Physical Therapy Self-Referral ( Direct Access )

Physical Therapy Self-Referral ( Direct Access ) Summary of Statutes and Regulations by State December 2007 The American Association of Orthopaedic Surgeons (AAOS) supports a patient-centered approach to health care. This approach is based on a strong physician-patient relationship and is complemented by physician recommended ancillary care services, such as physical therapy. However, the American Physical Therapy Association and allied groups advocate for state direct access laws that would enable non-physician providers, including physical therapists, to take on patient care responsibilities that are beyond the scope of their education and training. Direct access laws represent a move away from collaboration between physicians and non-physicians, resulting in a fragmentation of the traditional patient-centered model. Any time a health care professional works outside of the scope of practice justified by their education and training, patients are needlessly put at risk. Safe, high-quality patient care depends on the ability of the provider to render an accurate medical diagnosis. While physicians depend on physical therapists to provide quality rehabilitative services, only a licensed physician is qualified to determine the type and duration of treatment. The practice of self-referral by physical therapists prompts patients to bypass physicians and directly access physical therapy services, placing patients at serious risk for complications resulting from delayed or missed diagnoses of more serious conditions. To preserve the quality of our health care system, patients must be assured that the care they receive is collaborative and based on an accurate medical diagnosis. Direct access laws very widely from state to state. The AAOS has developed a tiered system of classification system for state laws and regulations to identify those states where patient safety may be at greatest risk: Tier I: Tier II: Tier III: Tier IV: Tier V: Comprehensive PT Self-Referral Protections Limited PT Self-Referral Protections (Durational and Conditional Limitations) Minimal PT Self-Referral Protections (Narrow Conditional Limitations) Silent or Ambiguous PT Self-Referral Protections Unrestricted Direct Access

Tier I: Comprehensive PT Self-Referral Protections The state ensures patient safety by requiring a referral from an appropriate health care professional prior to the start of any treatment and to consult with the patient s physician on an ongoing basis. In some cases, the physical therapist may evaluate but not treat a patient without a referral. State Statutory Language AL Physical therapy shall be practiced only upon the referral of a physician licensed to practice medicine or surgery or a dentist licensed to practice dentistry. CA Prohibits diagnosis of a disease Requires diagnosis by a physician or other licensed professional before a physical therapist may commence treatment. HI Treatment of a person by a licensed physical therapist is prohibited unless the person has been referred to the licensed physical therapist for treatment by a physician, dentist, chiropractor, naturopath, optometrist or podiatrist. A licensed physical therapist may perform evaluation of any person without a referral. IL Physical therapists subject to disciplinary action for: Treating without referral or diagnosis from a physician, dentist, advanced practice nurse, physician assistant, or podiatrist; and Failure to notify the physician, dentist, advanced practice nurse, physician assistant, or podiatrist who established a diagnosis that the patient is receiving physical therapy pursuant to that diagnosis. IN It is unlawful for a person to practice physical therapy other than upon the order or referral of a physician, podiatrist, psychologist, chiropractor, or dentist. MI A physical therapist may not engage in the actual treatment of an individual without a referral. OK Physical therapist subject to disciplinary action if treatment is administered without the referral of a physician, surgeon, dentist, chiropractor or podiatrist.

Tier II: Limited PT Self-Referral Protections (Durational and Conditional Limitations) The state promotes patient safety to some extent by limiting duration and type of physical therapy treatments that may be performed without prior referral and by requiring physical therapists to seek regular physician consultations and referrals for new and/or prolonged physical therapy treatment. State Statutory Language CT Prohibits diagnosis of a disease Requires physical therapist to refer to a physician or other licensed practitioner if the condition for which the patient sought treatment for does not improve with a period of thirty days or six visits, whichever comes sooner. DE A physical therapist may provide treatment for up to thirty days after which time a physician must be consulted. Physical therapist must refer patient if patient displays symptoms requiring treatment outside the scope of physical therapy. FL Physical therapist may treat without a referral for up to 21 days for a condition not previously assessed by a physician or other licensed professional. After such time, the physical therapist must consult with an appropriate licensed professional on the course of treatment. Physical therapist must refer patient if symptoms present require treatment outside the scope of physical therapy. Prohibits physical therapists from developing treatment plans for patients in acute care settings. GA Physical therapist may treat without referral: For the purpose of fitness, wellness or prevention that is not related to the treatment of an injury or ailment; If the patient was previously diagnosed and received treatment for the same condition within 60 days and the physical therapist notifies the referral source within five business days of resuming treatment Provided the physical therapist refers the patient to a physician or other appropriately licensed practitioner if no substantial progress has been made within 90 days. KS Physical therapist may treat a patient for up to 30 days without a physician s referral if the patient has been referred to a physical therapist for that condition within the previous year. ME Prohibits diagnosis of a disease Physical therapist must refer patient to a physician, dentist or chiropractor if no progress been made within thirty days and must consult with a physician, dentist or chiropractor if treatment is to exceed 120 days. Physical therapist must make referral when required treatment is beyond the scope of physical therapy. Employers are not liable for physical therapy costs incurred under workers compensation unless the patient was referred to physical therapy.

