Medicare ADVISOR Q&A

Treating Medicare patients; SNF/LTC facilities

Question: I work in an outpatient practice that is associated with a hospital. My supervisor is telling me that it is within regulations that I treat a Medicare patient along with other patients. For example, she says I can schedule two patients at 10:00, (one Medicare, one another type of insurance) and a third patient at 10:30, who is also not a Medicare patient. Then she says I can bill for a 30 minute treatment for the Medicare patient as long as I am with that Medicare patient one-on-one. The aide is working with the other patient during this time. Is this correct or fraud? Can you direct me or send me documentation for this question?

Answer: You are correct and, we are sorry to say your supervisor is very wrong. In fact, CMS (Centers for Medicare and Medicaid) in their most recent transmittal on Part B services have added to Chapter 15 of the Medicare Benefit Manual, §230, "Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology." It says:

"A. Group Therapy Services. Contractors pay for outpatient physical therapy services (which includes outpatient speech-language pathology services) and outpatient occupational therapy services provided simultaneously to two or more individuals by a practitioner as group therapy services (97150). The individuals can be, but need not be performing the same activity. The therapist involved in group therapy services must be in constant attendance, but one-on-one patient contact is not required."

As the other services are being provided by a non-therapist, then, under accepted standards of practice, the aide is being "directly supervised by the therapist" and therefore cannot be providing one-on-one direct care to the patient. As far as Medicare is concerned, it does not matter who is paying for the care of other patients; under their definition, the therapist is providing supervised care, not one-on-one.

You should also look at your responsibilities as far as your practice act dictates. For example, we practice in Florida and under our regulations, the delegation of any task to an unqualified person requires direct supervision of the therapist, along with the responsibility for the services provided. This is from the Florida state practice act for physical therapy, and is given as an example:

"64B17-6.007 Delegation to Unlicensed Personnel by the Physical Therapist.

(1) Unlicensed personnel may be utilized to assist in the delivery of patient care treatment by the physical therapist, with direct supervision by the physical therapist or the physical therapist assistant.

(2) It is the sole responsibility of the physical therapist to consider the task delegated, select the appropriately trained personnel to perform the task, communicate the task or activity desired of the unlicensed personnel, verify the understanding by the unlicensed personnel chosen for the task or activity, and establish procedures for the monitoring of the tasks or activities delegated."

Therefore, as a licensed practitioner, you cannot change your standard to meet a reimbursement issue.

Your state practice act may have similar regulations. You should be able to access your practice act online.

Question: I have been noticing a trend in SNF/LTC facilities. In order to prevent paying a higher fee for PTs and OTs for a 40 hour work week, they are running therapy programs with only PTAs/COTAs and non-licensed rehab techs. They will have a PT or OT come into the facility only one or two times a week for a few hours to do paperwork (i.e. evaluations, recertifications and discharges). If patients and elderly are in SNFs and billing Medicare/Medicaid for PT and OT services, shouldn't a PT or OT be on the premises?

I didn't work so hard and pay for a Master's Degree to only be able to find 15 hours of work per week. This scenario does not sound legitimate to me. 

Answer: You are absolutely correct. Under Medicare regulations for provision of Part A services in a SNF, only a licensed physical or occupational therapist (and not licensed assistants) can supervise an aide and have those minutes of therapy count. Medicare requires the therapist to provide general supervision with periodic observation of the assistant providing the care to each Medicare patient. General supervision is defined as being available through any communication device while the assistant is providing services.

If they are providing any Part B services, only the time of the therapist or therapist assistant can be billed to Medicare, not the time of an aide. Also, under the new Part B regulations, a therapist must personally perform at least one treatment in the certification period.

As with the previous question, you also need to look at what your state practice act requires in terms of supervision. Remember, when you write a plan of care, it is your responsibility, not the facility's, to ensure compliance with your state regulations.

It is also prudent to mention that the assistants may be practicing out of their scope of practice and therefore are also putting their license in jeopardy.

You can find this information in the RAI Manual, Chapter 3. MDS item P1b; Chapter 8 of the Medicare Benefit Manual Pub. 100-02 available on the CMS at

Pauline Franko is owner and principal lecturer for Encompass Consulting & Education, LLC, a rehabilitation consulting and education company based in Tamarac, FL. The company's "Direction on Demand" service specializes in providing the rehabilitation professional with a clear, easy way to understand how to provide Medicare compliant services to their patients in the SNF and Outpatient settings. As a principle in Comprehensive Medicare Consultants, LLC, she is responsible for assisting with and directing compliance to Rehab Agencies. Danna Mullins is an associate and lecturer with Encompass. You may contact the authors through the Encompass website at

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