The Difference Between State License Laws and Medicare Billings for Physical Therapy Assistants

You are urged to read 42CFR section 410.26(b)(1)-(7) and CMS Medicare Benefit Policy

Manual Pub 100-4 ch 15,sec 60.1-69.5.

Please remember the incident to provisions of the HCFA CMS 1500 Claims Forms.

Remember that when billing for services under a physical therapy license and NPI in box 31 of the 1500 form you certify:

1. That the items and services are medically necessary and reasonable;

2. The CPT codes used are accurate and documented in your clinical records;

3. That you provided the services or the non licensed PTA provided the items and services under your direct onsite supervision.

Remember, how many patients PT can supervise in one setting depends upon state not federal


Practice tip: I remember years ago that a Miami Teaching Hospital once had one board certified

anesthesiologist supervise eight surgeries. CMS determined no one physician could supervise

all those services and it recouped money going back four years from that hospital. Apply the

analogy to your PT practice and err on the side of caution.


The answer to al, RAC audits, ZONE audits or FI audits is quality of documentation.

Be it Web-PT of any other reputable clinical recorder program nothing beats personalized

individualized PT progress or initial evaluation notes that do not read all the same.

Be AWARE of 97002 CPT codes audits for Re-evaluations; too many cause audits.

In this writer's opinion, CMS never fully funded for the Jimmo settlement agreement and how

much money that costs the program nationwide, even using the G and G-59 and KX modifier.