The document discusses direct access to physical therapy without a physician referral. It notes that direct access laws can save $1200 per patient per episode of care by removing unnecessary medical visits. Direct access allows patients to see a physical therapist for musculoskeletal issues without a prior doctor's order, though some restrictions may apply. Common physical therapy treatments include back pain, neck pain, dizziness, and muscle aches. The document also reviews Medicare regulations regarding physical therapy coverage and annual visit limits.

1. A N D A P P L I C A B L E M E D I C A R E R E G U L A T I O N S
Direct Access to Physical Therapy

2. What is Direct Access?
 To have "direct access" to physical therapy means
you do not need to see a physician prior to initiating
therapy treatment
 No order/referral necessary
 See physical therapist directly for skeletomuscular
ailments

3. Direct Access Approach
Study shows a cost savings
of $1200 per patient, per
episode of care with the
implementation of direct
access laws
The main purpose of direct
access legislature is to have
easier, faster access to skilled
professionals (such as
physical therapists) and to
decrease the cost of medical
expenses.

4.  Patients do not need a referral from a physician to
initiate therapy, but there are still some restrictions
and criteria that need to be met
 TN allows Provisional Access*
*Please reference booklet for
details
Provisional Access in Tennessee

5. What common ailments can a physical therapist
treat?
 Backaches
 Neck pain
 Dizziness/ vertigo
 Muscle aches and nerve pain/ numbness

6. Medicare Facts
 2014 Part B deductible is $147
 After this, Medicare covers 80% of costs and will
forward the balance to any supplemental insurance/
gap coverage you may have
 Medicare limits how much it pays for your medically
necessary services in one calendar year. These limits
are called “therapy caps.”

7. Medicare Regulations and Limitations
 Even with direct access laws, payment of Medicare
claims is dependent on physician approval of
therapist’s Plan of Care (POC)
 Outpatient therapy cap limits:
-$1,920- $3700 per calendar year for 2014
-Includes physical therapy and speech-language
pathology
 Cap exception for qualifying services: $3700
 For services above $3700, submission of
documentation is required

8. Services above Medicare caps
 Therapist must issue “Advance Beneficiary Notice of
Non-coverage” before providing services not deemed
medically reasonable and necessary
 ABN lets you choose whether you want the services
 If you were not given ABN beforehand, you will not
be responsible for services deemed not medically
necessary

9. Keeping track of Therapy Caps and Services
 Your Medicare services can be tracked online at
MyMedicare.gov
 Check your Medicare Summary Notice (comes in the
mail about every 3 months)
 More information about Medicare services can be
obtained by calling 1-800-MEDICARE