MN To treat without a referral, the physical therapist must: Seek referral from a physician, dentist or chiropractor to treat for more than 30 days. Practice for at least one year under a physician s supervision Consult with appropriate provider before altering a patient s treatment plan. Refer to an appropriate provider when necessary treatment is beyond scope of physical therapy practice. MO Physical therapist may not treat without a diagnosis made by a physician, chiropractor, dentist, or podiatrist within the last year. Physical therapist must refer patient to a physician, chiropractor, dentist, or podiatrist if progress is not made within 14 days or 6 visits, whichever comes first. Physical therapist must consult with a physician, chiropractor, dentist, or podiatrist if treatment is to exceed 30 days. NJ Physical therapist must refer to licensed health care professional if the patient fails to demonstrate reasonable progress within 30 days of initiating treatment. Physical therapist must consult with patient s licensed health care professional within 30 days of initiating treatment for functional limitation or pain as to appropriateness of treatment. If no health care provider is on record, the physical therapist must recommend that the patient consult with a licensed health care provider of the patient s choice. NY Physical therapist may treat without referral for up to 30 days or 10 visits, whichever comes first. Must provide written notification to the patient that services provided without a referral may not be covered by insurance. OH Physical therapist must have a master s degree or two years of experience to treat without a referral. Must refer to appropriate health care provider if no progress has been made in 30 days unless the patient has already been diagnosed with chronic, neuromuscular or developmental conditions. Physical therapist must inform the patient s health care provider within 5 days of initial evaluation. RI Physical therapist with more than one year of clinical experience may treat without referral provided the patient is given a written explanation of the scope of physical therapy and signs their consent hereto. Patient must be referred to a licensed practitioner within 90 days after initiation of treatment. SC Physical therapist may treat without referral for up to 30 days. Must refer to a physician or dentist if the patient s condition is beyond the scope of physical therapy. TN Physical therapist may treat without referral for up to 30 days if the therapist has a master s degree and/or the minimum required clinical experience. Must notify patient's physician, chiropractor, dentist, podiatrist, or osteopath of evaluation and treatment plan within five days of initial evaluation.

TX Prohibits diagnosis of disease. Physical therapists with more than one year of experience may treat a patient for the same condition that was previously cited in a physician s referral if: Physical therapist notifies physician within five days of commencing treatment. Physical therapist consults with the source of the original referral if treatment exceeds 30 days or 20 visits, whichever comes first. Treatment begins within one year of the original referral date. VA Physical therapist may evaluate and treat a patient for up to 14 consecutive business days without a referral if: The patient is not already receiving care for the condition by a physician or other licensed health care provider. The patient identifies a provider they intend to seek treatment from if the physical therapy treatment fails to improve the condition within 14 days. The patient agrees to allow the physical therapist to share all personal health information with that provider. The physical therapist informs the identified provider of the treatment and patient history obtained through the evaluation. WY Physical therapists with a master s degree or five years experience may treat without a referral for 30 days or 12 visits, whichever comes first. Treatment for chronic or recurring conditions must have been diagnosed and treated by an appropriate provider in the previous year.

Tier III: Minimal PT Self-Referral Protections (Narrow Conditional Limitations) The state demonstrates limited support for patient safety in the context of physical therapy treatment. The state requires physical therapists to seek consultations and/or referrals for physical therapy treatment under specific circumstances and for certain diagnoses, but allows the physical therapist to treat with minimal or no medical oversight in other cases. State Statutory Language AR Physical therapist may treat without a referral except in cases involving bronchopulmonary hygiene, debridement and wound care. IA Physical therapist may treat without referral outside of a hospital setting for an indefinite period of time. In a hospital context, the hospital may require medical examination prior to treatment. KY Referral is required only when patient s condition is beyond the scope of practice of a physical therapist. LA Physical therapist may conduct initial consultation or evaluation without a referral. Physical therapist may not commence treatment without a referral from a person licensed to practice medicine, surgery, chiropractic, dentistry, or podiatry except in the following cases: To children diagnosed with a developmental disability pursuant to the patient s plan of care. As part of a home health care agency pursuant to the patient s plan of care. To a patient in a nursing home pursuant to the patient s plan of care Related to conditioning or to providing education or activities in a wellness setting for the purpose of injury prevention, reduction of stress, or promotion of fitness. To an individual for a previously diagnosed condition for which physical therapy treatment is appropriate after informing the health care provider rendering the diagnosis, provided the diagnosis was made in the previous ninety days. The physical therapist must provide the health care provider with a plan of care with the first fifteen days. MS Physical therapist may not perform treatment without referral from an appropriate health care provide except in the following cases: To children diagnosed with a developmental disability pursuant to the patient s plan of care As part of a home health care agency pursuant to the patient s plan of care To a patient in a nursing home pursuant to the patient s plan of care Related to conditioning, education or activities in a wellness setting for the purpose of injury prevention, reduction of stress, or promotion of fitness. To an individual for a previously diagnosed condition for which physical therapy treatment is appropriate after informing the health care provider rendering the diagnosis, provided the diagnosis was made in the previous 180 days. The physical therapist must provide the health care provider with a plan of care with the first fifteen days.

