Physical Therapist in Private Practice

Affected Providers

Physical therapists in private practice (PTPPs) who bill Medicare Part B directly for services they provide.

To qualify to bill Medicare directly as a PTPP, you must be enrolled as a private practitioner and employed in 1 of these practice types:

• Unincorporated solo practice
• Unincorporated partnership
• Unincorporated group practice
• Physician or non-physician practitioner (NPP) group or groups that aren’t professional corporations, if allowed by state and local law

Physician or NPP group practices may use a PTPP if state and local laws allow this employee relationship.

Background

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the improper payment rate for PTPPs who bill Part B is 15.8%, with a projected improper payment amount of $659.2 million.

A physical therapist must provide physical therapy services within physical therapists’ scope of practice and necessary for diagnosing and treating patient impairments, functional limitations, disabilities, or changes in physical function and health status.

Denial Reasons

Insufficient documentation accounted for 88.6% of improper payments for PTPP during the 2024 reporting period, while no documentation (8.3%), incorrect coding (1.5%), and other errors (1.6%) also caused improper payments. “Other” errors include duplicate payment, non-covered or unallowable service, or ineligible Medicare patient errors.

Preventing Denials

To prevent denials, follow these documentation requirements:

• Evaluation, including:
  • Initial evaluation
  • Re-evaluations (if applicable)
• Plan of care
• Certification (physician or NPP approval of the plan) and recertifications
• Progress reports (including discharge notes, if applicable)
• Treatment notes for each treatment day (may be progress reports when you include required information)

Document Information to Meet Requirements

• The patient is under the care of a physician or NPP and they’ve certified (approved) the plan of care documents. Although not required, other evidence of physician or NPP involvement in the patient’s care may include:
  • Order or referral
  • Conference
  • Team meeting notes
  • Correspondence
• The qualified provider must provide the services and these services require the ability, knowledge, clinical judgment, and decision making of a physical therapist, which assistants, qualified personnel, caretakers, or the patient can’t provide independently.
• The services are the right type, frequency, intensity, and duration for the patient’s needs. Documentation should show:
  • The variables that influence the patient’s condition, especially the factors that influence the clinician’s decision to provide more services than are typical of the patient’s condition
  • The patient is making progress toward goals, using objective measurements