Eli's Rehab Report

Keep incident-to billing and assistant supervision issues separate.

While you're thinking about incident to (see previous article), it's worth examining your supervision compliance. Medicare incident to rules require that a physician billing incident to must provide direct supervision when a therapist performs the services. "Direct" means the physician must be in the office suite, explains Gayle Lee, JD, director of federal payment policy and advocacy for the American Physical Therapy Association.

Note: There is no "in the room" requirement for therapists in physician offices, says Judy Thomas, senior policy manager for the American Occupational Therapy Association. "The only real distinction between incident to and OTs [or PTs] in private practice is that for therapists billing incident to, the physician must be in the office suite." This means a therapist billing incident to cannot provide therapy services in a person's home. "Some of our members working in physicians' offices would like to be able to provide therapy in the home, where they can best analyze the environment and provide more individual interventions, but understand that this is a limitation of law," Thomas says.

The biggest issue healthcare attorney Donna Thiel notices with incident to and therapists is supervision noncompliance. "Physicians must be present at all times in the physician office when Medicare services are being rendered," she says.

And this means not cutting any corners. Thiel, with Baker, Donelson, Bearman, Caldwell, & Berkowitz, PC in Washington, D.C., advises offices to "schedule Medicare patients carefully -- not around lunch time when the doctor is likely to be out, and not late in the day, etc."

Good idea: "Make a note in the record of who the supervising doctor is on site that day," Thiel adds.

Tip: If you do your research, you may find your state bends on incident-to rules. For example, "in many states, an OT [or PT] can join a physician group and bill as an OT in private practice under his or her own Medicare number, in the same manner as any other member of the group (non-incident to)," Thomas points out. But proceed with caution. "This is not allowed in some states, where OT services must be billed incident to," she says.

Occupational therapy assistants (OTAs) and physical therapy assistants (PTAs) may not provide "incident to" physician services, Thomas clarifies. Medicare incident-to rules do not apply to the therapist-assistant relationship.

But the therapist-assistant relationship still has important supervision rules by itself.

Of note: OTAs and PTAs must be under the supervision of an OT or PT. In an OT/PT private practice setting, the qualified assistants must be under a therapist's direct supervision. This means the supervising therapist must be in the office suite. In all other settings therapy assistants must be under general supervision. This means the therapist must be available (usually by phone) but not necessarily in the clinic at the same time as the OTA or PTA.

Important: Check your state laws regarding scope of practice because they could be stricter than Medicare, Lee recommends.