Eli's Rehab Report

Certain states may issue other rules that PTs should follow. For example, "In North Carolina, the only requirements are to refer out anyone the PT determines has a problem not in the PT's scope of care, according to the N.C. practice act," says Jean Genova, MS, PT, OCS, ATC, a physical therapist at Advance Physical Therapy and Holistic Health in Chapel Hill.
 
Make sure to check with your state PT licensing board for details.

No More Hassle and Wasted Time

"The cost benefit is to the insurance company, because they do not have to pay an E/M visit to the doctor," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for the CRN institute, an online coding certification center.
 
The American Physical Therapy Association Overview, Direct Access to Physical Therapy Services, states that "these states and insurance companies will realize cost savings of about $1,200 per patient episode of care, according to the results of a recent study by Dr. Jean Mitchell and Dr. Greg de Lissovoy of Georgetown University and Johns Hopkins University, respectively."
 
"The savings extend to hassle and wasted time," Jandroep adds, "because the patient did not have to make an appointment with their PCP first and then make an appointment with a PT -- and that's important if you're in pain."

Musculoskeletal Complaints Can Be Something Else

But direct access is not all good news. For one thing, you may not receive many direct-access patients. "It is harder to get patients into the clinic without that referral gatekeeper as with direct access, so the volume of direct- access patients is typically lower than those referred by PCPs," Genova says.
 
Also, your practice may not receive reimbursement as easily. Having preauthorization and certification for therapy from another physician makes payer acceptance easier. Without that step, you may have a tougher time proving medical necessity.
 
Take note: Medicare does not now allow direct access for their patients. "Medicare requires a referral prior to evaluation, an update at 60 days, then another update every 30 days. Without the proper documentation, claims will be denied," Genova says. That may change if the government accepts a national amendment proposed to allow direct access for Medicare.

Brush Up on Differential Diagnosis

Although PTs cannot make a medical diagnosis or prescribe either treatment or medications, they should strengthen their differential diagnosis abilities, especially if they plan to see more direct-access patients, Mulford says.
 
In general, PT practices evaluate whether a patient truly requires their services or not, owing to good business practices - but now that the patient enters their office directly, PTs can be liable for not recognizing potentially serious conditions.
 
For example: A patient may visit a PT with complaints of musculoskeletal pain when he really has a tumor, infection, organ pathology, vascular abnormality, other malignancies, fractures, or other metabolic problems, Mulford says. The PT's responsibility is to know the difference.
 
"There are red flags," Genova says. "A patient with a malignancy tends to have pain at rest, an infection accompanies fever and redness, and cardiac problems are often associated with exertion - all of these require further investigation."