Omar Bennett
Physical therapy is a treatment that helps to restore or improve physical movement in the body after an injury, illness, or surgery. It can also be used to improve or maintain current physical functions or slow decline. Physical therapy is considered to be medically necessary when it is prescribed by a qualified health professional, such as a chiropractor, DO, MD, nurse practitioner, or podiatrist, and when it is deemed that the patient's condition can significantly improve as a result of the treatment. A physical therapy prescription, or referral, is a written or electronic document that authorizes the need for an evaluation and/or treatment. This prescription is often required by insurance companies and should include the doctor's name, address, educational degree, registration details, contact information, and logo.
| Characteristics | Values |
|---|---|
| Prescribed by | Chiropractor, DO, MD, nurse practitioner, podiatrist or other health professional qualified to prescribe physical therapy |
| Purpose | To significantly improve, develop or restore physical functions lost or impaired as a result of a disease, injury or surgical procedure |
| Criteria | The member’s condition can improve significantly based on physical measures (e.g. active range of motion (AROM), strength, function or subjective report of pain level) within one month of the date that therapy begins |
| Treatment plan | Must be reviewed and approved by the treating physician in accordance with applicable state laws and regulations |
| Coverage | Medicare Part B (Medical Insurance) helps pay for medically necessary outpatient physical therapy |
| Cost | After meeting the Part B deductible, the patient pays 20% of the Medicare-approved amount |
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What You'll Learn
Physical therapy prescription
A physical therapy prescription, sometimes referred to as an order or referral, is a written or electronic document from a medical professional that authorises the need for a physical therapy evaluation or treatment. The prescription should be on the doctor's letterhead and include their name, address, educational degree, registration details, contact details, and logo. While a prescription is not always required to receive physical therapy, local regulations and insurance requirements often mandate it under certain circumstances.
Prescription formats can vary, but they usually include one or more International Classification of Diseases diagnosis codes associated with the need for physical therapy treatment, as well as a written explanation of the reason for the intervention. The prescription should also include the diagnosis, type, frequency, and duration of the prescribed therapy, the goals of the therapy, and any necessary safety precautions. The ultimate goal of any physical therapy intervention is to improve the patient's long-term function, typically through exercise, manual therapy, and modalities.
In the United States, as of February 2021, there were 20 states that allowed direct access to physical therapy services without restrictions, 27 states and territories that allowed direct access with some parameters or restrictions, and three states that permitted direct access only under specific circumstances. Even in states that allow direct access, insurance providers may still require a prescription under certain circumstances.
It is important to note that physicians are not licensed as physical therapists and, therefore, cannot directly supervise physical therapy assistants. Physical therapy must be provided in accordance with an ongoing, written plan of care that is reviewed and approved by the treating physician, following applicable state laws and regulations. The plan of care should contain sufficient detail and data to demonstrate the medical necessity of the proposed treatment.
When considering the medical necessity of physical therapy, Aetna specifies that it is medically necessary when prescribed by a qualified health professional to significantly improve, develop, or restore physical functions lost or impaired due to a disease, injury, or surgical procedure. Additionally, it is considered medically necessary when it is determined that the member's condition can improve significantly within one month of starting therapy or when it is necessary for establishing a safe and effective maintenance program that the member can perform independently without ongoing skilled therapy services.
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Medical professionals qualified to prescribe physical therapy
In the United States, a physical therapy prescription is a written or electronic document from a specific medical professional, authorizing the need for a physical therapy evaluation or treatment. The prescription should be on the letterhead of the doctor, mentioning their name, address, educational degree, registration details, contact details, and logo.
According to the American Physical Therapy Association, as of February 2021, there were 20 states that allowed direct access without any restrictions, 27 states with some form of restrictions, and three states that allowed direct access only under specific circumstances.
The medical professionals qualified to prescribe physical therapy include:
- Physicians: Physicians can prescribe physical therapy as part of a patient's treatment plan. However, they are not licensed to directly supervise physical therapy assistants.
- Nurse Practitioners: Nurse practitioners are qualified to diagnose conditions and recommend physical therapy.
- Chiropractors: Chiropractors are qualified to prescribe physical therapy to help restore physical functions.
- Doctors of Osteopathy (DO): Doctors of Osteopathy can prescribe physical therapy, but they are not medical doctors.
- Podiatrists: Podiatrists are also qualified to prescribe physical therapy according to state law.
- Other Authorized Providers: In some cases, other healthcare providers, such as occupational therapists or mental health professionals, may be authorized to prescribe physical therapy, depending on local regulations and the patient's specific needs.
It is important to note that the requirements for a physical therapy prescription may vary based on location, insurance requirements, and individual circumstances.
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Medical necessity of physical therapy treatment plans
Physical therapy is considered medically necessary when prescribed by a qualified health professional, such as a chiropractor, DO, MD, nurse practitioner, or podiatrist, to improve, develop, or restore physical functions affected by a disease, injury, or surgery. The treatment plan should be detailed, reviewed, and approved by the treating physician, adhering to state laws and regulations. It should include objective and subjective data to demonstrate medical necessity.
