Information for Clinical Instructors - Frequently Asked Questions

What expectations should I have for a PTA student as compared to a PT student?

Confusion related to expectations for PTA student performance typically fall into one of two categories. Either (1) the SPTA is expected to exhibit competency with skills appropriate for the SPT and beyond the training and education of the SPTA or (2) the SPTA is held to expectations more consistent with PT technician training and is not challenged to perform to their level of education.

Some of the more common issues or examples are outlined below. Clinical instructors are encouraged to contact the PTA Program's ACCE with any specific or additional questions related to appropriate SPTA supervision, practice and goals/expectations for performance.

Expectations too HIGH for PTA level education/training JUST RIGHT Expectations too LOW for PTA level education/training
  • SPTA performing initial examination components

  • SPTA establishing PT diagnosis or hypothesizing prognosis based on initial examination findings
  • SPTA identifying appropriate interventions and/or therapy progression based on incomplete or vague PT Plan of Care
  • SPTA performing interim assessment or intervention skills with “complex” patients (multi-system involvement, rapidly changing status, etc..) without direct supervision
  • SPTA performing assessments or interventions not appropriate for the PTA based on state law (sharp debridement, spine mobilization, etc..)
  • SPTA follows only a scripted list of specific exercises and modalities
  • SPTA not challenged to give rationale for selected interventions or identify alternative interventions that could be used to achieve PT established goals
  • SPTA not asked to perform any interim reassessments (strength, ROM, sensation, balance, posture/gait, functional status, etc..)
  • SPTA given few opportunities to practice clinical documentation skills
  • SPTA not given opportunities to practice interpreting and implementing a written PT Plan of Care

Have there been any recent LA PT Board rule changes associated with Act 139 that effect clinical education/supervision of PTA students?

Yes. The Louisiana Board of Physical Therapy recently adopted administrative rules changes (changed prompted in large part by Act 139). These were published in the October 20, 2011 issue of the La Register. Included in those changes are items related to/effecting clinical education:

  1. Change that service as a primary clinical instructor for a PT or PTA student may be used for continuing education hours/credit. From Title 46, Part LIV, Subpart 1, Chapter 1, Sub-Chapter J, Item 195, 4.b:

    "a maximum of five hours credit for clinical instructors serving as the primary clinical instructor for PT and PTA students or provisional licensees. One hour credit may be earned per 120 hours of clinical instruction during the renewal period. Proof of clinical instruction shall be documented on a form provided by the board and shall be signed by two of the following:
    1. clinical instructor,
    2. student,
    3. center coordinator clinical education; or
    4. academic coordinator clinical education."
  2. Change that PTAs may serve as clinical instructors for PTA students without a full-time PT on premise (PT available by beeper or phone). From Title 46, Part LIV, Subpart 2, Chapter 3, Sub-chapter C, Item 337.a.

    "A clinical instructor shall provide continuous supervision to a PT or PTA student in all practice settings. A PTA may act as a clinical instructor for a PTA student in all practice settings provided that the PT supervisor of the PTA is available by telephone or other communication device."
  3. Change that PTAs serving as clinical instructors for PTA students have one year's experience. From Title 46, Part LIV, Subpart 2, Chapter 3, Sub-chapter C, Item 337.b.

    "A PTA can be a clinical instructor for the PTA student provided the PTA has one year of experience in that practice setting."

You can access the full text of the adioted rule changes on the LA PT Board website at http://laptboard.org.Will open new browser window or tab

What are the Medicare rules that I should be aware of when supervising PT/PTA students?

Updated September 2011

Medicare reimbursement for student services differs between Medicare Part A and Part B. Services rendered by students in the hospital, SNF and IP rehab environments (part A) are reimbursable and no longer require "line of sight" supervision. However, in those settings the student is still considered an extension of the qualified practitioner (PT/PTA), not an individual practitioner and as such the supervising PT or PTA cannot be treating or supervising other individuals (patients or students) during the time in which the student is rendering services to the Medicare part A patient.

Student services under Medicare part B (outpatient, non-SNF nursing home, private practice) continue to not be reimbursable. However, the student may still be present and participate in the care of the part B patient so long as the qualified practitioner is present in the room directing and guiding the service delivery.

More detailed examples including those related to delivery of care in "group therapy" treatments are described below the chart.

Practice Setting PT Student PTA Student
Part A Part B Part A Part B
PT in Private Practice N/A X1 N/A X1
Certified Rehab Agency N/A X1 N/A X1
Comprehensive OP Rehab Facility N/A X1 N/A X1
Skilled Nursing Facility Y1 X1 Y2 X1
Hospital Y3 X1 Y3 X1
Home Health Agency NAR X1 NAR X1
Inpatient Rehab Faciltiy Y4 N/A Y4 N/A
Key:
Y: reimbursable
X: not reimbursable
N/A: not applicable
NAR: not addressed in regulation. Please defer to state law.

Y1: Reimbursable: The minutes of student services count on the Minimum Data Set. Medicare no longer requires that the professional therapist (the PT) provides line of sight supervision. It is now the authority of the supervising therapist to determine the appropriate level of supervision for the student, but the student is still considered an extension of the therapist, not an individual practitioner. In addition, the rules from FY2011 regarding the student services based on PT/PTA supervision and whether minutes can be recorded as individual, concurrent, or group therapy minutes remain the same (RAI Version 3.0 Manual, September 2011).

