Does Medicare Require a Referral for Physical Therapy?

If you’re questioning, “does Medicare require a referral for physical therapy?”, rest assured, the process is more flexible than you might think. Medicare does not outright require a referral, but physician approval is essential to ensure coverage.

This article demystifies Medicare’s role in physical therapy for inpatient and outpatient services, direct access across different states, and strategic pointers for maneuvering through the coverage landscape.

Key Takeaways

• Medicare covers both inpatient and outpatient physical therapy services under different parts (Part A for inpatient and Part B for outpatient), with outpatient services subject to an annual deductible and therapy caps requiring medical necessity confirmation.

• While Medicare beneficiaries may have direct access to physical therapy services without a physician’s referral in certain states, Medicare requires physician involvement for care plans, including certifications and recertifications, to ensure coverage.

• Medicare Advantage (Part C) and Medicare Supplement (Medigap) plans can offer alternative coverage options for physical therapy, potentially tailoring cost-sharing and network requirements to individual beneficiary needs.

Medicare plays a significant role in covering physical therapy for many beneficiaries. Both inpatient and outpatient services fall under this coverage, with different parts of Medicare catering to each setting. Inpatient services, such as those provided in hospitals or skilled nursing facilities, are covered under Part A of Medicare. On the other hand, outpatient services typically fall under Part B. However, the physician’s involvement varies depending on the setting and state laws, adding a layer of complexity to the process.

Contrary to common belief, a physician’s referral isn’t always necessary for accessing physical therapy services.

Although Medicare doesn’t enforce a strict rule for patients to procure a physician’s prescription for physical therapy, it does insist on physician involvement. Physicians typically provide a physician’s referral for patients to undergo physical therapy and authorize up to 30 days of treatment at a time for continued coverage.

Inpatient Physical Therapy Coverage

Inpatient physical therapy, covered under Medicare Part A, is a critical part of the recovery process for many individuals. To be eligible for this coverage, a patient must have been admitted to the hospital as an inpatient for at least 3 days. Furthermore, a physician needs to confirm the need for specialized care to aid recovery from an illness, injury, or surgery.

This coverage encompasses rehabilitation services like physical therapy treatment, occupational therapy, and speech-language pathology services. Remember, coverage for inpatient rehabilitation care mandates at least a 3-day inpatient hospital stay and may extend to both inpatient and outpatient rehabilitation following surgery or for in-home care.

Medicare will pay for a rehab facility for up to 90 days per benefit period.

Outpatient Physical Therapy Coverage

On the other side of the coin, outpatient physical therapy services fall under Medicare Part B coverage. These services include occupational therapy and speech-language pathology, offering a comprehensive range of treatments for various conditions.

However, coverage for these services comes with its set of rules. Namely, an annual deductible of $226 applies, after which Medicare covers 80 percent of the approved amount for these services.

Additionally, there’s a cost threshold of $2,230 for combined physical therapy and speech-language pathology services, and a separate $2,230 threshold for occupational therapy. Once these thresholds are met, confirmation of medical necessity is required for continued coverage.

Direct Access to Physical Therapy: State Laws vs. Medicare Requirements

The complexity of navigating physical therapy increases when considering direct access – a term denoting a patient’s ability to directly seek treatment from physical therapists without a physician’s referral.

It’s important to note that while all 50 states, the District of Columbia, and the U.S. Virgin Islands allow some form of direct access to receive physical therapy services, the degree of access can vary greatly due to different direct access laws.

As for Medicare, it stipulates that:

• A physician’s signature must be obtained on the care plan within 30 days to facilitate unlimited direct access services.
• Recertification, through a physician’s signature, is required whenever the plan of care is updated or every 90 days, whichever occurs first.
• Failure to adhere to these guidelines can lead to the denial of payment by Medicare for the services rendered.

Direct Access States

In states permitting direct access, Medicare beneficiaries can opt to directly seek treatment from physical therapists without a physician’s referral.

However, if a direct access patient becomes eligible for Medicare during treatment, it is crucial to establish and certify a plan of care, possibly requiring an initial evaluation. The treatment must also comply with both the state practice act and Medicare’s guidelines.

Limited Direct Access States

Conversely, Limited Direct Access States impose more restrictive rules, frequently necessitating a physician’s referral before initiating Medicare-covered treatment.

These restrictions can include limitations on the types of services or patient populations that can be treated without a physician’s referral. Failure to secure a physician referral in these states can result in delays in receiving care, increased costs, and potential decline in functional outcomes.

Navigating Medicare Direct Access for Physical Therapy

The journey through Medicare direct access for physical therapy may seem overwhelming, but acquiring a good grasp of the process can significantly ease the process. This involves familiarizing oneself with:

• Initial evaluations
• Treatment plans
• Billing
• Documentation requirements

Medicare beneficiaries can undergo an initial evaluation directly by a physical therapist without a referral. Therapists can then create a personalized treatment plan for the patient without consulting a physician beforehand.

However, Medicare necessitates precise documentation, including a diagnosis or a description of the condition. This documentation is essential to accurately record and justify direct access services.

Initial Evaluations and Treatment Plans

An initial evaluation can be the first step in a patient’s physical therapy journey. Medicare patients can directly schedule this evaluation with a physical therapist to assess the suitability of physical therapy for their needs. This evaluation forms the basis for the development of a personalized plan of care (POC) for the patient.

Nevertheless, Medicare stipulates the following requirements for POC treatment:

1. The initial evaluation should ascertain the necessity for the treatment.
2. The treatment plan needs to be certified by a physician, PA, or NP with a dated signature or verbal order within 30 days post-evaluation.
3. If the physical therapist determines that therapy is not suitable, a physician referral or signature on the evaluation is necessary for Medicare to cover the cost of the service.

Billing and Documentation Requirements

Billing and documentation are crucial aspects of navigating Medicare direct access for physical therapy. When billing for Medicare-covered physical therapy services, therapy providers must include the name and NPI number of the certifying physician or NPP in the ‘referring provider’ section of the claim form.

When it comes to documentation, Medicare requires the following:

• The signed plan of care must be established before treatment commences, as outlined in the Medicare Benefit Policy Manual.
• This plan must be recertified within 90 days or in case of a change in condition.
• The plan must bear a dated signature by the physician or another authorized healthcare professional.