Physical therapy credentialing

Medicare enrollment for a PT in private practice

Medicare pays a physical therapist directly only as a physical therapist in private practice. Under 42 CFR 410.60(c), each therapist must:

• Hold a license in the state where they practice
• Practice privately on a regular basis: solo, in a group or partnership, or as an employee of one
• Bill Medicare only for care in the practice’s office or the patient’s home (not a hospital or SNF)
• Use office space the practice owns, leases or rents, used only for the practice
• Treat patients of the practice, with fees collected by the practice

A solo PT enrolls on the CMS-855I. A group enrolls on the CMS-855B as a Physical/Occupational Therapy Group in Private Practice, and CMS expects each therapist it employs to enroll too, reassigning benefits on their own CMS-855I (the old CMS-855R form is discontinued). A PT hired by an orthopedic practice or other physician group is still screened as moderate risk. A clinic billing as a rehabilitation agency takes a different route: a CMS-855A, a state survey and a provider agreement.

PTAs, new hires and supervision

Since January 1, 2025, a PT in private practice can supervise physical therapist assistants under general supervision, so the PT no longer has to be on site while a PTA treats a Medicare patient. CMS made the change in the CY 2025 physician fee schedule final rule, for OT assistants too. Where state law requires closer supervision, state law still applies.

Two rules did not change. A PT who is not yet enrolled can treat Medicare patients only under direct supervision of an enrolled PT. And everyone working under the PT must be an employee of the practice, billed under the supervising therapist, with PTA services paid at 85 percent.

So a new PT’s Medicare application should go in as soon as the offer is signed.

NPIs, taxonomy codes and practice locations

Each therapist has an individual (Type 1) NPI; a practice set up as a corporation, LLC or partnership also needs an organization (Type 2) NPI. In the NUCC taxonomy code set used on the NPI application, a physical therapist is 225100000X, with specialty codes such as 2251X0800X (Orthopedic), and a clinic can use 261QP2000X (Physical Therapy Clinic/Center).

Location details matter more for PTs, because Medicare checks them in person. Before we file, we confirm:

• The legal business name matches exactly across the IRS letter, NPPES and PECOS
• Each office has a street address; post office boxes are not accepted
• Hours are posted and staffed, because the site visitor comes during them
• A home-visit practice lists the area it serves and where it keeps records
• A new or moved office is reported, and each one gets its own site visit

Under the Medicare Program Integrity Manual, if the office is not open, staffed and operating when the visitor comes, the application can be denied. So we file once the office is open and equipped and the posted hours are accurate.

Medicaid and commercial plans

Medicaid starts with your state program. Physical therapy is an optional Medicaid benefit for adults, so states set their own coverage and limits, while children under 21 are covered for medically necessary care through EPSDT. Federal rules define Medicaid physical therapy as services prescribed by a physician or other licensed practitioner, so expect Medicaid to want a prescription on file.

Medicaid managed care plans credential you on their own, and the state must screen and enroll every network provider. A plan can sign you while state enrollment is pending for up to 120 days, so we file both together.

Commercial plans add two PT-specific steps. UnitedHealthcare’s credentialing FAQ sends outpatient therapy providers (physical, occupational and speech) to OptumHealth Physical Health for credentialing and contracting, as it does for chiropractic practices. The same FAQ says it closes requests when it is not accepting new applications for a specialty or area. Both vary by plan and state, so we check each plan before we file.