Medicare Rules for Student Supervision

Medicare Rules for Student Supervision in Skilled Nursing Facilities

New Medicare regulations remove line-of-sight supervision requirements for therapy students in skilled nursing facilities (SNFs) but other restrictions remain, according to recently released guidance.  The regulations state “each SNF would determine for itself the appropriate manner of supervision of therapy students consistent with applicable state and local laws and practice standards.” However, in guidance on adherence to the new regulations [PDF] (slides 18–28, 33–34), the Centers for Medicare and Medicaid Services (CMS) clarifies that the supervising clinician cannot treat another resident or supervise another student while the student is treating a resident. CMS notes that ASHA (and the American Physical Therapy Association and American Occupational Therapy Association) provides recommended guidelines for student supervision [ZIP]. ASHA’s guidelines are reproduced below.

The CMS restrictions on billing students’ services are based on two principles; for billing purposes, the student is considered an extension of the therapist and only one billable service can be provided at one time by the student/supervisor. Billing guidance includes the following:

Code as individual therapy when the speech-language pathologist (SLP) or student is treating one resident, while the other is not treating/supervising any other residents/students.
Code as concurrent therapy (i.e., patients are performing different activities) if the SLP is treating two residents while the student is not treating any residents or if the student is treating two residents while the SLP is not treating any residents.
Code as group therapy (i.e., patients are performing similar activities) if the full group is conducted by either the supervising SLP or the student; the other may not be supervising any other students or treating residents.

These regulations apply only to Part A residents in SNFs; more restrictive student rules for Part B services (i.e., 100% supervision in the room) in SNFs and other settings remain unchanged.

For more information, please contact Mark Kander, director of health care regulatory analysis, at

ASHA's Student Supervision Guidelines

ASHA submitted the following guidance on supervision of students to CMS; the guidelines are not included in the regulation, but are references in implementation guidelines.

Graduate students who have been approved by the supervising speech-language pathologist to practice independently in selected patient situations can perform the selected clinical services without line-of-sight supervision by the supervising speech-language pathologist. The supervising speech-language pathologist must be physically present in the facility and immediately available to provide observation, guidance, and feedback as needed when the student is providing services.
The amount of supervision must be appropriate to the graduate student’s documented level of knowledge, experience, and competence.

When the supervising speech-language pathologist has cleared the graduate student to perform medically necessary patient services and the student provides the appropriate level of services, the services will be counted on the MDS as skilled therapy minutes.

The supervising speech-language pathologist is required to review and co-sign all graduate students’ patient documentation for all levels of clinical experience and retains full responsibility for the care of the patient.  Supervising speech-language pathologists are required to have one year of practice experience.

Graduate students who have not been approved by the supervising speech-language pathologist to practice independently require line-of-sight supervision by the qualified speech-language pathologist during all services. In addition, the supervising speech-language pathologist will have direct contact with the patient during each visit. The graduate student services will be counted on the MDS as skilled therapy minutes.