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Know the Rules for PTA Supervision

Vol. 16 •Issue 5 • Page 79
Medicare Update

Know the Rules for PTA Supervision

As the "Medicare Advisors" for ADVANCE newsmagazines, we have recently received numerous questions about the supervision requirements of physical therapy personnel. The purpose of this article is to clarify requirements about supervision of therapy treatment as it relates not only to Medicare, but also to state practice acts.

Understanding Medicare Rules

Know your site of service. Medicare rules for supervision vary somewhat according to the provider type. For example, physical therapists in private practice (PTPP) have different requirements for supervision of therapy personnel than therapists practicing in a comprehensive outpatient rehabilitation facility (CORF). You need to know what type of provider practice you are working under.

Know Medicare's supervision definitions.

General Supervision—Medicare defines general supervision as the initial direction and periodic inspection of the actual activity; the supervisor need not always be physically present or on the premises when the assistant is performing services. However, the therapist must be readily available for consultation (for example, by telephone).

Direct Supervision—Medicare defines direct supervision as the therapist being on the premises and readily available when a procedure is performed.

Line of Sight Supervision—This level of supervision only refers to the requirement of therapy aide supervision in a SNF under Part A. Line of sight supervision requires that supervision be provided by a licensed therapist (not an assistant) so that the therapist has visual contact with the aide at all times during which services are being provided.

Know if the patient falls under Part A or Part B regulations. Supervision regulations for Part A and Part B services are very different. Services provided in a skilled nursing facility (SNF) under Part A are different than the regulations for Part B because of the use of PT aides. Under Part A, therapy treatment provided by an aide that is in the "line of sight" supervision of a therapist can count toward the minutes of treatment in the Minimum Data Set (MDS) section P1(b) for a beneficiary. A physical therapist assistant cannot supervise an aide and count the minutes for classification into a RUG-III category. Under Part B, aides cannot treat patients in any provider type and bill their time to Medicare.

Medicare provides the following directions to its contractors during their review process. If, in the course of their medical review, they find that therapy services are not being furnished under proper supervision, then they deny the claim and bring it to the attention of the CMS Regional Office.

State Practice Acts

Licensed physical therapists and physical therapist assistants fall under the rules and regulations of the state practice act under which they are licensed. There is enormous variety among state practice acts—some are highly rigid about the type and frequency of required supervision; others do not mention it at all. It is vital that you know exactly what your state says about supervision of therapy services in your provider type. It is also vital to know how your state defines each type of supervision. If you do not have a current copy of your state practice act, it is available at no charge on the Internet through your state board.

APTA guidelines

While physical therapists and PT assistants are not legally bound to the guidelines of the American Physical Therapy Association, these guidelines are used by Medicare contractors during the review process as professional standards. They can also be used as professional standards in medical malpractice cases against therapists.

The following are excerpts from the APTA's Direction And Supervision Of The Physical Therapist Assistant (Hod 06-00-16-27).

"The physical therapist assistant is the only individual permitted to assist a physical therapist in selected interventions under the direction and supervision of a physical therapist. Direction and supervision are essential in the provision of quality physical therapy services. The degree of direction and supervision necessary for assuring quality physical therapy services is dependent upon many factors, including the education, experiences, and responsibilities of the parties involved, as well as the organizational structure in which the physical therapy services are provided.

"The physical therapist is directly responsible for the actions of the physical therapist assistant related to patient/client management. The physical therapist assistant may perform selected physical therapy interventions under the direction and at least general supervision of the physical therapist. In general supervision, the physical therapist is not required to be on-site for direction and supervision, but must be available at least by telecommunications. The ability of the physical therapist assistant to perform the selected interventions as directed shall be assessed on an ongoing basis by the supervising physical therapist. The physical therapist assistant may modify an intervention in accordance with changes in patient/client status within the scope of the established plan of care.

"When supervising the physical therapist assistant in any off-site setting, the following requirements must be observed:

1. A physical therapist must be accessible by telecommunications to the physical therapist assistant at all times while the physical therapist assistant is treating patients/clients.

2. There must be regularly scheduled and documented conferences with the physical therapist assistant regarding patients/clients, the frequency of which is determined by the needs of the patient/client and the needs of the physical therapist assistant.

3. In those situations in which a physical therapist assistant is involved in the care of a patient/client, a supervisory visit by the physical therapist will be made:

a. Upon the physical therapist assistant's request for a reexamination, when a change in the plan of care is needed, prior to any planned discharge, and in response to a change in the patient's/client's medical status.

b. At least once a month, or at a higher frequency when established by the physical therapist, in accordance with the needs of the patient/client.

c. A supervisory visit should include:

i. An on-site reexamination of the patient/client.

ii. On-site review of the plan of care with appropriate revision or termination.

iii. Evaluation of need and recommendation for utilization of outside resources."

What Rules Should I Follow?

Medicare rules for supervision do not negate your state practice act, nor does your state practice act negate Medicare rules. When determining which rules to follow about supervision, simply select the strictest rule.

For example, if Medicare requires only general supervision of a treatment, but your state practice act says you must give direct supervision, then you must give direct supervision. If your state does not define the type of supervision for your provider type, then follow Medicare guidelines.

Further, your organization or the insurance companies you are dealing with may have supervision requirements that are stricter than Medicare or your state practice act.

The bottom line is that you need to know all of the supervision rules that impact you and which one is the strictest. The table provides an easy reference source for you to use to determine which supervision rules are the strictest.

Danna D. Mullins and Pauline M. Franko are the principal lecturers for Encompass Consulting and Education LLC, a rehabilitation consulting and education company in Tamarac, FL. You may contact the authors through their Website at


I have worked with PT's who have formed PC/LLC and use PTA's to treat pts in home without direct supervision. They rationalize this as "home care services" which allows for general supervision. I think there is a misunderstanding of the definition of what "PT in private practice". I have read that even a PT who forms a PC/LLC is considered a PT in private practice and would require direct supervision for PTAs. - Public health law defines PT in private practice for PT.
Is there a way to find out if a provider/company's site of service identity?

joseph dauria,  ptMarch 10, 2013
new york, NY

Dear Ms Mullins,

I am trying to find information on the options of an OT supervising PTAs in a Home Health Setting in Oregon.

Duane Connor,  EDNovember 30, 2012
Gold Beach, OR

The PT should be referred to her state board. (If no-one else has mentioned that yet). If she is not following accepted guidelines for practice, she is probably violating state practice acts. Patients have the right to contact the state board and complain (as do you). Then it's up to the state baord to review her practice habits.

William Byers,  LTC,  Bethesda National Naval Med CtrOctober 12, 2010
Bethesda, AA

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