Rehab

A primer on the use of aides, assistants in outpatient settings

Rehab Regs, July 9, 2003

A primer on the use of aides, assistants in outpatient settings

There's a good chance that assistants and aides serve as a valuable resource in day-to-day treatment of patients at your facility-whether you're the owner of a successful rehabilitation practice or a PT or OT employed in an outpatient setting.

While aides may perform such tasks as escorting patients to treatments and assistants often deliver the treatments under various levels of supervision, a nagging question may recur: Is the work they perform reimbursable?

The question remains multifaceted, with any complete answer falling under an umbrella of state and federal regulations, as well as rules set by various commercial payers, industry experts say. When it comes to the services of aides and assistants-and reimbursement for their responsibilities-you must remember the following:

 Differentiate between the two positions. In most practices, PT and OT aides provide support services critical to the successful delivery of therapy, says Angie Phillips, PT, president and chief executive officer of Images Inc., a health care consulting company based in Amarillo, TX. For example, aides may clean a treatment room after the delivery of services, escort patients to treatments, or provide as an extra "safety factor" during a treatment session.

Although the regulations differ by state, PT or OT assistants generally hold a two-year associate's degree and have benefited from some education and training. Many states require people to meet licensing or training standards in order to qualify as a PT or OT assistants, Phillips says.

"Obviously, the assistant has a much higher level of skill and training than the aide," she says. When providing care for Medicare patients, federal regulations create further restrictions on supervision for PT assistants in certain practice settings, Phillips says.

"Based on the specifics of the state practice act, the assistant can perform care and treatment, which has been outlined by the therapist, based on an initial assessment," she says. "The assistant can't do evaluations, assessments, or modify care plans without the collaboration of the therapists." Medicare, however, specifies levels of supervision based on the practice setting. Medicare requirements for supervision are more restrictive for the therapist in private practice.


 Look to state and federal regulations. When it comes to reimbursement issues, there's a host of federal and state regulations-as well as industry best practice standards-that you should keep in mind:

State practice acts. The scope and responsibilities of PTs and OTs, as well as aides and assistants, vary for each state, dependent upon the practice act that regulates duties and responsibilities, experts say. It's critical that you remain compliant with these regulations-before you even tackle whether you'll receive reimbursement for services delivered.

"Some states license PTs and assistants, or register them," Phillips says. "Some license or register one and not the other. Within each state's practice acts, there are guidelines for what a PT or OT [assistant or aide] can or can't do. This is a separate issue from the question of what you will receive payment for."

When studying the practice acts, it's just as important to pay attention to any omissions in language.

"Some state practice acts specifically state that physical therapy can only be provided by the PT and the PT assistant-and not PT aides," Rick Gawenda, PT, director of rehab services for the Detroit Receiving Hospital in Detroit.

"In Michigan, however, [the state practice act] does not mention PT aides and does not define requirements for a PT assistant-it's silent on the subject of responsibilities. So it does not prohibit them [from delivering therapy]."

Medicare regulations. While your first step must center on compliance with practice acts, it's only one piece of the puzzle. When it comes time to treat Medicare patients, specific federal criteria and guidelines limits determine what aides and assistants can-and can't-do.

"Medicare does not recognize PT aides, so providers can not bill for services PT aides provide to Medicare beneficiaries," Gawenda says.

"From a Medicare standpoint, aides can't deliver services, but they can perform some of the components [needed to deliver service], such as getting the patient ready for the therapist or setting up the ultrasound booth. Basically, they can perform those tasks that don't require clinical decision-making or clinical problem solving."

Commercial payers. Further complicating matters, commercial payers insuring your patients may have varying rules and regulations when it comes to reimbursable services delivered by aides and assistants. For example, some payers may not reimburse for services delivered by an assistant, Phillips says.

"[Practices] really need to function under a multitude of policies-it's an umbrella of regulations," Phillips says. "You need to be in legal accordance with your state's practice act. If you treat Medicare patients, you agree to follow Medicare policies. And then each commercial payer may have its own policy, and some are likely more restrictive than others."

And it's critical that you differentiate between payer policies and the general scope of the practice act, she adds.

"It's important for the provider to review payer policies prior to delivering care," Phillips says.

"You need to focus on the state law that [dictates] what PTs and OTs can do legally. That's going to affect your ability to keep your license. And then there are the payer issues. You can do everything that the practice act allows, but you might not get reimbursement because of a payer policy that states, 'We don't give payment if [the service] is provided by a certain individual.' "

Industry standards. Finally, the OT and PT industry organizations have also developed best practice standards and positions that will serve as further guidance to members of the respective organizations, and it's wise to familiarize yourself with them, Gawenda says.

For example, the American Physical Therapy Association's (APTA's) position recommends that PT or PT assistants directly supervise aides, and that aides do not provide PT treatment, Gawenda says.

"There are-of course-states that do not prohibit this," he says. "But the APTA position says-no matter the state law or insurance-aides should not provide services that you would be billing for."

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