With the upcoming payment changes for PTAs and OTAs, we’ve received a lot of questions regarding supervision requirements for therapy assistants in the outpatient setting. So, we thought our readers would benefit from some examples of common, real-world scenarios the type of supervision each one requires.

Disclaimer: We are not your attorneys, and we do not know all the details of every state practice act, requirements for every commercial payer, or rules that apply to your specific clinic setting. 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 federal payer requirements. Thus, we strongly recommend that you review your state supervision requirements and payer contracts as well as seek the help of a qualified attorney if you have lingering questions.

With that, let’s get to it:

Scenario #1: An occupational therapy assistant is licensed in the state of New York and works in an outpatient private practice, and an occupational therapist asks him or her to assist with an evaluation of a Medicare Part B patient.

According to the New York Occupational Therapy Practice Act, licensed occupational therapy assistants “provide occupational therapy and client-related services under the direction and supervision of an occupational therapist.” More specifically, New York law authorizes OTAs to contribute to patient evaluations by assisting with assessments and gathering data under the  supervision of the OT. However, because Medicare is the payer, Medicare rules will also apply here. And because Medicare does not reimburse occupational therapy assistants for evaluative or assessment services, this trumps New York state law. So, in this scenario, the OT risks denial of payment and possible allegations of fraud if the OTA contributes to the evaluation. 

Scenario #2: A physical therapist assistant is licensed in the state of New York and works in an outpatient private practice, and a physical therapist asks him or her to assist with an evaluation of a Medicare Part B patient.

Now, let’s take a look at the same scenario, only this time it’s a patient being seen under a physical therapy plan of care. According to the New York state practice act, “Duties of physical therapist assistants shall not include evaluation, testing, interpretation, planning or modification of patient programs.” As such, the PT cannot instruct the PTA to perform an evaluation on the patient. Furthermore, just as with evaluations performed by an occupational therapy assistant, Medicare will not reimburse an evaluation that a PTA completes. 

For more details about Medicare’s rules for PTAs and OTAs, check out Chapter 15 of the Medicare Benefits Policy Manual, Section 230.2

Scenario #3: An occupational therapist evaluates a Medicare Part B patient and develops a plan of care, and the occupational therapist assistant conducts subsequent treatment. 

Now, consider the second scenario, except in this case, the therapist has evaluated the patient and determined the plan of care, and the therapist assistant carries out treatment during subsequent appointments. New York’s law does not specify the level of supervision an occupational therapist assistant must be under while carrying out these services, but the OT must implement the appropriate level of supervision based on the competency and experience of the OTA—as well as the complexity of the patient’s condition. That said, in private practice settings, Medicare requires direct supervision of an assistant by a licensed therapist “unless state practice requirements are more stringent.” As WebPT’s Erica McDermott explains in this blog post, “direct supervision means that the supervising therapist is physically present in the office—but not necessarily in the same room—and available to intervene if necessary at the time the assistant performs the services.” So, in this scenario, the physical therapist or occupational therapist would have to directly supervise the OTA during the Medicare patient’s care.

Scenario #4: A physical therapist evaluates a Medicare Part B patient and develops a plan of care, and the physical therapist assistant conducts subsequent treatment. 

Unlike their occupational therapy counterparts, PTAs are required to be under a specific degree of supervision while carrying out treatment modalities per the New York state practice act: “Supervision of a physical therapist assistant by a licensed physical therapist shall be on-site supervision, but not necessarily direct personal supervision.” In other words, a licensed physical therapist must be in the same building while the PTA treats the patient. However, he or she does not need to be in the same room as the assistant.

This actually aligns with Medicare’s physical therapist assistant supervision rules as well. Just as with OTAs, Medicare requires PTAs to be under the direct supervision of a physical therapist during treatment. This simply means a PT must by on-site—but not necessarily in the same room—while a PTA conducts treatment.

What if the assistant is treating a Medicare beneficiary in a different setting?

Now, if the patient is receiving therapy treatment in a different practice setting, the rules may change. Medicare’s direct supervision requirement only applies to the outpatient private practice setting—so if, for example, the above scenarios occurred in an assisted living or skilled nursing setting, the PTA or OTA would only need to be under the general supervision of a PT or OT. As we state in the aforementioned blog post, “General supervision 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.”

