All states have amended their PT practice acts to allow for providing some form of PT services under direct access—or, put more simply, treating without a physician referral. But with this right comes added risks. It’s important to understand some of the potential risks and, hopefully, avoid them as much as possible. With that in mind, here are some main points to consider.
1.) Each state has its own rules governing direct access;
therefore, it’s important to understand the rules for the state in which you practice. For example, here in Pennsylvania, PTs must:
- have a special direct access license,
- have extra liability insurance, and
- provide treatment for a duration of no more than 30 days.
In some other states—Maryland, for example—there is no restriction to direct access. Moral of the story: Know your state’s direct access laws before you start treating.
2.) Medicare rules trump your state’s direct access laws.
For example, Medicare will only reimburse for outpatient PT services provided under Part B when those services are delivered under the care of a physician. We meet this condition when we have a physician participating in the care of the patient “certify” a plan of care by signing and dating it. So, while the PT doesn’t need the physician’s referral, he or she does need the physician to certify the plan of care within 30 days of when the PT established it—which ultimately means that, while treating patients without a certified plan of care may not violate a state’s practice act, it does violate Medicare’s condition of payment.
3.) When it comes to commercial payers, the manner in which you’re legally allowed to provide direct access services may not align with what documentation you’re legally required to provide for payment.
Once you understand your state’s direct access requirements, you then need to check the medical policies and provider agreements of those insurances with which you participate to ensure they allow for direct access treatment. For instance, one United Healthcare Insurance I checked does not require its beneficiaries to obtain physician referrals, and it covers physical therapy services that are medically necessary. That’s just one example, though. Every commercial insurance provider is independent, so it’s important you check with the insurances with which you participate to ensure you’ve met the state’s practice act requirements as well as each carrier’s billing requirements.
4.) You have a lot to prove in your documentation.
There’s a reason PTs here in Pennsylvania must carry additional liability insurance: We’re not able to order tests or X-rays; therefore, we must rely on our evaluation and clinical decision-making skills to identify patients who might not be physical therapy candidates (differential diagnosing) and refer them to the appropriate care providers. Our documentation must demonstrate how we arrived at our treatment diagnosis, and that explanation must include answers to such questions as:
- What other potential diagnoses did I consider?
- How did I rule out other diagnoses?
- Did I perform a review of systems (ROS)?
- Did I make additional referrals to the appropriate providers to assist in the ROS?
Here’s an example: A patient comes in with a complaint of low back pain (724.2). This is a diagnosis PTs commonly treat. That being said, the PT also needs to consider what other conditions could present as low back pain. As the PT rules out any other possible conditions, he or she must document the process of ruling out those conditions.
Ultimately, your documentation should always support the professional standard of care you provide to a patient. Regardless of a physician’s involvement, you should demonstrate why the patient needs the skills of a therapist to treat what ails him or her, thus supporting the medical necessity of your services. If you don’t fulfill all the documentation requirements for your state practice act and payers, then you run the risk of potential claim denials, insufficient reimbursements, compliance fines, or litigation. (On that note, it’s not a bad idea for therapists to consider having their own liability insurance if their employer does not provide it. And even if there is employer-sponsored liability insurance, a therapist may want to get his or her own as there can be conflicts of interest between employer and employee. For further information on personal liability insurance, check out this article or post a comment on this blog post, and I’ll reach out to you.)
Thank you very much for the opportunity to chat with you about this important topic. As healthcare continues to evolve, and as we continue looking for ways to provide important care to our patients, it is important to understand some of the risks associated with providing that care and take steps to mitigate those risks.