How does therapy direct access and Medicare get along? Therapists with direct access are often discouraged to learn that the freedom to practice without physician referral may come at a cost of insurance reimbursement, including Medicare. Does a Medicare beneficiary need a physician referral for physical or occupational therapy? Well it depends on if the evaluation results in a certified plan of care with additional visits or the evaluation is a one time service resulting in no additional therapy under a plan of care.
Therapy Direct Access and Medicare – The Facts
If a beneficiary presents for an evaluation, but does not have a physician referral, the certification of the plan of care (including therapy visits under the plan) by the referring physician serves as documentation that he/she is under the care of the physician. Therapy records, per CMS should justify that:
- The patient is under the care of a physician (or NPP).
- Physician care shall be documented by physician certification of the plan of care; and
- Although not required, other evidence of physician involvement in the patient’s care may include, for example: order/referral, conference, team meeting notes, and correspondence.
Therapy Evaluation is the only Service
However, according to CMS in the Medicare Benefits Policy Manual:
….. when evaluation is the only service, a referral/order and evaluation are the only required documentation. If the patient presented for evaluation without a referral or order and does not require treatment, a physician referral/order or certification of the evaluation is required for payment of the evaluation. A referral/order dated after the evaluation shall be interpreted as certification of the plan to evaluate the patient.
Best Practice for Direct Access and Medicare
Direct access and Medicare? The answer may seem simple, if the evaluation results in a POC a referral is not necessary, but what if you evaluate a beneficiary and develop a plan of care and the patient never returns, and the plan of care is never certified? In this instance the evaluation is not a payable service unless, as noted above there is a referral or the physician signs (certifies) the evaluation. So best practice in your practice should include the requirements for a physician referral.
Oh, by the way, a little secret: even though a referral is not required, RACs, and MACs ADR documentation requests often include a “physician referral” in the list of requested response documents. This creates a risk of denial, likely reversible on appeal. Why create a reason for an appeal?
Does your state have direct access? What is the policy at your practice? Do you require physician referrals for Medicare?