Medicare and Direct Access

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—as long as your state practice act allows for that. 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 requirements 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. 

Already sold on the importance of direct access for Medicare beneficiaries? Click here to jump down to our robust Q&A on how Medicare and direct access work together in action.

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, 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 current 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.

Medicare Direct Access in Action

That’s the Medicare direct access rules in a nutshell, but let’s break it down in practice. What happens when a Medicare beneficiary calls to schedule an appointment? Can you book the session and perform an initial evaluation—or do you need to obtain a physician signature first? Read on to learn the answers to these questions and more:

What happens when a Medicare patient schedules an initial appointment at your practice?

Because some form of direct access is available in every state—and Medicare allows its beneficiaries to receive physical therapy services via direct access—physical therapists who have a relationship with Medicare may book a Medicare patient for his or her initial evaluation, perform that initial evaluation, and bill Medicare for that service (as long as doing so aligns with the rules outlined in your state practice act). And that can all happen prior to you obtaining a physician signature or a referral. 

That said, if during your initial evaluation, you determine that therapy is not appropriate for this patient—and thus, you do not initiate a plan of care—you still must obtain a physician referral or physician signature on the evaluation in order to receive payment from Medicare for that service. However, you can do this after performing the evaluation.

How does billing work when the initial evaluation is the only service provided to a Medicare patient—and he or she does not obtain further treatment?

As CMS explains here, “When an evaluation is the only service provided by a provider/supplier in an episode of treatment, the evaluation serves as the plan of care if it contains a diagnosis, or in states where a therapist may not diagnose, a description of the condition from which a diagnosis may be determined by the referring physician/NPP.” Furthermore, “When evaluation is the only service, a referral/order and evaluation are the only required documentation. If the patient presented for evaluation without a referral or order and does not require treatment, a physician referral/order or certification of the evaluation is required for payment of the evaluation. A referral/order dated after the evaluation shall be interpreted as certification of the plan to evaluate the patient.” Keep in mind that in such cases, the therapist can only bill one evaluation unit using CPT code 97161, 97162, or 97163, as these codes are all untimed. The therapist may not bill additional treatment codes. 

What happens when it comes time to perform Medicare-covered treatment?

Unlimited Direct Access

It all depends on the rules in your state. If you practice in a state that has unlimited direct access, then after performing an initial evaluation to determine that physical therapy is appropriate, you may provide treatment before obtaining anything from the physician. However, Medicare requires that within 30 days, you obtain a physician signature on the plan of care. This meets Medicare’s requirement that a physical therapy patient be under the active care of a physician. 

If you are unable to obtain a physician signature on the plan of care, then Medicare may deny payment. (Although the agency can, at its discretion, provide an extension if you can provide documentation that supports consistent, reasonable attempts to obtain certification.) Beyond that, Medicare requires that you obtain a physician signature again (recertification) anytime you update the plan of care or every 90 days, whichever comes sooner.

Limited Direct Access

If you practice in a state that has provisional or limited direct access, then Medicare’s rules still apply; however, you also must comply with the specific direct access rules of your state. (To be clear, you must always comply with the specific direct access rules of your state, but in this case, state direct access laws are more restrictive than Medicare rules.) For example, if you practice in Missouri, which has limited direct access to physical therapists, then you must comply with Missouri’s direct access laws, which means you’ll need to obtain a referral from a physician prior to initiating Medicare-covered treatment. In most cases, providers can still perform and bill Medicare for an initial evaluation to determine whether or not physical therapy is appropriate for a given patient. Additionally, all Medicare rules still stand, which means you must also have the physician sign off on the patient’s plan of care and recertify it at least every 90 days.

What information should be included on a Medicare certification and recertification?

As we explained here, “according to Chapter 15 of the Medicare Benefit Policy Manual, ‘The format of all certifications and recertifications and the method by which they are obtained is determined by the individual facility and/or practitioner.’ CMS considers the following documents acceptable documentation of certification:

• Progress note
• Referral or order
• Plan of care that has been signed and dated by a physician or non-physician provider 

Furthermore, the signed plan of care must indicate that ‘the physician/NPP is aware that therapy service is or was in progress and the physician/NPP makes no record of disagreement with the plan when there is evidence the plan was sent.’”

What if I want to provide wellness services to a Medicare beneficiary?

As long as your state practice act allows for it, you may provide never-covered wellness services to Medicare beneficiaries without any physician involvement. In this case, Medicare also allows you to collect payment for the services directly from the patient without the use of an ABN—although you could have your patient complete a voluntary ABN if you so choose. In this situation, you do not need to have a relationship with Medicare and you do not need to submit claims to the payer. That said, as Meredith Castin explains here, “you need to be very clear about Medicare’s definition of ‘wellness services’ versus ‘physical therapy services’” to not land yourself in hot water.

What if Medicare is the secondary payer?

As WebPT’s Kylie McKee explained here, “according to PT compliance expert Rick Gawenda (as mentioned in a comment here), you must adhere to all of Medicare’s plan of care rules and documentation standards when you submit claims to Medicare—even when it’s a secondary insurance. Furthermore, avoid the temptation to not bill Medicare when it’s the secondary payer. Just as when Medicare is primary, you are legally obligated to bill Medicare for any covered services you provide to a beneficiary.” 

Just note that, “similar to any other scenario involving primary and secondary payers, you’ll need to ship the claim off to the primary payer first. Only once you’ve received an Explanation of Benefits (EOB) from the primary insurance can you attempt to bill Medicare.”

What if a direct access patient becomes eligible for Medicare in the midst of treatment?

As we explained here, you’ll “need to establish and certify a plan of care, which may warrant an initial evaluation.” In other words, from here on out, adhere to your state practice act and Medicare’s guidelines. 

Want some more examples of Medicare direct access in action? 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.