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CMS Guidelines for Co-signing a Physical Therapy Assistant’s Documentation


Physical Therapy Assistant SupervisionA visitor to our web site asked the following question …  “Is it appropriate for the supervising physical therapist to co-sign a physical therapy assistant's (PTA’s) daily physical therapy treatment charges which have been posted when the supervising physical therapist has no physical means of ensuring that such treatment charges were actually done by the PTA?  I am being asked to do this in my current work place.”

Our response is as follows …

The Medicare Benefit Policy Manual is lenient regarding the supervision of a PTA.  See Publication 102, Chapter 15, and Section 230.1 for more details.  It states …

“A physical therapist must supervise PTA’s.  The level and frequency of supervision differs by setting and by state or local law.  General supervision is required for PTA’s in all settings except private practice, which requires direct supervision, unless state practice requirements are more stringent.  In these cases, state or local requirements must be followed.  See specific settings for details.  For example, in clinics, rehabilitation agencies, and public health agencies, 42CFR485.713 indicates that when a PTA provides services, either on or off the organization’s premises, those services are supervised by a qualified physical therapist who makes an onsite supervisory visit at least once every 30 days or more frequently if required by state or local laws or regulation.”

State Practice Acts may be more stringent.  To verify that treatments were actually performed, the supervising physical therapist would have to be within line of sight or have some means of verifying each session’s clock time.  That is not required.  Reviewing supervision requirements in the State in which you practice is the best advice.

Visit these related CarePoint blog posts for additional information on this topic …

Are You In Compliance With CMS Regulations? Resources for Therapy Departments

Therapy EMR Signature Regulations: Compliance Made Easy!

Daily Therapy Notes: Write High Quality EMR’s Fast & Easy

Daily Therapy Notes: Linking Billing Codes to EMR’s Fast & Easy

Therapy EMR: Common SOAP Note Abbreviations & Acronyms

CPT Code Descriptions – Defining Your Therapy Practice


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