Physical therapists are actually only one component of the total providers/suppliers billing Medicare L-Codes, acknowledges Walter Gorski, director of legislative and regulatory affairs for the American Orthotic & Prosthetic Association (AOPA). So, why is the proposed Physical Therapist Direct Access federal legislation regarded as a bad idea as far as the O&P field is concerned?
"It is likely that if national direct access is enacted, more PTs will decide to provide O&P services," Gorski explains. "AOPA maintains that state-licensed PTs simply do not have the education or training to provide the full range of O&P services." He continues, "This is a fight that we need to take care of now. It's time to draw a line in the sand and fight for what we know is right."
The American Physical Therapy Association (APTA) claims that currently 48 states have a form of what it refers to as "direct access" legislation in place. One could just as easily refer to "direct access" as "PT self-referral," it has been noted. However, according to the American Academy of Orthopedic Surgeons (AAOS), of those laws, only two state laws actually allow unrestricted, unimpeded direct access. The proposed federal direct access legislation would allow PTs to selfprescribe and provide physical therapy services without a physician's prescription and without the patient being required to first be seen by a physician. The range of services a PT is able to provide has been historically tied to their scope of practice in the state in which a particular PT practices.
Therefore, if a state were to include orthotics and prosthetics in its PT scope of practice, much like North Dakota in its recently expanded PT scope of practice legislation, PTs may have a "green light" to both prescribe and provide O&P services and devices if they so desire," says Peter Thomas, general counsel of the National Association for the Advancement of Orthotics & Prosthetics (NAAOP). Thomas adds, "This depends upon how the Medicare program would interpret the federal PT direct access legislation."
If revenues from traditional physical therapy services decline, entrepreneurial PTs could thus look at O&P as a potential additional revenue stream, it was noted.
"Although the Durable Medical Equipment Regional Carriers (DMERCs) currently require that a physician's prescription is necessary for payment of an O&P claim, this is a 'program instruction,' and is not in the Medicare statute," Thomas explains. "CMS could change that relatively quickly if national legislation passes which allows physical therapists to provide their services without a physician's prescription. Arguably that federal law could trump the program instruction."
If this were CMS's interpretation of the statute, the DMERCs would then have to allow PTs to bill Medicare for O&P services they provide without a physician's prescription, assuming O&P falls under the physical therapist scope of practice in the relevant state. Thomas adds, "The physical therapists' parallel goal in the states to expand their scope of practice to include O&P exacerbates this potential problem."
The federal PT Direct Access legislation also defines the term "qualified physical therapist" very broadly to include virtually every practicing physical therapist, Thomas notes. He points out that the regulation that interprets the work of the 2003 negotiated rulemaking process, mandated by the Medicare, Medicaid, and SCHIP Benefits Improvement & Protection Act of 2000 (BIPA), which sought to define what constitutes a "qualified practitioner" of O&P services and a "qualified physical therapist" is due to be published in proposed form in November. The impact of this regulation could be negated by the direct access legislation if this section of the bill passes. Says Thomas, "That regulation and all the work that went into it and the negotiated rulemaking process could essentially become null and void - the physical therapists would have done an end run around it."
Editors note: An upcoming article will discuss O&P organizations current legislative agenda, including other issues, in more detail.