A physical therapy prescription, also known as an order or referral, is a written or electronic document authorizing the need for an evaluation and/or treatment. While direct access to physical therapy services is possible without a prescription in some cases, local regulations and insurance requirements often mandate a prescription under specific circumstances. The prescription should be on the doctor's letterhead, including their name, clinic address, educational degree, registration details, contact information, and logo.
To justify the medical necessity of physical therapy treatment plans, therapists must provide clear and appropriate documentation. This documentation should evaluate and articulate the client's medical necessity, illustrate the complexity of the therapist's skills, and recognize what constitutes appropriate documentation.
Medicare Part B (Medical Insurance) covers medically necessary outpatient physical therapy when certified as necessary by a doctor or healthcare provider, such as a nurse practitioner or physician assistant. There is no limit to how much Medicare pays for these medically necessary services in a calendar year, and the patient pays 20% of the Medicare-approved amount after meeting the Part B deductible.
Some specific physical therapy interventions are considered experimental or investigational, and their effectiveness is yet to be established. For example, adhesion removal physical therapy for bowel obstructions and various taping methods for lower extremity spasticity, knee or back pain, and other indications lack proven outcomes. Therefore, these interventions are not considered medically necessary, and standard methods of physical therapy available in-network should be utilized.
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Physical therapy as an extension of case management services
Physical therapy is considered medically necessary when prescribed by a qualified health professional, such as a chiropractor, DO, MD, nurse practitioner, or podiatrist. The goal is to improve, develop, or restore physical functions lost or impaired due to disease, injury, or surgery. Case management in physical therapy involves planning, organizing, coordinating, monitoring, and evaluating rehabilitation services and resources for patients. Case managers ensure comprehensive and tailored rehabilitation services, which are crucial for effective recovery. They operate in various settings, including hospitals, inpatient and outpatient centres, home health settings, insurance companies, and private practices.
Case management can be an extension of physical therapy services, especially in complex cases involving multiple chronic conditions or severe injuries. These cases demand intensive management and a multidisciplinary approach. Case managers play a pivotal role in ensuring patients receive comprehensive care, which includes physical, emotional, and psychological support. Social workers, for instance, help patients cope with stress and anxiety accompanying physical ailments and connect them with community resources that aid in their rehabilitation.
The integration of telehealth services has revolutionized patient access to physical therapy, offering remote consultations and treatments. Telehealth platforms ensure continuity of care and support, especially during periods when in-person sessions are not feasible. Additionally, advancements in rehabilitation technology, such as wearable sensors and smart devices, have enhanced the precision and effectiveness of physical therapy treatments.
Physical therapy case management often involves educating patients about their specific diseases, empowering them to understand and manage their conditions more effectively. This education can take the form of information sessions, workshops, and educational materials. Case managers also address transportation and accessibility issues, coordinating with transportation services or providing resources to help patients reach treatment locations efficiently.
In the context of reducing hospital admissions, ED-based physical therapy, and case management consultations have been explored as a viable method. This approach enables rapid evaluation and disposition of patients, potentially reducing resource utilization, length of hospital stay, and costs for both patients and the healthcare system.
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Physical therapy without a prescription
In the United States, the requirement for a prescription to receive physical therapy treatment varies from state to state. Some states have restrictions that require patients to see a physician and obtain a prescription before seeing a physical therapist. However, many states have direct access laws, which allow patients to seek physical therapy services without a prescription or referral from a physician. These laws differ across states, with some offering complete unrestricted direct consumer access to physical therapy, while others place limitations on the number of visits or duration of treatment before a prescription or referral is needed.
Direct access to physical therapy provides several benefits to patients. Firstly, it enables patients to commence treatment sooner, reducing the time spent on multiple appointments and waiting periods. This early intervention can lead to quicker recovery and pain relief, allowing individuals to resume their daily activities, work, and athletic pursuits more promptly. Additionally, direct access can help patients save money by potentially avoiding unnecessary visits to physicians, medications, surgeries, and extensive imaging tests. Research supports these advantages, with a study by BlueCross BlueShield of South Carolina indicating that direct access to physical therapy resulted in a 31% reduction in total healthcare costs, an 80% decrease in patient out-of-pocket expenses, and a 90% reduction in opioid use.
It is important to note that even with direct access, physical therapy clinics typically have licensed healthcare professionals who assess a patient's condition and create a personalized plan of care. This plan includes information about the patient's injury or condition, as well as the recommended recovery process, which may involve follow-up with the patient's physician or a specialist. Physical therapy without a prescription does not imply a lack of collaboration or coordination with other healthcare providers.
While direct access provides convenience and benefits to patients, it is always advisable to consult with a healthcare professional or your primary care physician to determine the most appropriate course of treatment for your specific condition. They can guide you on whether physical therapy is medically necessary and suitable for your individual needs.
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Frequently asked questions
A physical therapy prescription, sometimes called an order or a referral, is a written or electronic document from a specific medical professional, authorizing the need for a physical therapy evaluation and/or treatment.
Medical necessity for physical therapy is when this care is prescribed by a qualified health professional, according to State law, to significantly improve, develop or restore physical functions lost or impaired due to a disease, injury, or surgery.
For billing and coding purposes, it is essential to have documentation that clearly illustrates the medical necessity of the client. This includes providing objective and subjective data to demonstrate the necessity of the proposed treatment.
