Medicare and Direct Access to Physical Therapy

As promised here is some more information on Direct Access and Medicare ;

Direct Access and Medicare

Medicare beneficiaries are able to go directly to physical therapists (PT) without a referral or visit to a physician. This policy became effective in 2005 through revisions to the Medicare Benefit Policy Manual (Publication 100-02).

Medicare beneficiaries are able to go directly to physical therapists (PT) without a referral or visit to a physician. This policy became effective in 2005 through revisions to the Medicare Benefit Policy Manual (Publication 100-02). The 2005 revisions eliminated the physician visit requirement. However, a patient must be "under the care of a physician," which is indicated by the physician certification of the plan of care. Learn more from a summary of the 2005 revisions..
 

The following information is offered to help physical therapists provide access to PT services to patients and remain in compliance with laws and regulations. For more detailed information on CMS requirements, review section 220.1.1-3 of the Medicare Benefits Policy Manual (.pdf) and national and local coverage determinations.

What the Rules Say

·         PTs must comply with the laws in their state related to the need for a referral for physical therapy. Review your state practice act.

·         The plan of care developed by the PT must be certified by a physician or nonphysician practitioner (NPP) within 30 days of the initial therapy visit.

·         The plan of care must include, at a minimum, (1) diagnoses; (2) long-term treatment goals; and (3) type, amount, and duration of therapy services.

·         Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care. Stamped signatures are not acceptable. If the order to certify is verbal, it must be followed within 14 days by a signature.

·         Medicare does not require that the patient visit the physician/NPP. However, a physician/NPP may require the visit.

·         Medicare does not require a physician order for PT services.

·         Recertification of the plan of care is required if changes in a patient's condition requires revision of long-term goals or within 90 calendar days from the date of the initial treatment, whichever is first.

What This Means for PTs

To be paid by Medicare for their services, PT practices should have procedures in place to ensure that the plan of care is certified. Medicare does not require certification of the plan of care before treatment is initiated. However, if the PT does not have a relationship with the physician or is not confident that the physician will sign the plan of care, it may be prudent for the PT to contact the physician for verbal authorization before initiating treatment. If state law is more restrictive that Medicare regulations, physical therapists must comply with state law.

Filing Medicare Claims Under Direct Access

Medicare regulations specify how to report information on the certifying physician/NPP on claims for outpatient therapy services:

·         Effective October 1, 2012, providers must report the name and NPI number of the certifying physician/NPP on the claim for therapy services.

·         For claims processing purposes, the certifying physician/NPP is considered a referring provider. The term “referring provider” is used by Medicare in this case simply because this is the term that is currently on the claim form.

·         The use of the term “referring provider” does not change existing regulations stating that Medicare does not require a patient visit with the physician/NPP.