Aide and assistant rules demystified

When it comes to reimbursement, the answers are never as easy as yes and no.

Not only should you check Medicare requirements regarding the use of assistants and aides, but also any state and other payer-specific regulations.

Begin with the payer, says Rick Gawenda, PT, director of rehab services for the Detroit Receiving Hospital. "Start with the insurance company and find out whether it reimburses for services performed with an aide under the supervision of a therapist," says Gawenda. "Then go to your state practice act to see whether [those services] are allowable."

In other words, if Medicare or another insurance carrier reimburses for a specific service performed by an aide but your state prohibits it, don't perform it and don't bill for it.

A general rule of thumb is that you must follow the regulation that is most restrictive, be it a payer policy, practice act, or state law.

According to Medicare, assistants can follow a patient's plan of care established by a therapist without needing that therapist in the room to oversee their work. But also remember to check your state practice acts and laws to determine under what type of supervision an assistant can perform these services.

"In Arizona, there are much stricter supervision [regulations] than in Texas," says Melissa Ortiz Cannata, OT, therapy consultant for Ensign Group in Mission Viejo, CA. "You have to be very knowledgeable about the payer and also aware of your own state practice act."

In skilled nursing facilities, hospital outpatient facilities, and certified outpatient rehab facilities, the therapist does not have to be physically present for the assistant to perform services included in the plan of care.

However, in a recent final rule released by CMS, Medicare treats assistants in private practice rehab facilities differently.

Previously in a private practice, the therapist had to be in the room with the assistant. The rule changed the requirement from "personal" supervision to "direct" supervision, meaning that therapist assistant can perform the services if the therapist is "on the premises." So now the therapist must be somewhere in the facility, but does not have to be present during the patient's care.

Although the rule loosened the requirements for therapist supervision, it still requires therapists to be available to respond to assistants' needs within a reasonable amount of time.

Some practice acts also require that the actual therapist see the patient periodically.

"[Therapist assistants] can't change or stray from the plan of care, and they should be continually talking with the therapist," says Gawenda. "Some practice acts say that the therapist must see the patient every certain number of treatments."

For aides, the supervision requirement is a bit easier. Under Medicare Part B, aides cannot perform any rehab services with or without the supervision of a therapist. They can perform some of the components needed to deliver services, says Gawenda, and those tasks that don't require clinical decision-making or clinical problem solving.

As mentioned earlier, therapist assistants can perform tasks associated with a patient's plan of care, and a facility can bill Medicare for those services. Exceptions are evaluations and reevaluations.

For example, the following codes are not reimbursable if performed by an assistant:

"Therapists can bill for [services] besides evaluations and reevaluations, [but] there are also additional assessments they shouldn't bill for," says Gawenda. However, services performed by an assistant in general "are billable as long as they are within the assistant's scope of practice, education, and training."

Services performed by a rehab aide are not reimbursable under Medicare.

"The Texas state practice act says that therapists and therapist assistants can supervise aides who provide services-they just can't bill for those services," says Ortiz Cannata.

However, services might be reimbursable by a third-party payer in some states.

For example, in Michigan, Medicare doesn't reimburse services performed by an aide but BlueCross BlueShield does, provided the therapist signs the note, says Gawenda. "We don't have anything in our state practice act saying that aides can't perform the services."

Medicare supervision requirements for PT assistants

CMS regulations regarding the use of assistants vary based on practice setting. Here is a list of the most common situations:

Skilled nursing facility-PT assistants (PTAs) may provide rehab services under the general supervision of a therapist. The supervisor doesn't need to be physically present or on the premises while the PTA provides treatment, but he or she should be available to give initial direction and periodic inspection of the activities the PTA performs.

Certified rehabilitation agency-A PT must provide initial direction and periodic observation of the PTA's performance. If that assistant doesn't meet assistant-level practitioner qualifications, then the PT must be on the premises during treatments.

Comprehensive outpatient rehabilitation facility-A PT, available on the premises, must supervise any services provided by an assistant. He or she should be able to instruct the assistant in ap-propriate patient care and techniques and retain responsibility for the assistant's actions.

Home health agency-A PTA can perform therapy services under the general supervision of a skilled therapist. The supervisor doesn't need to be physically present when the assistant performs services but should be available for initial direction and periodic observation of the treatment.

Private practice-Effective January 1, PT services must be provided under the direct supervision of the PT in private practice. CMS defines this supervision as being physically available within the office suite when the PTA provides services to a patient.

Outpatient hospital facilities-CMS regulations do not specify the type of supervision required for PTAs in this setting, so therapists should consult their state practice acts for additional guidance. However, services can be provided by a PTA if they are safely and effectively performed under the supervision of a qualified PT.