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.

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Medicare’s Rules

Rule numero uno: comply with your state’s laws regarding direct access. The APTA recommends PTs review their states’ practice acts. In general, though, Medicare does not require patients to obtain prescriptions from physicians for PT services.

Plan 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.
  • The plan of care must include, at a minimum, diagnoses, long-term treatment goals, and the type,quantity, duration and frequency of therapy services.

Certification

  • 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. Have questions about Medicare regulations regarding direct access? Post them in the comment section below.

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