NH Physical therapist must refer patient to an appropriate health care provider in the following cases: The patient s symptoms or conditions require treatment that is beyond the scope of practice of physical therapy Physical therapy is contraindicated. There is no documented improvement with 25 days of the initiation of treatment. NC Diagnosis of a disease is prohibited. Physician referral is required for physical therapist to perform manipulation of the spine. It is unlawful for a physical therapist to fail to refer patient to a physician when the condition presented is beyond scope of physical therapy practice. NM Physical therapist can only practice without a referral if: The patient is a child enrolled in a an approved special education program; or The patient requires acute care and the treatment is not outside the physical therapist s scope of practice. OR Physical therapist must refer patient when symptoms present require treatment beyond the scope of physical therapy practice. Physical therapist must meet minimum education requirements in order to treat without referral. Referral is required when physical therapy treatment initiated without prior referral exceeds 60 days, unless: Patient is a child or student eligible for special education. Patient is a student athlete seeking treatment in the role as an athlete. Patient is a resident of a long-term care facility, residential care facility, adult foster home or an intermediate care facility for mental retardation. PA Physical therapist may apply for a certificate of authorization from the Pennsylvania Board of Physical Therapy to perform treatment without referral provided the PT meets minimum educational and experiential requirements. Physical therapist may not treat any condition that is nonneuroligic, nonmuscular or nonskelatal, or treat any patient who has an acute cardiac or pulmonary condition without first consulting the patient s licensed physician, dentist or podiatrist. WA Physical therapist may treat without a referral for the purposes or evaluating and testing individuals to determine a diagnosis, and to alleviate impairments and functional limitations. Physical therapist may not perform wound care services or treatment utilizing orthoses for the foot or ankle without a referral or consultation with an authorized health care provider. Physical therapist must refer to appropriate health care provider if symptoms or conditions present are beyond the scope of physical therapy practice. WV Prohibits physical therapists from performing electromyography examination and electrodiagnostic studies other than the determination of chronaxia and strength duration curves except under supervision of physician.

WI Physical therapist may not treat without a referral unless the services provided are: In schools to children with disabilities. As part of a home health care agency pursuant to the patient s plan of care. To a patient in a nursing home pursuant to the patient s plan of care Related to athletic activities, conditioning or injury prevention. To an individual for a previously diagnosed medical condition after informing the practitioner who made the diagnosis.

Tier IV: Silent or Ambiguous PT Self-Referral Protections Tier IV: The state is either silent or ambiguous as to whether a physical therapist is required to seek a physician s referral or consultation before treating a patient. State Statutory Language AK Physical therapist subject to discipline if PT has failed to refer to another qualified professional when patient s condition is beyond the training or ability of the person. AZ Physical therapist must refer to an appropriate health care practitioner if symptoms or conditions present require treatment beyond the scope of practice of physical therapy or if physical therapy is contraindicated. CO Disciplinary action may be taken if PT fails to refer to appropriate licensed health care professional another qualified professional when patient s condition is beyond the level of competence of the PT or beyond the scope of physical therapy practice. DC Omission ID Physical therapist may not diagnosis disease. Patient must be referred to appropriate health care provider when condition is beyond scope of physical therapy practice. MD Physical therapist may be disciplined for practicing physical therapy inconsistent with any written or oral order of a licensed physician. MA Sets PT Code of Ethics as standard for referral relationships. Physical therapist must refer to a licensed practitioner when physical therapy treatment is contraindicated for conditions indicated by symptoms present. Physical therapist must refer to a licensed practitioner when symptoms or conditions are beyond the scope of physical therapy treatment. Physical therapist must provide ongoing communication with referring practitioner. NE Performing procedures beyond the scope of physical therapy practice constitutes unprofessional conduct. NV Physical therapy does not include the diagnosis of physical disabilities. ND Physical therapist subject to license revocation for failure to refer to a licensed health care professional when condition is beyond scope of physical therapy practice. UT Physical therapist may not perform diagnosis of disease, surgery, acupuncture or x-ray for diagnostic or therapeutic purposes.

Tier V: Unrestricted Direct Access The state does not support patient safety through required referrals for physical therapy. Physical therapists in the state are not required to seek physician referrals or consultations to initiate or perform physical therapy treatment for any period of time. State Statutory Language MT Physical therapist may perform evaluation and treatment without a referral. Physical therapist may be subject to license revocation if treatment provided is beyond PT scope of practice. SD No restrictions. VT No restrictions.