Recently, we’ve received a whole lot of questions about what physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) can and cannot do in practice—likely because many practice owners are re-evaluating staff roles and clinic operations in preparation of the upcoming reimbursement reductions for assistant-provided services, which will affect payments from Medicare and some other commercial payers in 2022. (Keep in mind, though, that providers need to begin affixing specific modifiers to applicable assistant-provided services on January 1, 2020). For an example of how to streamline your operations to soften the blow of this cut, check out this EIM post by WebPT Co-Founder and Chief Clinical Officer Heidi Jannenga. For answers to your most pressing questions about what PTAs and OTAs can and cannot do in practice, read on.
But first, a quick disclaimer: The information in this blog post is for educational and informational purposes only. The delivery of physical therapy and occupational therapy is governed by state law and payer requirements. Thus, we strongly recommend that you review your state practice act and payer contracts as well as seek the help of a qualified attorney before establishing practice policies. This should in no way be construed as legal advice.
Can PTAs and OTAs complete progress notes?
Not for Medicare beneficiaries. According to Rick Gawenda here, CMS does not allow assistants to complete full progress notes. Instead, licensed clinicians (i.e., PTs or OTs) must write progress notes themselves. That said, as long as it is within their scope of practice in accordance with their state practice act, assistants are permitted to collect and provide documentation that supports the progress note, including, as WebPT’s Kylie McKee writes here, “the patient’s response to education and progress with certain skills,” as well as “the services provided as part of the intervention plan—including any home programs or adaptive equipment recommendations and the patient’s subjective comments about the services.” To be clear, all assessment as to whether or not a patient has met his or her goals—including “any clinical observation or objective tests and measures”—is the sole responsibility of the licensed therapist.
While many payers adhere to Medicare’s guidelines, some have their own rules, so it’s best to review your individual contracts as well as your state practice act. You’ll always want to adhere to whichever requirement is most stringent.
To learn whether or not an assistant can discharge a patient, check out McKee’s post in full.
Can PTAs and OTAs assist with initial evaluations?
For Medicare beneficiaries, the answer is yes—but only if the assistant follows the lead of the PT or OT and does not exercise any clinical judgement. As McKee explains, “Medicare does not reimburse OTAs [or PTAs] for evaluative or assessment services since they require clinical judgements rendered by an OT [or PT].” So, if it is not clear that the OTA or PTA is only assisting within the limits of Medicare’s guidelines and his or her state practice act, “the OT [or PT] risks payment denials and possible fraud allegations.” For non-Medicare beneficiaries, you’ll want to review your payer rules and state practice act. For example, “New York law authorizes OTAs to contribute to patient evaluations by assisting with assessments and gathering data under the supervision of the OT”; however, New York PTAs are not allowed to perform or assist with evaluations. If there’s ever a discrepancy between your state practice act and the payer rules, adhere to the strictest one.
Can PTAs and OTAs create, update, or modify a plan of care?
Not under any circumstances. The licensed therapist must be the one to create, update, or modify a patient’s plan of care.
Can PTAs and OTAs provide ongoing treatment to patients when the supervising PT is home sick?
That depends. All PTA-and OTA-provided services must be supervised by a licensed PT or OT, respectively, but to what degree depends on the “competency and experience of the [assistant]—as well as the complexity of the patient’s condition.” Beyond that, you’ll also need to factor in the guidelines outlined in your state practice act, if any, as well as your payer’s rules for your office setting.
In private practice settings, Medicare requires, at a minimum, direct supervision of an assistant by a licensed therapist. That means the supervising PT or OT must be physically present in the office (albeit not necessarily in the same room) and available to intervene if necessary while the assistant is performing the services. In other words, assistants may not treat Medicare beneficiaries without a licensed therapist on site and available. That said, Medicare does not specify that the supervising therapist needs to be the same therapist who created the plan of care—only that he or she is familiar enough with the plan of care and the patient to properly support or provide guidance if needed.
In skilled nursing or assisted living settings, Medicare only requires general supervision of an assistant by a licensed therapist, which means “that the supervisor must provide initial direction and periodic inspection of the activity, but he or she does not necessarily need to be on the premises during every treatment.” That said, if there’s any reason to think that a patient or an assistant requires more supervision than the minimum, it is the licensed therapist’s obligation to provide it.
If you’re an APTA member, you can access a PTA direction and supervision algorithm here.
Can PTAs or OTAs be supervised by another type of provider—say, a chiropractor or physician?
Nope. In all situations that we’re aware of, licensed physical therapists and occupational therapists are the only providers who are able to supervise physical therapist assistants and occupational therapy assistants, respectively. Neither chiropractors nor physicians may supervise therapy assistants.
Can a PTA or OTA diagnose a patient?
No. According to the APTA, “physical therapists’ practice responsibility includes all elements of patient and client management.” As such, “The entirety of evaluation, diagnosis, and prognosis, as well as components of examination, intervention, and outcomes, must be performed by the physical therapist exclusively due to the requirement for immediate and continuous examination, evaluation, or synthesis of information.” The same goes for OTs.
Can a PTA or OTA tweak treatments during a session?
Yes; as the APTA explains here, “although PTAs cannot make changes to the overall plan of care, they are trained to make treatment adjustments to accommodate a patient during a session.” The same holds true for OTAs.
Can a PTA provide joint mobilizations?
According to the above-mentioned APTA article, “PTAs provide many of the treatments that a PT provides—passive range of motion, electrotherapeutic modalities, mechanical modalities, gait training, functional training, transfer training, wound dressing, airway clearance techniques, and therapeutic exercise for strength, flexibility, and balance.” That said, “PTAs cannot perform selective sharp debridement in wound care management.” Furthermore, “depending on state practice acts, PTAs may or may not be able to perform joint mobilizations. Some states do allow PTAs to provide grade V high velocity low-amplitude thrust techniques.” However, even if a PTA or OTA can perform a service under state laws, it doesn’t necessarily mean that an insurance company will pay for the service. That’s why it’s always best to cross-reference your state practice act with your payer contracts. For the APTA’s list of PT-only services, check out this document.
Can a PTA or OTA be held accountable for HIPAA violations?
Yes; all HIPAA-covered healthcare providers, including therapy assistants, are responsible for properly handling patients’ protected health information—and could face legal repercussions for failing to do so.
Have a lingering PTA or OTA question? Leave it for us in the comment section below, and we’ll do our best to find you an answer.