42 CFR 410.60 - Outpatient physical therapy services: Conditions.
Title 42: Public HealthCHAPTER IV: CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES SUBCHAPTER B: MEDICARE PROGRAM PART 410: SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS Subpart B: Medical and Other Health Services 410.60 - Outpatient physical therapy services: Conditions. (a) Basic rule. Except as specified in paragraph (a)(3)(iii) of this section, Medicare Part B pays for outpatient physical therapy services only if they are furnished by an individual meeting the qualifications in part 484 of this chapter for a physical therapist or an appropriately supervised physical therapist assistant but only under the following conditions: (1) They are furnished to a beneficiary while he or she is under the care of a physician who is a doctor of medicine, osteopathy, or podiatric medicine. (2) They are furnished under a written plan of treatment that meets the requirements of ? 410.61. (3) They are furnished? (i) By a provider as defined in ? 489.2 of this chapter, or by others under arrangements with, and under the supervision of, a provider; or (ii) By, or under the direct supervision of a physical therapist in private practice as described in paragraph (c) of this section; or (iii) By, or incident to the service of, a physician, physician assistant, clinical nurse specialist, or nurse practitioner when those professionals may perform physical therapy services under State law. When a physical therapy service is provided incident to the service of a physician, physician's assistant, clinical nurse specialist, or nurse practitioner, by anyone other than a physician, physician assistant, clinical nurse specialist, or nurse practitioner, the service and the person who furnishes the service must meet the standards and conditions that apply to physical therapy and physical therapists, except that a license to practice physical therapy in the State is not required. (4) Claims submitted for furnished services contain prescribed information on patient functional limitations. (b) Condition for coverage of outpatient physical therapy services furnished to certain inpatients of a hospital or a CAH or SNF. Medicare Part B pays for outpatient physical therapy services furnished to an inpatient of a hospital, CAH, or SNF who requires them but who has exhausted or is otherwise +ineligible for benefit days under Medicare Part A. (c) Special provisions for services furnished by physical therapists in private practice?(1) Basic qualifications. In order to qualify under Medicare as a supplier of outpatient physical therapy services, each individual physical therapist in private practice must meet the following requirements: (i) Be legally authorized (if applicable, licensed, certified, or registered) to engage in the private practice of physical therapy by the State in which he or she practices, and practice only within the scope of his or her license, certification, or registration. (ii) Engage in the private practice of physical therapy on a regular basis as an individual, in one of the following practice types: (A) An unincorporated solo practice. (B) An unincorporated partnership or unincorporated group practice. (C) An unincorporated solo practice, partnership, or group practice, or a professional corporation or other incorporated physical therapy practice. (D) An employee of a physician group. (E) An employee of a group that is not a professional corporation. (iii) Bill Medicare only for services furnished in his or her private practice office space, or in the patient's home. A therapist's private practice office space refers to the location(s) where the practice is operated, in the State(s) where the therapist (and practice, if applicable) is legally authorized to furnish services, during the hours that the therapist engages in practice at that location. When services are furnished in private practice office space, that space must be owned, leased, or rented by the practice and used for the exclusive purpose of operating the practice. A patient's home does not include any institution that is a hospital, a CAH, or a SNF. (iv) Treat individuals who are patients of the practice and for whom the practice collects fees for the services furnished. (2) Supervision of physical therapy services. Physical therapy services are performed by, or under the direct supervision of, a physical therapist in private practice. All services not performed personally by the therapist must be performed by employees of the practice, directly supervised by the therapist, and included in the fee for the therapist's services. (d) Excluded services. No service is included as an outpatient physical therapy service if it would not be included as an inpatient hospital service if furnished to a hospital or CAH inpatient. (e) Annual limitation on incurred expenses. (1) Amount of limitation. (i) In 1999, 2000, and 2001, no more than $1,500 of allowable charges incurred in a calendar year for outpatient physical therapy services are recognized incurred expenses. (ii) In 2002 and thereafter, the limitation shall be determined by increasing the limitation in effect in the previous calendar year by the increase in the Medicare Economic Index for the current year. (iii) The limitation is not applied for services furnished from December 8, 2003 through December 31, 2005. (2) For purposes of applying the limitation, outpatient physical therapy includes: (i) Except as provided in paragraph (e)(3) of this section, outpatient physical therapy services furnished under this section; (ii) Except as provided in paragraph (e)(3) of this section outpatient speech-language pathology services furnished under ? 410.62; (iii) Outpatient physical therapy and speech-language pathology services furnished by a comprehensive outpatient rehabilitation facility; (iv) Outpatient physical therapy and speech-language pathology services furnished by a physician or incident to a physician's service; (v) Outpatient physical therapy and speech-language pathology services furnished by a nurse practitioner, clinical nurse specialist, or physician assistant or incident to their services. (3) For purposes of applying the limitation, outpatient physical therapy excludes services furnished by a hospital or CAH directly or under arrangements. [63 FR 58906, Nov. 2, 1998, as amended at 67 FR 80041, Dec. 31, 2002; 69 FR 66422, Nov. 15, 2004; 72 FR 66399, Nov. 27, 2007; 77 FR 69363, Nov. 16, 2012]