Do We Need an Order for Therapy to See Medicare Patients
A question I am often asked is does the Medicare program require we have an order to begin therapy in addition to the physician signing and dating our plan of care? There are actually 2 answers to this question and the answer also depends on your practice setting (i.e. private practice versus non-private practice settings).
Under Medicare Part B therapy rules and regulations, the Medicare program does
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On billing (private practice) you’re required to report the referring physician & the date of the order on the HCFA form. If direct access is provided how do we report those?
You would have to check with the specific insurance carrier. They may tell you to leave that field blank. This would not apply to Medicare beneficiaries since the Medicare program does not recognize direct access for therapy services.
Do these CMS requirements apply to commercial insurances?
When I address CMS and the Medicare program, I am only commenting on the Medicare program.
I would appreciate some clarification on the subject of direct access…With CMS/Medicare patients, Physical therapy can be completed without an initial script if we know who is following the patient’s plan of care and that they will sign the plan of care before 30 days. Does this apply for OT and SLP? Is this with any insurance or is it insurance specific? What if the patient’s primary physician does not agree with Direct Access, can a different doctor sign the plan of care even though that doctor is not really following the patient? Thank you in advance.
In order to receive payment from the Medicare program, a physician or non-physician practitioner who is responsible for the oversight of care received by the Medicare beneficiary must certify or recertify the plan of care for outpatient physical, occupational, and speech therapy services. The Medicare program does not recognize Direct Access.
On this subject of orders for Outpatient services. How do you feel about standing orders? EX: A client has standing orders for PT from a adult day health program, that are carried over month to month via the pharmacy. How valid are they?
You would want to check with your state therapy Board and applicable insurance carrier.
as it relates to direct access, I live in the state of GA, and manage and OP rehab department that is part of a hospital system. I have reviewed the APTA information and it looks like GA is a state with patient access with provisions. As long as the provisions are being followed, are their challenges with reimbursement from providers and CMS if services are rendered without a prescription?
For outpatient therapy services, the Medicare program does not recognize direct access. The Medicare program does require the therapist establish a plan of care that is then sent to the patient’s physician or nonphysician practitioner to sign and date certifying the plan of care. You must also look at the Conditions of Participation per your practice setting to see if an order is required for therapy services prior to performing the initial evaluation.
For Medicare part B patients: If an Initial Eval & treat order or Clarification order for dates of service are missed how do you correct this? I know for POC/UPOC’s you can complete a delayed certification to be in compliance, is there anything for an order?
Under Medicare Part B therapy services, an order is not required. If your Conditions of Participation (CoP) for your practice setting require an order, then you must comply with the CoP. For Medicare Part B, it’s the signed and dated plan of care that is required for payment.