Examples:
In order to record the minutes as individual therapy when a therapy student is involved in the treatment of a resident, only one resident can be treated by the therapy student and the supervising therapist or assistant (for Medicare Part A and Part B). Under Medicare part A, the supervising therapist or assistant cannot be treating or supervising other individuals. The resident and student no longer need to be within the line-of-sight supervision of the supervising therapist. It is within the supervising therapist's authority to determine the appropriate level of supervision for the student. Under Medicare Part A, when a therapy student is involved with group therapy treatment, and one of the following occurs, the minutes may be coded as group therapy:

  • The therapy student is providing the group treatment at the appropriate level of supervision as determined by the supervising therapist and the supervising therapist or assistant is not treating any residents and is not supervising other individuals (students or residents); or
  • The supervising therapist/assistant is providing the group treatment and the therapy student is not providing treatment to any resident

Under Medicare Part B, when a therapy student is involved with group therapy treatment, and one of the following occurs, the minutes may be coded as group therapy:

  • The therapy student is providing group treatment and the supervising therapist or assistant is present and in the room and is not engaged in any other activity or treatment; or
  • The supervising therapist or assistant is providing group treatment and the therapy student is not providing treatment to any resident
Documentation: APTA recommends that the physical therapist co-sign the note of the physical therapist student and state the level of supervision that the PT determined was appropriate for the student and how/if the therapist was involved in the patient's care.

Y2: Reimbursable: The minutes of student services count on the Minimum Data Set. However, Medicare requires that the PT/PTA provide line-of-sight supervision of physical therapist assistant (PTA) student services as appropriate within their state scope of practice. See Y1

Documentation: APTA recommends that the physical therapist and assistant should co-sign the note of the physical therapist assistant student and state that the PT/PTA was providing line of sight supervision of the student and was involved in the patient's care. Also, the documentation should reflect the requirements as indicated for individual therapy, concurrent therapy, and group therapy see Y1.

Y3: This is not specifically addressed in the regulations, therefore, please defer to state law and standards of professional practice. Additionally, the Part A hospital diagnosis related group (DRG) payment system is similar to that of a skilled nursing facility (SNF) and Medicare has indicated very limited and restrictive requirements for student services in the SNF setting.

Documentation: Please refer to documentation guidance provided under Y1.

Y4: This is not specifically addressed in the regulations, therefore, please defer to state law and standards of professional practice. Additionally, the inpatient rehabilitation facility payment system is similar to that of a skilled nursing facility (SNF) and Medicare has indicated very limited and restrictive requirements for student services in the SNF setting.

X1: B. Therapy Students

1. General
Only the services of the therapist can be billed and paid under Medicare Part B. The services performed by a student are not reimbursed even if provided under "line of sight" supervision of the therapist; however, the presence of the student "in the room" does not make the service unbillable.

Examples:
Therapists may bill and be paid for the provision of services in the following scenarios:

  • The qualified practitioner is present and in the room for the entire session. The student participates in the delivery of services when the qualified practitioner is directing the service, making the skilled judgment, and is responsible for the assessment and treatment.
  • The qualified practitioner is present in the room guiding the student in service delivery when the therapy student and the therapy assistant student are participating in the provision of services, and the practitioner is not engaged in treating another patient or doing other tasks at the same time.
  • The qualified practitioner is responsible for the services and as such, signs all documentation (A student may, of course, also sign, but it is not necessary since the part B payment is for the clinician's service, not for the student's services).

2. Therapy Assistants as Clinical Instructors
Physical therapist assistants and occupational therapy assistants are not precluded from serving as clinical instructors for therapy students, while providing services within their scope of work and performed under the direction and supervision of a licensed physical or occupational therapist to a Medicare beneficiary. Documentation: APTA recommends that the physical therapist or physical therapist assistant complete documentation.

When documenting SPTA performance in the PTA MACS, when is it appropriate to use the “NI-needs improvement” notation vs. the “NE-needs experience” notation. Especially on a fall/first clinical rotation, wouldn’t most areas of weakness be expected to just “need experience” ?

The use of NE vs. NI is a common source of confusion for CI’s. While CI’s may often feel that a skill will naturally improve with “more experience”, the “NE” notation in the PTA MACS is definitely over utilized when the “NI” notation would be more appropriate. Clinical instructors should consider the following when selecting NE/NI:

  • The NE is appropriate when the student had minimal opportunity during the clinical experience to practice the skill but not when the skill was performed/observed frequently. For example, a student in OP who had only 1 patient for transfer training who was not yet proficient may = NE. A student in acute care who did transfers 5+ times per day and is still not proficient should = NI.
  • For affective/professional skills the use of NE is rarely if ever appropriate. If a student is not exhibiting “entry-level” skill with communication, behavior, responsibility, etc that is something that should be reflected with an NI and not an NE.
  • Students, even on a first/fall rotation are expected to work toward becoming entry-level with the skills utilized in that setting on a regular basis. If by the end of the rotation the student is not proficient with a commonly used skill, the NI is appropriate.
  • An NI is actually more helpful to the student and the ACCE than the NE. An NI should include documentation/comment as to the exact nature of the skill deficit and therefore guides the student and the program toward the interventions needed to correct the weakness. An NE on the other hand is fairly vague and is less useful in identifying the needed improvements.
  • When identifying deficits in student skill, it is important to give that feedback as soon as possible. At a minimum this should consist of a formal mid-rotation and final MACS assessment, but ideally the student is receiving feedback (formal or informal) on a more regular basis so that he/she knows what areas need improvement and has the opportunity to work on those areas.
  • Be sure and involve the school when areas of weakness are identified. The ACCE (at the midrotation visit or at any time before/after) can give you feedback on whether the skill was perceived to be weak in the class/lab, whether the NE or NI is appropriate and help suggest teaching strategies to facilitate improvement in the skill.