HI 00610.090 Services of Physical Therapists in Independent Practice

A. General

Coverage of outpatient physical therapy under Part B includes the services of a qualified physical therapist in independent practice when furnished in his office or the beneficiary's home in accordance with health and safety requirements set forth in regulations, Sections 405.1730ff. Reimbursement is based on the reasonable charge less coinsurance and any deductible amounts due; however, expenses incurred for such services in a calendar year may not exceed $100 for a calendar year before 1982 and $500 for calendar years beginning with 1982. Thus, where the beneficiary has already satisfied the Part B deductible, the maximum amount payable under this benefit is $80 ($400 beginning 1982) in each calendar year.

Payment is made by the carrier to the beneficiary or, on assignment, to the physical therapist.

NOTE: Outpatient physical therapy services furnished by the therapist in his office under arrangements with hospitals in rural communities and public health agencies, or therapy services provided in the beneficiary's home under arrangements with a provider of outpatient physical therapy services are not covered under this provision.

B. Setting for covered services

Coverage of services furnished by a qualified physical therapist in independent practice is limited to those services performed in the beneficiary's home or an office he maintains for that purpose at his own expense (but not in an institution which meets the basic requirements in HI 00401.260).

C. Additional conditions

The following additional conditions must be met.

1. Patient must be under the care of a physician

This physician should be the attending physician. He may be the patient's private physician or a physician associated with an institution. There must be evidence in the clinical record maintained by the therapist that the patient has been seen by the physician at least every 30 days and the therapist must indicate on his bill the name of the physician and the date the patient was last seen by the physician.

2. Services must be furnished under a plan of treatment

The physical therapy must be furnished under a plan established and periodically reviewed by the physician caring for the patient. The plan must be established (i.e., reduced to writing either by the physician who makes the plan available to the physical therapist or by the therapist himself when he makes a written record of the physician's oral orders) before treatment is begun. The plan must be promptly signed by the physician and incorporated into the physical therapist's permanent record for the patient.

The plan must relate the type, amount, frequency, and duration of the physical therapy services that are to be furnished the patient and indicate the diagnosis and anticipated goals. Any changes should be made in writing and signed by the physician or by the physical therapist pursuant to the attending physician's oral orders. The services specified in the plan may not be altered in type, amount, frequency, or duration by the therapist (except in the case of an adverse reaction to a specific treatment).

The plan must be reviewed by the physician, in consultation with the physical therapist at such intervals as the severity of the patient's condition requires, but at least every 30 days. Each review of the plan should contain the initials of the physician and the date of review. The patient's plan normally need not be forwarded to the carrier for review but will be retained in the physical therapist's file. The physical therapist must certify on the billing form that the plan is on file and was in effect at the time the services were rendered.

The plan of treatment and the physical therapist's clinical records concerning the beneficiary will be retained by the therapist but must be available to the carrier or its professional consultants when the carrier deems review of these documents necessary to the performance of its claims processing obligations.

D. Nature of covered services

The personal services of the qualified physical therapist and services of supportive personnel in his employ are covered under this provision. However, the services of unqualified supportive personnel are covered only when performed under the direct personal supervision of a qualified therapist and included in the independent practitioner's bill.

To be reimbursable under the Medicare program as physical therapy, services furnished the patient must be of the type and must have been rendered under the conditions specified in HI 00610.370.