For OTAs, just as with the outpatient setting, New York law does not specify the level of supervision required for an occupational therapy assistant in an assisted living or home health setting. However, the law requires the assistant to provide services under the direction of a licensed therapist, which includes consultation with the OT. Furthermore, the OT must implement the appropriate level of supervision based on the competency and experience of the OTA—as well as the complexity of the patient’s condition. The therapist can supervise the assistant by being available by phone, meeting with the assistant regularly to discuss patient goals and progress, and reviewing the assistant’s documentation.

Scenario #5: An OTA completes a progress report on a Medicare Part B patient on the 10th visit.

Now, let’s look at the second scenario again, but in this case, the therapist asks the assistant to assess the patient’s progress and administer treatment on the patient’s 10th visit. New York law authorizes an OTA to participate in progress updates as these are considered regular treatment notes. So, if the patient was a non-Medicare patient, an OTA could complete the progress report. Remember, though: CMS rules always trump state rules. CMS defines a progress report as something that is written on or by every 10th visit regardless of the reason for the visit, and while the CMS benefit policy manual allows assistants to contribute information to these reports, they cannot execute progress reports on their own.

So, in the outpatient private practice setting or assisted living setting, the assistant can participate in the progress note by observing the patient as he or she performs the tasks associated with his or her therapy goals, but the therapist must be the one who assesses whether or not the patient met those goals. (This includes any clinical observation or objective tests and measurements.)

Scenario #6: A PTA completes a progress report on a Medicare Part B patient on the 10th visit.

Similar to the OTA scenario, the New York state practice act allows PTAs to complete progress reports, and therefore, a PTA could complete a progress report on a non-Medicare patient. However, if the patient is a Medicare Part B patient, the PTA may not complete a progress report. That said, a PTA can document certain elements of a progress report.

What parts of the documentation can an assistant complete?

Medicare progress notes typically summarize treatment sessions up to the date of the progress note, and the PTA or OTA can help document the patient’s response to education and progress with certain skills. The assistant can also document 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.

Can an assistant discharge the patient?

The same supervision requirements that apply to progress reports also apply to the discharge phase of treatment. This is because a discharge note essentially functions the same as a progress report: it summarizes the patient’s care up to that point and includes assessment and documentation of the patient’s progress toward—or completion of—his or her goals. Under the direct supervision of the therapist, the assistant can review any home programs and provide the patient with adaptive equipment and/or durable medical equipment (DME) recommendations. The assistant can also suggest home modifications and the level of family assistance needed for certain activities of daily living as well as provide recommendations for continued therapy. But because this is essentially a progress report, the PT or OT should step in to assess progress toward goals and record objective measurements. Both the therapist and the assistant can document the summary of the intervention in the discharge note.

Final Considerations

If you’re ever unsure about whether a PTA or OTA can perform duties during treatment, here are a few things to consider:

  • The jurisdiction comes first. You must always follow the rules of your state practice act—even if the insurance payer has less stringent rules. While we used New York state as the example in these scenarios, there is a ton of variation among state practice acts, so it’s important you know what your state says about the responsibilities of PTAs and OTAs. 
  • CMS’s supervision rules vary between settings. In our scenarios above, the assistant works in an outpatient private practice. However, the rules for supervision change from setting to setting.
  • PTAs and OTAs can never create, update, or modify a plan of care. Establishing a plan of care is entirely up to the therapist. However, assistants can participate in an evaluation, re-evaluation, or progress update by collecting data (e.g., taking vital signs) and/or supervising patient treatment—as long as it is initially determined by the PT (e.g., the assistant can review a home exercise program). But again, the level of data collection allowed is contingent upon the state practice act.
  • Assistants can advance treatment within the established plan of care. Assuming the PT or OT outlined the advancement of treatment within the established plan of care, the assistant may progress treatment as necessary. For example, let’s say a patient who underwent knee replacement surgery has a goal to walk with a cane, but he or she starts with a walker. Assuming the therapist performs regular status checks over the course of the episode, an assistant could work from walker to crutches to cane.

So, there you have it: six PTA and OTA supervision scenarios. If you have any questions regarding supervision—or you’d like to provide a scenario of your own—let us know in the comment section below!