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The wait for Direct Access in Texas for physical therapy is nearly over (this means treatment with out referral)!  The Texas Board of Physical Therapy Examiners has approved a draft of the proposed Rules that will govern the new provisions for Direct Access in the Practice Act. These Rules are the vehicle that give Direct Access its wings as well as its brakes. The purposed Rules was sent to the Governor and will be published in the Texas Register for public comments. Please note that the Rules are not official until after the public comment period ends and the Rules are codified in the Texas Administrative Code. This is estimated to take approximately 30-45 days.

Frequently Asked Questions Regarding Direct Access in Texas:

Q:  When can physical therapists begin treating patients without a referral?

A:  Effective September 1, 2019 a physical therapist may begin accepting patients without a referral, if all specified qualifications and requirements are met.


Q:  What qualifications must a physical therapist possess to be eligible to treat patients under the direct access law?

A:  Qualifications & requirements of a physical therapist include the following:

  • A physical therapist with a doctoral degree in physical therapy will be able to treat patients without a referral for not more than ten (10) consecutive business days;
  • A physical therapist who does not have a doctoral degree but has completed thirty (30) CCUs in the area of differential diagnosis will be able to treat patients without a referral for not more than ten (10) consecutive business days;
  • A physical therapist with a doctoral degree in physical therapy who has completed a residency or fellowship will be able to treat patients without a referral for not more than fifteen (15) consecutive business days;
  • A physical therapist must have been licensed to practice physical therapy for at least one year;
  • A physical therapist must be covered by professional liability insurance; (proposed amount $100,000 per claim and $300,000 aggregate per year);
  • A physical therapist must obtain a signed disclosure from the patient receiving Treatment Without Referral. (This requirement does not go into effect until 11-1-19)


Q: What happens when the allotted days for direct access has been reached?

A:  Once the number of allotted days has been reached, a referral from a qualified healthcare practitioner will be required in order to continue physical therapy treatments.


Q:  What individuals are considered qualified healthcare practitioners for referring to physical therapists?

A:  Qualified referrers have not changed since 1990’s when the rules were expanded to include healthcare practitioners licensed in the state or country in which they practice and have the authority to refer, they are:

  • Physicians
  • Dentists
  • Chiropractors
  • Podiatrists
  • Physician Assistants
  • Advanced Nurse Practitioners


Q:  What is meant by Direct Access Disclosure Statement?

A:  The Physical Therapy Practice Act requires that physical therapists who utilize direct access provide his/her patients with a disclosure document (to be drafted by the TBPTE) relating to Treatment Without Referral. This Disclosure Document becomes mandatory November 1, 2019.


Q:  Did the new direct access language replace the previous ‘limited’ direct access provisions?

A:  Yes and No.

The direct access provisions that were not eliminated by the new law apply to physical therapists regardless of what degree level they have obtained and without any additional requirements. The remaining provisions are:

  • Physical therapists will still be able to evaluate a patient without a referral;
  • Physical therapists will still be able to provide instructions to a person who is asymptomatic relating to the instructions being given, including instruction to promote health, wellness, and fitness;
  • Physical therapists will still be able to provide emergency medical care to a person after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity if the absence of immediate medical attention could reasonably be expected to result in a serious threat to the patient’s health, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

Unfortunately, it appears that there was an oversight and the following “Prior Referral” provision is no longer permitted.

**Please note:  The section below is what is no longer permitted: 

Prior referrals. A physical therapist may treat a patient for an injury or condition that is the subject of a prior referral, if all the following conditions are met.

    • The physical therapist must notify the original referring healthcare personnel of the commencement of therapy by telephone within five days, or by letter postmarked within five business days;
    • The physical therapy provided must not be for more than 20 treatment sessions or 30 consecutive calendar days, whichever occurs first. At the conclusion of this time or treatment, the physical therapist must confer with the referring healthcare personnel before continuing treatment; Texas Board of Physical Therapy Examiners January 2019.
    • The treatment can only be provided to a client/patient who received the referral not more than one year previously; and
    • The physical therapist providing treatment must have been licensed for one year. The physical therapist responsible for the treatment of the patient may delegate appropriate duties to another physical therapist having less than one year of experience or to a physical therapist assistant. A physical therapist licensed for more than one year must retain responsibility for and supervision of the treatment.


Q:  According to billing requirements physical therapists affix both medical and impairment ICD-10 codes on the 1500 and UB-04 forms or their electronic equivalent. Will Texas physical therapist be permitted to affix medical ICD-10 codes on claims?

A:  No, not if it means they are making a medical diagnosis related to a disease. The Texas Physical Therapy Practice Act states in Sec. 453.006 Practice of Medicine. (a) A person may not engage in diagnosing diseases or in practicing medicine (b) A person may not use an affix indicating or implying that the person is a physician…

Daulong’s comment:

However, Texas physical therapists have been coding impairment diagnoses for years and may continue to do so. The APTA has an extensive list of codes frequently used by physical therapists, please go to this link:

 Physical therapist should continue to document what the patient relates about diagnoses or conditions they have or have had in the clinical record in order to assist in determining the complexity of the patient’s case and the selection of the correct evaluation code. Therapists should also list signs, symptoms, characteristics, observations and the patient’s medical history.

 Example: Patient states that he/she has diabetes and takes medication to control it. The therapist should relate that statement and confirm that a diabetic medication was included in his/her medication list.


Q:  Should physical therapists engage in Direct Access, in Texas, without having the rules approved?

A:  BCMS’ position is that it is risky to carry out a law prior to rules being promulgated; the proposed rules are posted in on the TBPTE website (Click Here for proposed rule). They will be also posted in the Texas Register by September 6, 2019 for at least 30 – 45 days.

Q:  When will the Treatment Without Referral Waiver Form be available for use?

A:  The Waiver Form is being drafted by the TBPTE and will be available for use November 1, 2019. BCMS will send it to Texas clients as soon as it is approved. The form will be available on the TBPTE’s website.


Q:  How do we handle Medicare patients with the new law granting Treatment Without Referral?

A:  Medicare does not require a referral and hasn’t for many years, but it does require two things that are stumbling blocks for Treatment Without Referral:

    • The first issue is that therapists must still obtain a signed Plan of Care in the same time frames as dictated in the Medicare Benefit Policy Manual (MBPM)…i.e. by 30 days and recertifications within 90 days. Medicare does state that it does not expect treatments to be held until the Plan of Care is certified.
    • The second issue is that Medicare claims must contain the NPI of the certifying physician.

Please remember that if you believe you will have problems with either of the two items above you should engage the patient to assist in expediting the cooperation of his/her physician. Medicare considers an uncertified Plan of Care to result in a technical denial which transfers the financial liability to the patient for therapists in private practice; unfortunately, this is not the case for Rehab Agencies as the provider assumes the financial liability when there is no signed Plan of Care.

Q:  Will the Texas Division of Worker Compensation honor the new treatment without Referral?

A:  No, the DWC is governed by laws that require physicians and other specified individuals to refer patients and under Texas laws physical therapists do not have that authority.


Learn More or Get Help!

Do you like getting timely information like above?  If yes, and if you want to continue to get timely information like above or learn how to better understand how compliance plays a role in your over all outpatient physical therapy compliance requirements, contact Alicia N. Mahoney at 713-899-9812 or schedule time for a free compliance program overview.