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Direct Access Physical Therapy: The Bare Basics

Whether you are a new grad physical therapist or a seasoned vet, Direct Access physical therapy rules can affect the way you look at your treatments and shape how you grow your career.

As a practitioner, how would you feel if you didn’t have to wait for a patient to bring a prescription to get treated? What if you could be the first line of treatment for patients’ pain? Depending on the state in which you practice, direct access can impact the ease with which you can pursue a number of niche clinics, cash pay physical therapy practices, or solopreneur endeavors as a PT.

It’s time for your patients to take their health in their own hands and for you to help them achieve their goals.

Here are 6 “bare basics” that every physical therapist should know about Direct Access (DA).

1. Know what Direct Access physical therapy is

Do you know what the Direct Access Law is? It is a law that allows patients to self-refer to physical therapy in all 50 states, the District of Columbia, and the US Virgin Islands as of January 2015. [i]

Many physical therapists don’t realize that Direct Access laws apply nationwide. Others are widely versed in the details. Whatever your work setting is, whatever type of PT you are, and whatever you plan to do with your degree, it’s important to understand how physical therapists practice in your state under the Direct Access Law. The more you know, the more you can educate patients and the general public about what the physical therapy field can offer.

2. Research your state’s Direct Access guidelines

As noted above, every state in the US has Direct Access, but the differences in the rules arise at the state level.

The limitations at the state level include the following (from most restrictive to least restrictive):

  • Limited patient access: Access to evaluation, fitness & wellness, and limited treatment only to certain patient populations or under certain circumstances (i.e. treatment restricted to patients with a previous medical diagnosis or subject of a previous physician referral).
  • Patient access with provisions: Access to evaluation and treatment with some provisions such as a time or visit limit, or referral
    requirement for a specific treatment intervention such as needle EMG or spinal manipulation.
  • Unrestricted access: No restrictions or limitations whatsoever for treatment absent a referral.

The Direct Access Law in California (a “patient access with provisions” state) allows a licensed physical therapist to provide physical therapy services for 45 days or 12 visits, whichever occurs first. After that limit has been reached, the physical therapist may continue to see that patient only after receiving a signed plan of care or a prescription for physical therapy.

On the other hand, the Direct Access Law in Alaska (an “unrestricted access” state) states that a patient can be seen for an unlimited amount of visits or days as long as the physical therapist refers out if the patient is beyond the help of physical therapy. [ii]

3. Know which insurance plans will cover Direct Access physical therapy treatments

Ah, insurance. Always changing, and always confusing. Savvy PTs should know the basics about how Direct Access works with insurance, even if they look up the specifics on a case-by-case basis. This will likely be the case, as insurance changes too often to reliably cover all the details in this article.

Private Health Insurance companies

For Blue Cross Blue Shield, Cigna, United Health Care, and many private health insurance companies, the rule of thumb is that PPO plans are covered under DA. HMO plans will always require a referral for payment on physical therapy services. This does not mean a therapist cannot legally treat an HMO patient without a physician’s prescription, but it does mean that the therapist will likely be denied payment by the insurance company without the physician’s prescription.

Medicare

There are different guidelines when treating a Medicare patient. Medicare will allow you to treat a patient under Direct Access, as long as you stay within the limits of their laws. During the initial evaluation, you must establish a plan of care (POC) for the patient. In order to continue to see the patient, the physical therapist must have the POC signed off by a licensed physician. Once you receive the POC signed from the physician you can continue to see the patient.

When billing for the evaluation, you can only bill the evaluation code; 97161, 97162, or 97163. If you bill other CPT codes during the evaluation, Medicare will deny them.

4. Leverage the initial evaluation

Regardless of the type of insurance your patient is using, always establish a POC during the evaluation, and send that POC to the patient’s physician. The plan of care can be used as a catalyst to your ever-growing referral pool (which, as discussed in more detail in #6, will have a very reciprocal feel under the Direct Access Law).

If your POC states that your treatments will last longer than the limits of Direct Access Law in your state, you want to already have a potential referral source for your patient.

5. Using Direct Access to foster commitment to the physical therapy process

During your evaluation, you want to make sure your patients are not only motivated to do the exercises and the homework that you give them, but also to recognize the fact that they only have as long as the DA law allows them, before they need to go back to the doctor. For example, in California a patient gets 12 visits or 45 days of treatment.

If a patient knows he or she only has this long before needing to schlep back to the physician (and possibly deal with a high co-pay), it can often light the proverbial fire under his/her butt to keep PT appointments and prioritize getting to appointments on time.

6. Use Direct Access to help grow your referral pool

In the traditional sense of physical therapy practice, building a base of referring doctors can be a daunting task. With Direct Access, you have already have a patient who needs a doctor. The patients themselves are your referral sources. You can market directly to patients to get them in the door. And there’s a double benefit, because when they leave your clinic, thrilled with their care, they will tell their physicians about you, which will get you even more referrals.

Thinks about this? What’s better than a sticky note with your logo? An actual patient carrying that sticky pad with a logo on it.

Be picky about the physicians to whom you refer your patients, as the care they receive from those physicians will be reflection on your practice.

Got questions? Good! Ask away, and we’ll do our best to provide the answers. We really only scratched the surface of this topic. Don’t forget to read up on the APTA’s FAQs about Direct Access.

 

References:

http://www.apta.org/StateIssues/DirectAccess/
https://www.apta.org/uploadedFiles/APTAorg/Advocacy/State/Issues/Direct_Access/DirectAccessbyState.pdf

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About Carrie Hayes

Carrie Hayes
Hello! I have been in the healthcare field my entire life. I am currently the Clinic Manager of Movement Rx Physical Therapy. My passion is to help new and old PTs learn the tricks and the trade of the office staff. I also just recently started a website carriehayesco.com. It's a work in progress and still isn't live since i am a full time mom to a 5 year old daughter. If i'm not helping MRx and other practitioners you can find me hiking or camping.

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