Tag: Physical Therapy

Physical Therapy Referrals: Not Needed

Physical therapist services are generally covered as a basic benefit by all major health insurance companies. Ask your physical therapist to contact your insurance company to determine your specific benefits.

Physical therapist services are generally covered as a basic benefit by all major health insurance companies. Ask your physical therapist to contact your insurance company to determine your specific benefits.

CAN I RECEIVE PHYSICAL THERAPY SERVICES WITHOUT A PHYSICIAN’S REFERRAL?

Consumers are not required to have a referral or diagnosis in order to receive physical therapist services in the State of California. Physical therapist services may be obtained without a physician’s referral if you are a cash carrying patient, receiving treatment for up to 45 calendar days/12 visits, receiving health and wellness services, or if you are a UnitedHealthCare or Medicare beneficiary.

Please note: some health insurance companies require a referral in order for your provider to be paid. Please confirm your benefit requirements by reviewing your coverage documents or calling member services of your respective insurance company. The contact number to your insurance company is listed on the back of your health insurance identification card.

The California Physical Therapy Practice Act requires all licensed physical therapists to disclose (in writing) the following information to all consumers receiving physical therapist treatment without a physician or surgeon referral or diagnosis:

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Under California law, you may continue to receive direct physical therapy treatment services for a period of up to 45 calendar days or 12 visits whichever occurs first.


Under California law, you may continue to receive direct physical therapy treatment services for a period of up to 45 calendar days or 12 visits, whichever occurs first, after which time a physical therapist may continue providing you with physical therapy treatment services only after receiving, from a person holding a physician and surgeon’s certificate issued by the Medical Board of California or by the Osteopathic Medical Board of California, or from a person holding a certificate to practice podiatric medicine from the California Board of Podiatric Medicine and acting within his or her scope of practice, a dated signature on the physical therapist’s plan of care indicating approval of the physical therapist’s plan of care and that an in-person patient examination and evaluation was conducted by the physician and surgeon or podiatrist.

ADDITIONAL RESOURCES

Noridian Healthcare Solutions is the current Medicare Administrative Contractor for all healthcare services provided in California
Centers for Medicare and Medicaid Services
Health Insurance and Physical Therapy (For consumers)
Consumer Guide to Health Insurance

Physical Therapy Incident-to Billing Guidance

Evaluation and Management Coding for Physical Medicine and Rehabilitation

Incident-to services are services performed that are integral to and an incidental component of the physician’s professional services in an outpatient setting. Such services can be services performed, where permitted by the physician’s licensure rules, by auxiliary personnel, which may Include the physician’s staff.

For example, a chiropractic assistant applying electrical stimulation pursuant to the physician’s order and under that doctor’s direct (on-premise) supervision. While incident-to services are commonly performed by mid-level providers known as NPPs such as physician assistants (PAs), advanced registered nurse practitioners (ARNPs), and certified nurse midwives, for Medicare purposes, “auxiliary personnel can be anyone from an assistant to another physician provided that the ordering/supervising physician’s license permits delegation of the service that is performed by auxiliary staff.”

“auxiliary personnel can be anyone from an assistant to another physician provided that the ordering/supervising physician’s license permits delegation of the service that is performed by auxiliary staff.”


To bill services incident to, the physician must have initiated the care by personally performing the examination and personally developing the diagnosis and the plan of care. Auxiliary staff may perform services ordered where such delegation is permitted under the doctor’s license, provided that the physician is in the office suite providing supervision.

The physician does not need to be in the room, but they must be in the office and immediately available to intervene if needed. For physical and occupational therapists, the rule Is slightly different. Where permitted by their licensure rules, certified assistants can provide direct patient care under the supervision of a licensed PT/OT pursuant to a plan of care developed by the physical or occupational therapist and approved by a
medical physician.