How to Bill Medicare for a Therapist Not Yet Credentialed

October 1, 2018
Rick Gawenda

A question I receive often from therapists in private practice is “I just hired a new physical therapist (PT), occupational therapist (OT) and/or speech-language pathologist (SLP) and they are not yet approved as a Medicare provider; can they see Medicare patient’s while waiting to become approved and if yes, how do I bill for their visits?” In this article, I will explain the 2 options private practices have when this situation occurs. Keep in mind that when I say Medicare, this is traditional Medicare Part B and does not include Medicare Advantage plans.

Option #1

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  1. Can you summarize how this would be different for those in pediatrics, contracted with Medicaid and insurances?

    1. I will do a follow up article on non-Medicare patients in the future. Simple answer is you need to look at your contracts and see what it states regarding being credentialed.

  2. If we bill under the supervising therapist wont there be more than 4 1-1 for the hour or do we treat like a PTA where the therapist name/co-signature is adequate to overcome an audit. Eg Therapist A (credentialed) is supervising Therapist B (in process) and they both see 1 patient each. Both charge 4, 1 on 1 timed codes; Therapist A signs his note as himself; Therapist B signs and Therapist A co-signs treatment done by Therapist B but bill is under Therapist A name. is that how it should be done?

    1. Please read Option #2 in how to bill for a therapist not yet credentialed with the Medicare program and follow the CMS guidelines.

  3. Thank you for the clarification of Option #2. If a co-signature was inadvertently left out of a note, but the supervising PT was in the office, readily available at all times, and even giving input as to the patient’s treatment, is it acceptable to do an addendum note or flex note to explain the therapy was supervised and submit the claim?

  4. Can you comment on a coverage PT who is enrolled (I know this is different). Do they need to be resigned to your company for the coverage billing under the covering provider or can we bill them under a TPP?

    1. A PT who is enrolled in the Medicare program would need to complete the 855R to reassign payment to your group.

  5. Just to be clear on option 2:

    Since the supervising TPP (enrolled) is assuming responsibility for the care of any patients under the TPP (not yet enrolled), can the supervising TPP (enrolled) see their own patient as well as supervise the TPP (not yet enrolled) patient and bill for both? Or would that be the equivalent to the supervising TPP (enrolled) seeing 2 patients at the same time on their own schedule?

    Thank You

    1. Yes, they could see another patient at the same time. It’s no different than a PT using a PTA. Keep in mind to contact a healthcare attorney if you have questions or want to use option #2 if you have any concerns about this option.

  6. If a therapist is credentialed with Medicare B (primary) but not with the patient’s secondary plan, such as a BCBS commercial plan. It is ok to bill the overall claim thru a STAFFED physician at the time of service (rather than thru the therapist) so when the secondary portion processes you can get 20% payment from the secondary since the physician is credentialed? Thanks!

    1. If Medicare is primary, the therapist does not need to be credentialed with the secondary in order for the secondary to pay the 20% of the Medicare allowed amount.

      1. Our therapists are not credentialed with commercial plans of BCBS. We have attempted on multiple claims to bill thru the therapist where Medicare B is primary and BCBS is secondary (for example BCBS Federal) & the secondary is denying for OON/non-recognized provider & when we call for followup they say provider is not-par. This has been an on-going issue.

        1. You would need to contact with BCBS has you do not have to be credentialed with them in order for them to pay the 20% of the Medicare allowed amount.

  7. So I have a question – what if you were just made aware of this. And I have a provider who is going through the credentialing process with Medicare. We are holding notes but also we are allowing him to treat patients, and the other TPP who is credentialed with Medicare is signing the notes and billing to Medicare. I’m waiting for him to be credentialed before I release the notes that he treated patients.
    So it’s okay if he completes a IE and Progress notes as well.

  8. Hi Rick, for option 2, has the onsite supervision requirement relaxed due to the PHE? Similar to assistants? Thanks

  9. We hired a PT and a PTA at the same time. The application for the PT has been submitted and we will hold charges as you suggested. Can the PT co-sign for the PTA while we are awaiting approval and then hold those charges also?

    1. Do you have another PT that is already credentialed with Medicare that was supervising the PTA?