Outpatient Physical Therapy/Outpatient Speech Pathology

10.2.1.11 - Outpatient Physical Therapy/Outpatient Speech Pathology Services (OPT/OSP) (Rev.: 12796; Issued: 08-15-24; Effective: 09-16-24; Implementation: 09-16-24) A. General Background Information Physical therapists and speech pathologists provide therapy targeting a person’s ability to move and perform functional activities in their daily lives typically inhibited by illness or injury. Care is typically coordinated by therapists in conjunction with a physician and is based on an agreed upon plan of care. As explained in Pub. 100-07, chapter 2 section 2292, there are three types of organizations that may qualify as providers of OPT and OSP services under 42 CFR Part 485, Subpart H: clinics, public health clinics, and rehabilitation agencies. However, rehabilitation agencies are the only organizations that are currently enrolled as a Medicare provider with a CCN. The primary purpose of a rehabilitation agency is to improve or rehabilitate an injury or disability and to tailor a rehabilitation program to meet the specific rehabilitation needs of each patient referred to the agency. A rehabilitation agency must provide, at a minimum, physical therapy and/or speech language pathology services to address those needs of the patients. Social/vocational services are no longer a requirement. Note that: • If an OPT/OSP provider elects to convert to a CORF, it must meet the CORF conditions of coverage and participation. An initial Form CMS-855A enrollment application, state survey, and CMS program approval are also required. • Only those OTP/OSP providers covered under 42 CFR Part 485, Subpart H that furnish OPT/OSP services (as listed above) have provider agreements under 42 CFR § 489.2. Part B physician groups – the supplier type that most people normally associate with the term “clinics” – do not have certified provider or certified supplier agreements. • Occupational therapy cannot be substituted for the physical therapy requirement. It may, however, be provided in addition to physical therapy or speech pathology services. (See Pub. 100-07, chapter 2, section 2292A.) There is no prohibition against an organization operating on the premises of a supplier (e.g., physician or chiropractor) or another provider if they are not operating in the same space at the same time. (See Pub. 100-07, chapter 2, section 2304.) B. Processing Instructions for OPT/OSP Initial Form CMS-855A Applications 1. Receipt of Application Upon receipt of an OPT/OSP initial Form CMS-855A application, the contractor shall undertake the following (in whichever order the contractor prefers unless directed otherwise in this chapter): (A) Perform all data validations otherwise required per this chapter. (B) Ensure that the application(s) is complete consistent with the instructions in this chapter. (C) Ensure that the OPT/OSP has submitted all documentation otherwise required per this chapter. For OPT/OSP initial enrollment, this also includes the following: • Form CMS-1561 (Health Insurance Benefit Agreement, also known as a “provider agreement”) • Evidence of successful electronic submission of the Form HHS-690 through the Office of Civil Rights (OCR) portal, as applicable. (Evidence should be either written or electronic documentation.) (See https://www.hhs.gov/sites/default/files/forms/hhs-690.pdf for more information.) (The OPT/OSP must complete, sign, date, and include the Form CMS-1561, though the OPT/OSP need not complete those sections of the form reserved for CMS. For organizational OPT/OSPs, an authorized official (as defined in § 424.502) must sign the form; for sole proprietorships, the sole proprietor must sign.) Notwithstanding the foregoing, if the Form CMS-1561 or the Form HHS-690 evidence is missing, unsigned, undated, or otherwise incomplete, the contractor need not develop for the form(s) or the information thereon; the contractor shall instead notify the state in its recommendation letter which document(s) was/were missing or otherwise incomplete. For all other missing or incomplete required documentation, the contractor shall follow the normal development instructions in this chapter. 2. Conclusion of Initial Contractor Review (Nothing in this section 10.2.1.11(B) prohibits the contractor from returning or rejecting the OPT/OSP application if otherwise permitted to do so per this chapter. When returning or rejecting the application, the contractor shall follow this chapter’s procedures for doing so.) (A) Approval Recommendation If, consistent with the instructions in section 10.2.1.11(B) and this chapter, the contractor believes an approval recommendation is warranted, the contractor shall send the recommendation to the state pursuant to existing practice and this chapter’s instructions. The contractor need not copy the SOG Location or PEOG on the recommendation. Unless CMS directs otherwise, the contractor shall also send to the provider the notification letter in section 10.7.5.1(E) of this chapter. The state will: (1) review the recommendation package for completeness; (2) review the contractor’s recommendation for approval; (3) perform any state-specific functions; and (4) contact the contractor with any questions. The contractor shall respond to any state inquiry in Item (4) within 5 business days. If the inquiry involves the need for the contractor to obtain additional data, documentation, or clarification from the OPT/OSP, however, the timeframe is 15 business days; if the provider fails to respond to the contractor within this timeframe, it shall notify the state thereof. The contractor may always contact its PEOG BFL should it need the latter’s assistance with a particular state inquiry. (B) Denial If the contractor determines that a denial is warranted, it shall follow the denial procedures outlined in this chapter. This includes: (1) using the appropriate denial letter format in section 10.7.8 of this chapter; and (2) if required under section 10.6.6 (or another CMS directive) of this chapter, referring the matter to PEOG for review prior to denying the application. 