One Word, Many Meanings: Defining Medicare's Supervision Levels

Recently, Heidi Jannenga, WebPT’s co-founder and president, co-hosted a webinar about Medicare misconceptions with compliance expert Tom Ambury. Following the webinar, we received quite a few questions regarding Medicare’s supervision requirements for therapy assistants, which we attempted to answer in this section of this FAQ document and this blog post. However, we thought we’d go one step further and provide you with clear-cut definitions of Medicare’s supervision levels—specifically: general supervision, direct supervision, and personal supervision. Here goes:

General Supervision

According to this Advance article and the APTA, under general supervision requirements, the licensed therapist must provide the initial direction of treatment and periodic assessments, but he or she does not need to be onsite during treatment—only reachable by phone.

Direct Supervision

According to the above-cited Advance article, Medicare’s direct supervision requirement dictates that the licensed therapist must be physically onsite (although not necessarily in the treatment room) and readily available to intervene if necessary. In other words, the therapist must be in the office and not otherwise engaged enough that he or she is unable to step in should the assistant—or patient—need help.

Personal Supervision

Per the above-cited APTA resource, the licensed physical therapist must be physically present in the treatment area and immediately available to intervene, direct, or alter the treatment or any other patient-related task for the duration of the service. The APTA also notes that some states allow physical therapy assistants to provide supervision in certain settings. However, Medicare will not cover such services. According to Advance, this level of supervision  (i.e., “line-of-sight” supervision) is only relevant for therapy aide supervision in a skilled nursing facility under Medicare Part A. Please note that “under Part B, aides cannot treat patients in any [setting] and bill their time to Medicare.”

Therapist Responsibility

Now, regardless of which payer you’re billing, what state you live in, or what setting you’re working in, the APTA makes one thing perfectly clear: the therapist “remains responsible for the physical therapy services provided when the physical therapist’s plan of care involves the physical therapist assistant.” To determine the appropriate level of assistant participation with a particular patient, therapists must consider the following:

• “The [assistant’s] education, training, experience, and skill level
• “Patient/client criticality, acuity, stability, and complexity
• “The predictability of the consequences
• “The setting in which the care is being delivered
• “Federal and state statutes
• “Liability and risk management concerns
• “The mission of physical therapy services for the setting
• “The needed frequency of reexamination”

Furthermore, no matter how involved a therapist assistant is in the treatment of a patient, the APTA says the therapist must still:

1. Handle referrals.
2. Perform the initial examination, evaluation, and re-examination (if necessary) as well as determine the diagnosis and prognosis.
3. Develop—and revise when necessary—a plan of care that is based on the results of the initial examination or reexamination and includes treatment goals and outcomes;
4. Determine whether a situation requires his or her “expertise and decision-making capability”—meaning that he or she should perform the treatment—or whether it would be appropriate for a therapy assistant to do so. (If the latter applies, the therapist should determine how best to use the therapy assistant in a manner that ensures a “delivery of service that is safe, effective, and efficient.”)
5. Establish the patient’s discharge plan and complete thorough discharge documentation.
6. Oversee “all documentation for services rendered.”

As a reminder, in outpatient private practice settings, Medicare requires direct supervision of therapy assistants. According to the same CMS document, this is also what’s known as in-the-office-suite supervision. In skilled nursing facilities, comprehensive outpatient rehabilitation facilities (CORP), rehab agencies, and home health agencies, Medicare requires general supervision. While some state practice acts and commercial insurance companies follow Medicare’s lead when it comes to establishing supervision requirements, some do not. Therefore, it’s important to know all the supervision requirements that apply to you, so you can adhere to the strictest one. When in doubt, review your state practice act and contact your local MAC or private insurance representative for clarification.