.)
(RAI Version 3.0 Manual, October 2011)
 
Individual Therapy:
When a therapy student is involved with the treatment of a resident, the minutes may be coded as individual therapy when only one resident is being treated by the therapy student and supervising therapist/assistant (Medicare A and Medicare B). The supervising therapist/assistant shall not be engaged in any other activity or treatment when the resident is receiving therapy under Medicare B.
However, for those residents whose stay is covered under Medicare A, the supervising therapist/assistant shall not be treating or supervising other individuals and he/she is able to immediately intervene/assist the student as needed.
 
Example: A speech therapy graduate student treats Mr. A for 30 minutes. Mr. A.’s therapy is covered under the Medicare Part A benefit. The supervising speech-language pathologist is not treating any
patients at this time but is not in the room with the student or Mr. A. Mr. A.’s therapy may be coded as 30 minutes of individual therapy on the MDS.
 
Concurrent Therapy:
When a therapy student is involved with the treatment, and one of the following occurs, the minutes may be coded as concurrent therapy:
  • The therapy student is treating one resident and the supervising therapist/assistant is treating another resident, and both residents are in line of sight of the therapist/assistant or student providing their therapy; or
  • The therapy student is treating 2 residents, regardless of payer source, both of whom are in line-of-sight of the therapy student, and the therapist is not treating any residents and not supervising other individuals; or
  • The therapy student is not treating any residents and the supervising therapist/assistant is treating 2 residents at the same time, regardless of payer source, both of whom are in line of sight.
Medicare Part B: The treatment of two or more residents who may or may not be performing the same or similar activity, regardless of payer source, at the same time is documented as group treatment.
 
Example: An Occupational Therapist provides therapy to Mr. K. for 60 minutes. An occupational therapy graduate student, who is supervised by the occupational therapist, is treating Mr. R. at the same time for the same 60 minutes but Mr. K. and Mr. R. are not doing the same or similar activities. Both Mr. K. and Mr. R’s stays are covered under the Medicare Part A benefit. Based on the information above, the therapist would code each individual’s MDS for this day of treatment as follows:
  • Mr. K. received concurrent therapy for 60 minutes.
  • Mr. R. received concurrent therapy for 60 minutes.
Group Therapy:
When a therapy student is involved with group therapy treatment, and one of the following occurs, the minutes may be coded as group therapy:
  • The therapy student is providing the group treatment and the supervising therapist/assistant is not treating any residents and is not supervising other individuals (students or residents); or
  • The supervising therapist/assistant is providing the group treatment and the therapy student is not providing treatment to any resident. In this case, the student is simply assisting the supervising therapist.
Medicare Part B: The treatment of 2 or more individuals simultaneously, regardless of payer source, who may or may not be performing the same activity.
 
When a therapy student is involved with group therapy treatment, and one of the following occurs, the minutes may be coded as group therapy:
  • The therapy student is providing group treatment and the supervising therapist/assistant is not engaged in any other activity or treatment; or 
  • The supervising therapist/assistant is providing group treatment and the therapy student is not providing treatment to any resident.
Documentation: APTA recommends that the physical therapist co-sign the note of the physical therapist student and state the level of supervision that the PT determined was appropriate for the student and how/if the therapist was involved in the patient’s care.
 
Y2: Reimbursable: The minutes of student services count on the Minimum Data Set. Medicare no longer requires that the PT/PTA provide line-of-sight supervision of physical therapist assistant (PTA) student services. Rather, the supervising PT/PTA now has the authority to determine the appropriate level of supervision for the student, as appropriate within their state scope of practice. See Y1.
 
Documentation: APTA recommends that the physical therapist and assistant should co-sign the note of physical therapist assistant student and state the level of appropriate supervision used. Also, the
documentation should reflect the requirements as indicated for individual therapy, concurrent therapy, and group therapy in Y1.
 
Y3: This is not specifically addressed in the regulations, therefore, please defer to state law and standards of professional practice. Additionally, the Part A hospital diagnosis-related group (DRG)
payment system is similar to that of a skilled nursing facility (SNF) and Medicare has indicated very limited and restrictive requirements for student services in the SNF setting.
 
Documentation: Please refer to documentation guidance provided under Y1
 
Y4: This is not specifically addressed in the regulations, therefore, please defer to state law and
standards of professional practice. Additionally, the inpatient rehabilitation facility payment system is
similar to that of a skilled nursing facility (SNF) and Medicare has indicated very limited and restrictive
requirements for student services in the SNF setting.
 
X1: B. Therapy Students
 
1. General
Only the services of the therapist can be billed and paid under Medicare Part B. However, a student may participate in the delivery of the services if the therapist is directing the service, making the judgment, responsible for the treatment and present in the room guiding the student in service delivery.
 
EXAMPLES:
Therapists may bill and be paid for the provision of services in the following scenarios:
  • The qualified practitioner is present and in the room for the entire session. The student participates in the delivery of services when the qualified practitioner is directing the service, making the skilled judgment, and is responsible for the assessment and treatment.
  • The qualified practitioner is present in the room guiding the student in service delivery when the therapy student and the therapy assistant student are participating in the provision of services, and the practitioner is not engaged in treating another patient or doing other tasks at the same time.
  • The qualified practitioner is responsible for the services and as such, signs all documentation. (A student may, of course, also sign but it is not necessary since the Part B payment is for the clinician’s service, not for the student’s services). 
2. Therapy Assistants as Clinical Instructors
Physical therapist assistants and occupational therapy assistants are not precluded from serving as clinical instructors for therapy students while providing services within their scope of work and performed under the direction and supervision of a licensed physical or occupational therapist to a Medicare beneficiary.
 
Documentation: APTA recommends that the physical therapist or physical therapist assistant complete documentation.