Navigating the rules for physical therapy (PT) coverage under Medicare can be complex for beneficiaries seeking care. Whether a formal referral is required depends entirely on the type of Medicare coverage a person holds. Understanding the difference between a physician’s referral and the necessary physician certification is the most important step in securing coverage for outpatient PT services. These requirements are set by federal law to ensure that the services provided are medically necessary and appropriate.
The Medicare Part B Referral Requirement
For beneficiaries covered by Original Medicare, which includes Part B for outpatient services, a formal referral order from a physician is generally not necessary to begin physical therapy. The patient has the flexibility to directly schedule an appointment with a Medicare-enrolled physical therapist. However, the services must be furnished while the beneficiary is under the care of a physician or other non-physician practitioner (NPP), such as a Nurse Practitioner or Physician Assistant.
This distinction means that the physical therapist can perform an initial evaluation and start treatment without a referral. To ensure Medicare reimbursement, the physical therapist must promptly develop a comprehensive Plan of Care (POC) that details the treatment goals, frequency, and duration of the therapy. This POC must then be certified—meaning signed and dated—by the supervising physician or NPP within 30 calendar days of the initial treatment date. This physician certification confirms that the medical services are considered medically necessary for the patient’s specific condition.
If this signed certification is not secured within the 30-day window, Medicare may deny payment for the services rendered. The physician does not necessarily have to examine the patient before signing the POC, but the therapist must ensure the physician agrees with the treatment plan.
The Impact of State Direct Access Laws
State-level legislation known as “Direct Access” grants patients the ability to see a physical therapist without first obtaining a physician’s referral. These laws vary significantly, ranging from “full access,” which permits unrestricted treatment, to “limited access,” which might impose restrictions on the number of visits or the duration of treatment. Direct Access laws permit a patient to begin their initial physical therapy evaluation and treatment immediately, bypassing any potential delays caused by scheduling a separate physician appointment.
Despite the immediate access provided by state laws, the federal rules for Medicare reimbursement still apply. State law dictates how a patient accesses the provider, but federal Medicare law dictates how the provider is paid. Therefore, even in a state with full Direct Access, the physical therapist must still comply with the federal requirement for physician certification of the Plan of Care within the 30-day period following the start of treatment.
Physical Therapy Coverage Under Medicare Advantage
For beneficiaries enrolled in a Medicare Advantage (MA) plan, also known as Medicare Part C, the rules for accessing physical therapy often differ significantly from Original Medicare. MA plans are managed by private insurance companies, and while they must cover all the benefits of Original Medicare, they are permitted to impose stricter administrative requirements.
These plans often utilize managed care structures, such as Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs), which can affect access to specialists. In many cases, an MA plan—particularly an HMO—will require a formal referral from the patient’s primary care physician before physical therapy treatment can begin.
Additionally, these private plans frequently require prior authorization for services, meaning the plan must approve the number of visits or the type of treatment before it is rendered. This administrative hurdle can create a delay in starting care. Beneficiaries should always consult their specific plan documents or contact the insurer directly to confirm their referral and authorization requirements before scheduling their first appointment.
Essential Requirements for Medicare Reimbursement
Beyond the initial certification, continuous documentation and adherence to specific guidelines are necessary for Medicare to continue covering physical therapy services.
Plan of Care Documentation
The Plan of Care must contain measurable long-term treatment goals and clearly specify the type, amount, frequency, and duration of the therapy services provided. The therapist must conduct and document regular progress reports, at least every tenth visit, to evaluate the patient’s progress toward the established goals.
Recertification and Thresholds
Medicare also mandates physician recertification of the Plan of Care whenever there is a significant change in the patient’s condition or, at minimum, every 90 calendar days from the initial treatment date, whichever comes first. This ongoing oversight ensures the services remain medically necessary and skilled. Furthermore, if the patient’s therapy costs exceed an annual financial threshold—which is jointly applied to physical therapy and speech-language pathology services—the therapist must append a specific code, the KX modifier, to the claim. This modifier attests that the services exceeding the threshold are still medically necessary and that the required documentation is present in the patient’s record.