Regulatory Requirements - Physical Therapist in Private Practice

In order to qualify under Medicare as a supplier of outpatient physical therapy services, each individual physical therapist in private practice must meet the following requirements:

1. Be legally authorized (if applicable, licensed, certified, or registered) to engage in the private practice of physical therapy by the state in which he or she practices, and practice only within the scope of his or her license, certification, or registration.

2. Engage in the private practice of physical therapy on a regular basis as an individual in one of the following practice types:

• A solo practice;
• A partnership;
• A group practice; or
• As an employee of any of the above

3. Bill Medicare only for services furnished in his or her private practice office space, or in the patient's home. A therapist's private practice office space refers to the location(s) where the practice is operated, in the state(s) where the therapist (and practice, if applicable) is legally authorized to furnish services during the hours that the therapist engages in practice at that location. When services are furnished in private practice office space, such space must be owned, leased, or rented by the practice and used for the exclusive purpose of operating the practice. A patient's home does not include any institution that is a hospital, a CAH, or a SNF.

4. Treat individuals who are patients of the practice and for whom the practice collects fees for the services furnished.

Definition of a Qualified Therapist

Effective January 1, 2010

A qualified physical therapist is a person who:

• Is licensed, if applicable, by the state in which he or she is practicing (unless licensure does not apply);
• Has graduated from an accredited physical therapist education program; and
• Passed an examination approved by the state in which physical therapy services are provided.

The phrase “by the state in which practicing” includes any authorization to practice provided by the same state in which the service is provided, including temporary licensure, regardless of the location of the entity billing the services.

The curriculum accreditation is provided by the Commission on Accreditation in Physical Therapy Education (CAPTE) or, for those who graduated before CAPTE, curriculum approval was provided by the American Physical Therapy Association (APTA).

For internationally educated physical therapists, curricula are approved by a credentials evaluation organization either approved by the APTA or the credentials evaluation provided by the Federation of State Boards of Physical Therapy (FSBPT) and the Foreign Credentialing Commission on Physical Therapy (FCCPT).

License was obtained on or prior to December 31, 2009

A physical therapist whose current license was obtained on or prior to December 31, 2009 qualifies to provide physical therapy services to Medicare beneficiaries if he or she:

Graduated from a CAPTE approved program in physical therapy on or before December 31, 2009 (examination is not required); or

Meets both of the following:

• Graduated on or before December 31, 2009 from a physical therapy program outside the U.S. that is determined to be substantially equivalent to a U.S. program by a credentialed evaluation organization approved by the APTA or identified in 8 CFR § 212.15(e).
• Passed an examination for physical therapists approved by the state in which he or she is practicing.

A physical therapist whose current license was obtained before January 1, 2008, may meet the requirements in place on that date (i.e., graduation from a curriculum approved by either the APTA, the American Medical Association, or both)

A physical therapist meets the requirements if he or she

• Is currently licensed as a physical therapist,
• Was licensed or qualified as a physical therapist on or before December 31, 1977,
• Had 2 years of appropriate experience as a physical therapist, and
• Passed a proficiency examination conducted, approved, or sponsored by the U.S. Public Health Service.

A physical therapist meets the requirements if he or she is currently licensed and before January 1, 1966, he or she was:

• Admitted to membership by the APTA; or
• Admitted to registration by the American Registry of Physical Therapists; or
• Graduated from a 4-year physical therapist curriculum approved by a state Department of Education;

If licensed or registered and prior to January 1, 1970, he/she had 15 years of full-time experience in physical therapy under the order and direction of attending and referring doctors of medicine or osteopathy.

Physical Therapist Trained Outside the United States

A physical therapist meets the requirements if he or she:

• Is currently licensed;
• Was trained outside the U.S. before January 1, 2008;
• After 1928 graduated from a physical therapy curriculum approved in the country in which the curriculum was located and that country had an organization that was a member of the World Confederation for Physical Therapy; and
• He/she qualified as a member of that organization.

Reference

Medicare Program Integrity Manual

Chapter 10 – Medicare Enrollment 10.2.3.10