Medicare (and Other Payer) Rules
Understanding what payers say about aquatic therapy
Looking for more information about aquatic therapy and payers? Here are some quick links.
Justifying aquatic therapy with research
Medicare rules re: rental of facilities
Link to Aetna policy re: approval of aquatic therapy
There is so much misinformation floating (excuse the pun) around about Medicare regulations on use of a community pool.
Your questions sound something like this:
- Is it OK to lease space?
- Does the pool have to be closed to others during that time?
- Why does this rule only apply to the private practice therapist.... and so on.
Typical question from private practice therapist:
We have a Medicare provider number as a physical therapist in private practice. We occasionally see clients at a local pool. We work with the clients one on one and bill the services as aquatic therapy using #11 (the office) as place of service. We pay a fee to the pool to use the pool for our client but the pool is open for public swimming during the treatment time. Is this OK or do we need to exclusively rent the pool?
Response (source Shay Rogers, American Physical Therapy Association, Government Affairs):
It is appropriate to use #11 as the place of service code and bill for those services ONLY if you rent the entire pool and it is used exclusively for PT services while you are there. The following language is included in the CMS regulations and Medicare Manuals:
(EXCERPTED from pg 161 of the following Medicare link: www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf )
Medicare considers a therapist to be in private practice if the therapist maintains office space at his or her own expense and furnishes services only in that space or the patient’s home. Or, if a therapist is employed by another supplier and furnishes services in facilities provided at the expense of that supplier. Private practice does not include individuals when they are working as employees of an institutional Provider.
[Editor's note: The term Providers is used by Medicare to mean Hospitals, SNFs, CORFs and other facilities. It does not mean therapists.]
Services should be furnished in the therapist’s or group’s office or in the patient’s home. The office is defined as 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 the practice at that location. If services are furnished in a private practice office space, that space shall be owned, leased, or rented by the practice and used for the exclusive purpose of operating the practice.
For example, a therapist in private practice may furnish aquatic therapy in a community center pool. As required in other settings (such as rehabilitation agencies and CORFs), the practice would have to rent or lease the pool for those hours, and the use of the pool during that time would have to be restricted to the therapist’s patients, in order to recognize the pool as part of the therapist’s own practice office during those hours.
Therapists in private practice must be approved as meeting certain requirements, but do not execute a formal provider agreement with the Secretary. (Medicare Benefit Policy Manual, Chapter 15, Section 230.4 pg 126 of the link I pasted above).
OK. So we see how it is for therapists working in private practice? What about the therapist who works for a CORF or hospital or other Provider?
What happens when they rent the local pool?
See the answer in the next post entitled "Medicare on Use of Community Pool by a Therapist Working for a Provider."
Medicare on Use of Community Pool by a Provider (Hospital, CORF, SNF, etc.)
OK, above we tackled the issue of pool rental by the private practice therapist.
But what about the therapist who works for a CORF or SNF or other Medicare-recognized Provider. What happens when they want to use the local YMCA pool for Medicare patients?
Do they have to jump through the same hoops as the private practice therapist?
Well, actually, their regulations are even more detailed than those for the private practice therapist. Everything is cited from Medicare for your convenience.
Typical question from hospital/CORF/SNF therapist:
We are a Medicare recognized provider. We occasionally see clients at a local pool. We pay a fee to the pool to use the pool for our client but the pool is open for public swimming during the treatment time. Is this OK or do we need to exclusively rent the pool?
Response (source Medicare; references at end of article):
Medicare understands that a Provider may wish to use a community facility to provide outpatient therapy services.
For example, the OPT/OSP (stands for outpatient PT, OT, SLP) provider may want to use a community pool to provide aquatic therapy. According to Medicare, that is permissible, but certain regulations must be followed.
For instance, the State Agency (SA) must verify that the community pool meets all applicable state laws (i.e., health and safety, infection control requirements, etc.) governing the use of the community facility. Also the SA must review the OPT/OSP’s policies and procedures regarding the type of therapy being provided, training for staff, supervision, etc.
The pool must be closed to public use during the time the OPT/OSP is providing therapy to protect the privacy and safety of the patients being treated. The hours of operation and days of the week during which the facility will be used for therapy services, supervision, etc. must be clearly stated in the OPT/OSP’s policies and procedures as well as the contractual agreement between the community pool and the OPT/OSP.
The SA must verify that the OPT/OSP has a carefully detailed policy regarding specific arrangements for emergency services in the event that a medical emergency were to occur at the community location (i.e., is a telephone in close proximity to the qualified professional providing the service, is there a second person on site? etc.)
The SA must survey the site to determine if the location meets the State’s health and safety standards. The SA should consult with their RO regarding their reasons and decision to accept or deny the community facility. The community facility would not be considered an extension location.
An OPT/OSP provider may also provide services from locations other than its primary site. These locations may be freestanding offices, suites in an office or medical building or, in some cases, space in an existing Medicare/non-Medicare participating provider (SNF or hospital) and are called extension locations.
Normally Medicare will not allow any extension location to provide services that the primary location is not providing. The one exception to this rule is when the "service" provided is aquatic therapy. This is a nod to the fact that many providers do not have access to a pool at their primary location and require an extension office in order to provide these services.
1. Medicare. Revisions to Appendix E : "Providers of Outpatient Physical Therapy or Outpatient Speech Language Pathology (OPT/OSP) Services" . Effective Date: 11-21-05
2. Medicare. 2298A - OPT/OSP Services Provided at More Than One Location. 2298B - OPT/OSP Services at Locations Other than Extension Locations. Effective Date: 11-21-05.