3. Completion of State Review The state will notify the contractor once it has completed its review. There are two potential outcomes: (A) Approval Not Recommended If the state does not recommend approval, it will notify the contractor thereof. (The contractor may accept any notification that is in writing (e-mail is fine).) No later than 5 business days after receiving this notification the contractor shall commence the actions described in section 10.2.1.11(B)(2)(B) above. (B) Approval Recommended If the state recommends approval, it will typically (though not always) do so via a Form CMS- 1539; the contractor may accept any documentation from the state signifying that the latter recommends approval. (Note that the contractor will not receive a formal tie-in notice.) No later than 5 business days after receipt of the recommendation from the state, the contractor shall send an e-mail to MedicareProviderEnrollment@cms.hhs.gov with the following information and documents: • The Form CMS-855 application (or PECOS Application Data Report) and all application attachments • A copy of the Form CMS-1539 or similar documentation received from the state • A copy of the provider-signed Form CMS-1561 • A copy of the draft approval letter, with the effective date shown on the Form CMS-1539 (or similar documentation) included in the draft letter. (See section 10.7.5.1 for the model approval letter.) PEOG will countersign the provider agreement. Based on the information received from the contractor, PEOG will also (1) assign an effective date, (2) assign a CCN, and (3) enter the applicable data into ASPEN, and (4) approve (with possible edits) the approval letter. Within 5 business days of receiving from PEOG the signed provider agreement, effective date, and CCN, the contractor shall: (1) send the approval letter and a copy of the CMS-countersigned provider agreement to the OPT/OSP; (2) send a copy of both the approval letter and the provider agreement to the state and/or AO (as applicable)); and (3) switch the PECOS record from “approval recommended” to “approved” consistent with existing instructions. C. Extension Locations 1. Background As discussed in Pub. 100-07, chapter 2, sections 2298 and 2298A, an OPT/OSP provider can, in certain instances, furnish services from locations other than its primary site. (The provider must designate one location as its primary location on the Form CMS-855A, however.) These sites are called extension locations. An extension location is defined at 42 CFR § 485.703 as “a location or site from which a rehabilitation agency provides services within a portion of the total geographic area served by the primary site. The extension location is part of the agency. The extension location should be located sufficiently close to share administration, supervision, and services in a manner that renders it unnecessary for the extension location to independently meet the conditions of participation as a rehabilitation agency.” Per Pub. 100-07, chapter 2, section 2298A, only rehabilitation agencies are permitted to have extension locations. The clinics operated by physicians and public health clinics are not permitted extension locations. These two providers must provide outpatient therapy services at their Medicare approved location. An OPT/OSP provider may also furnish therapy services in a patient’s home or in a patient’s room in a SNF. (See Pub. 100-07, chapter 2, section 2300. Note that when the OPT provides services away from the primary site or extension location(s), this is referred to as “off-premises activity” at other locations. Section 2300 (referenced) above discusses such activities.) Because these are not considered extension locations, neither the home nor the patient’s room need be listed as a practice location on the provider’s Form CMS-855A. (See Pub. 100-07, chapter 2, section 2298B.) OPT/OSP extension sites fall under the parent’s Medicare provider agreement and CCN. They are assigned and identified by a unique 10-digit alphanumeric identification number (also sometimes referred to as a “Medicare Branch ID”) linked to the parent CCN. PEOG is responsible for the assignment or termination of OPT/OSP extension site identifiers and for updating ASPEN accordingly. 2. Extension Site Changes All extension site additions, deletions, changes, and relocations require a Form CMS-855A change of information application. a. Additions An addition or relocation/change of an extension site requires a referral to the state and thereafter to PEOG to review for final determination prior to approval. The approval letter sent to the OPT/OSP provider, with a copy to the state and/or AO, should include the assigned Medicare Branch ID and the effective date of the added or relocated extension site. The effective date of coverage for services provided from the extension site is the date CMS determines that the extension site meets all applicable federal requirements. b. Deletions Deletions do not require a referral to the state but do require post approval correspondence with PEOG and the state (and, if applicable, the accrediting organization) per section 10.6.1.2(B) of this chapter. D. CHOWs For OPT/OSP CHOWs, the contractor shall follow the instructions in section 10.6.1.1 of this chapter. E. Additional Information For more information on OPT/OSP providers, refer to: • Section 1861(p) of the Social Security Act • 42 CFR Part 485, subpart H • Pub. 100-07, chapter 2, sections 2290 – 2308 • Pub. 100-07, Appendix E