As of 2005, per the Medicare Benefit Policy Manual (Publication 100-02), Medicare beneficiaries may seek physical therapy services without seeing a physician or obtaining a referral. Sounds pretty straightforward, right? Well, we know it wouldn’t be Medicare if it was truly that straightforward. Here’s how the plot thickens: According to the APTA, “a patient must be ‘under the care of a physician,’ which is indicated by the physician certification of the plan of care.” Confused? Me too. Let’s sort this out. We’ll dive into all of Medicare’s nitty-gritty direct access details in a moment, but before that, let’s discuss why it’s so important for Medicare patients to have direct access to physical therapy in the first place.

Benefits of Direct Access

We all know it’s beneficial for patients to access physical therapy care first—before they receive other types of treatment (specifically, injections and surgery). After all, physical therapists provide long-term solutions to improve patients’ functional abilities and reduce pain—at a significantly lower cost. According to the Alliance for Physical Therapy Quality and Innovation (APTQI), however, many past studies supporting this assertion examined non-Medicare beneficiaries. That’s why the APTQI teamed up with The Moran Company (TMC) to evaluate different initial treatment interventions for low back pain—and their associated costs—for Medicare patients, specifically: “Using nationally representative Medicare claims datasets across multiple sites of service,” the study “provide[d] tabulations of total Medicare A/B spending on average for groups of beneficiaries with an incident lumbago (low back pain) diagnosis who received physical therapy first, injections first or surgeries first.” The results showed that “beneficiaries who are newly diagnosed with low back pain (as defined by the diagnosis code for lumbago) and receive physical therapy (PT) as a first line treatment option have lower total Medicare A/B costs on average in the period surrounding diagnosis and in the year following than do lumbago beneficiaries who receive injections or low back pain related surgeries as the initial treatment intervention.” In other words, receiving physical therapy first is both better for Medicare beneficiaries and the Medicare program. Here are some other highlights of the study, which looked at 2014 Medicare claims data for 472,000 Medicare Fee for Service beneficiaries who received a diagnosis of lumbago:

  • Nearly “13% of [the] beneficiaries received low back pain related physical therapy as the first line treatment.”
  • The average total Medicare A/B spending for those beneficiaries who received therapy first was approximately 19% lower than spending for those beneficiaries who received injections first and approximately 75% lower than spending for those patients who received surgery first.
  • Over the course of the year immediately following lumbago diagnosis, average total spending for those patients who received therapy first was 18% lower than spending for those patients who received injections first and 54% lower than spending for those patients who received surgery first.
  • The “beneficiaries who receive therapy within the first 15 days of diagnosis” appear to “have downstream costs that are ~ 27% lower on average than downstream costs observed for the group of beneficiaries who receive therapy between 45-90 days after diagnosis.”

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Now that we’re all on the same page as to why Medicare beneficiaries should seek out PT first, let’s talk about how to ensure you’re playing by Medicare’s rules and thus, better serving your Medicare direct access patients.

Medicare’s Direct Access Rules

As we discussed here, it’s important to understand the “degree of direct access that exists in your state—and that means you must become very familiar with your state practice act.” In general, though, Medicare does not require patients to obtain physician prescriptions for PT services. But, it does require physician involvement. Here’s how:

Plans of Care

  • PTs must develop a plan of care (POC) for every Medicare patient, and a physician or nonphysician practitioner (NPP) must certify that POC within 30 days of the initial therapy visit. That being said, Medicare does not require the patient to actually visit the certifying physician or NPP, although that physician or NPP may require a visit. Medicare also does not require that the certifying physician be the patient’s primary care physician. Thus, as we also explained here, “once the patient is in [your] door, you, as the therapist, are in the driver’s seat. That means you can refer the patient to your PT-friendly physician for next steps.”
  • The plan of care must include, at a minimum, diagnoses, long-term treatment goals, and the type, quantity, duration, and frequency of therapy services.

Certifications

  • When a physician or NPP certifies a POC, he or she must sign and date it. Stamped signatures are not allowed, and if the physician or NPP gives verbal certification, he or she must provide a signature within 14 days of that verbal notice.
  • The PT must recertify the POC “within 90 calendar days from the date of the initial treatment,” or if the patient’s condition evolves in such a way that the therapist must revise long-term goals—whichever occurs first.

Claims

As of October 1, 2012, therapy providers must list the name and NPI number of the certifying physician or NPP under the “referring provider” section of the claim form. Medicare uses the term “referring provider” because they’ve yet to update that portion of the claim form. So, while it’s not exactly relevant—nor does it affect existing regulations regarding direct access—it’s the current Medicare requirement.


That’s Medicare’s direct access rules in a nutshell. Want some examples? The APTA has developed three case scenarios, which APTA members can review here. And if you’re looking for more ways to encourage Medicare patients to seek physical therapy first, check out this post on patient-centered marketing strategies.