Direct access to physical therapy in the USA: state rules, Medicare and referral

Direct access means a patient can be evaluated and treated by a physical therapist (PT) without a physician's referral first. The American Physical Therapy Association (APTA) states that "As of July 1, 2025, all 50 states, the District of Columbia, and the U.S. Virgin Islands have either provisional or unrestricted direct access to physical therapist services for evaluation and treatment." A number of states still attach conditions: a cap on days or visits, a minimum time in practice, or a physician's sign-off after a set period. Original Medicare does not require an order, but a physician or nonphysician practitioner still has to certify the plan of care. Many insurance plans also have referral rules of their own.

This guide is written for US physical therapists and clinic owners, and for patients who want to see a PT without a referral. Where it quotes a source, the date of that source is in the reference list. It is education, not legal or billing advice. Practice acts and payer policies get amended. Read your own state's act and board rules, and each payer's current policy, before a new way of working goes into your clinic.

What does direct access to physical therapy mean?

In plain terms, the patient walks in, or books online, without a prescription from a doctor. You take the history, examine, decide whether physical therapy suits the problem, and start treatment if it does. When the findings point somewhere else, you send the patient on.

APTA's direct access page describes every state as having either unrestricted or provisional direct access. It adds that "some provisions tied to treatment absent a referral still persist in a number of states." Those provisions are written into each state's practice act and board rules. That is where to look for the real limits.

Direct access is about what the law allows you to do. Payment is another matter, and it depends on the payer. A state can let you treat without a referral while the patient's plan refuses to cover the visit unless there is one.

Is direct access allowed in every state?

Yes, in some form. APTA's direct access page counts all 50 states, plus the District of Columbia and the U.S. Virgin Islands, as of July 1, 2025. Its Direct Access by State page lists the level for each jurisdiction and says it is current as of July 2025. The state detail needs a free APTA account login.

The conditions vary a lot. Three state laws show the range.

Texas: a day limit and entry requirements

Section 453.301 of the Texas Occupations Code lets a PT treat without a referral if the PT has been licensed for at least one year, carries professional liability insurance at the level the board sets, and either holds a doctoral degree in physical therapy or has completed at least 30 hours of continuing competence activities in differential diagnosis. Since September 1, 2025, the time limit is "not more than 30 consecutive calendar days." Before that date it was 10 consecutive business days, with a longer limit for some PTs. Older summaries may still quote those numbers.

Beyond that limit, the PT "must obtain a referral from a referring practitioner before the physical therapist may continue treatment". Texas also requires a signed disclosure on a board form. In it, the patient acknowledges that physical therapy is not a substitute for a medical diagnosis by a physician, that it is not based on radiological imaging, that a physical therapist cannot diagnose an illness or disease, and that the patient's health insurance may not cover the PT's services.

Florida: a sign-off after 30 days

Florida lets a PT carry out a plan of treatment the PT developed. Section 486.021(11) of the Florida Statutes then adds a time point: "If physical therapy treatment for a patient is required beyond 30 days for a condition not previously assessed by a practitioner of record, the physical therapist shall have a practitioner of record review and sign the plan." The same subsection also places a duty to refer on the PT, which comes up again in the referral section below.

New York: visits or days, and years in practice

New York Education Law section 6731(d) allows treatment without a referral for "ten visits or thirty days, whichever shall occur first." The PT needs the equivalent of at least three years of full-time practice in physical therapy. The PT must also give the patient written notice that physical therapy "may not be covered by the patient's health care plan or insurer without such a referral", and both sign it.

How to check your own state

Go to the practice act and the board's rules themselves. A summary is not enough. You want answers to five questions:

1. Can you evaluate and treat without a referral, or only evaluate?
2. Is there a limit in days, business days or visits, and what happens when you reach it?
3. Do you need a minimum time in practice, a degree, or specific continuing education first?
4. Do you have to hand the patient a written disclosure, or tell their physician?
5. Are some patients or conditions excluded?

Put the answers in your clinic's intake policy, along with the section numbers and the day you read them. Then recheck them now and then. The Texas section quoted above was amended in 2019 and 2021, and again in 2025.

Does Medicare require a referral for physical therapy?

For Original Medicare Part B, no order or referral is required. The Medicare Benefit Policy Manual puts it this way in Chapter 15, section 220.1.1: "Although there is no Medicare requirement for an order, when documented in the medical record, an order provides evidence that the patient both needs therapy services and is under the care of a physician." It adds: "Payment is dependent on the certification of the plan of care rather than the order, but the use of an order is prudent to determine that a physician is involved in care and available to certify the plan."

So the paperwork moves to a different place. Section 220.1 sets out the conditions for payment. Among them, the patient must be under a physician's care while the services are given, and a physician or nonphysician practitioner (NPP) must review the plan periodically. In the manual's words: "Certification is required for coverage and payment of a therapy claim."

For a patient who came to you directly, you evaluate, write the plan, and then get it to the patient's physician or NPP for certification. Section 220.1.3 defines the timing: "Timely certification of the initial plan is met when physician/NPP certification of the plan is documented, by signature or verbal order, and dated in the 30 days following the first day of treatment (including evaluation)." A signature has to follow a verbal order within 14 days. The manual also wants the plan forwarded to the physician straight after you establish it. What the plan must contain, and how recertification works, are in the plan of care guide.

A 2025 change in the regulation matters here. From January 1, 2025, 42 CFR 424.24(c)(5) drops the need for the practitioner's signature when two things are true: the record holds a written order or referral, and you have documented delivering the plan to that practitioner within 30 days of completing the initial evaluation. The exception depends on that written order. Without one, the same paragraph says the therapist must get the plan signed, which means a patient who came to you without an order still needs a signature on the plan. The paragraph ends: "No references to an order or referral in this subsection shall be construed to require an order or referral for outpatient physical therapy, occupational therapy, or speech-language pathology services."

A visit where the evaluation is the only service has its own rule. Section 220.3 says: "If the patient presented for evaluation without a referral or order and does not require treatment, a physician referral/order or certification of the evaluation is required for payment of the evaluation." A referral or order dated after the evaluation counts as certification of the plan to evaluate.

Medicare's payment rules do not change what your state practice act allows. The Texas section, for example, makes no exception for Medicare patients. Its 30 day limit applies to them too, whatever Medicare's certification timing allows. The manual takes the same line for assistants in section 230.1: where state supervision rules are more stringent, the state rules must be followed.

Medicare Advantage plans set their own rules. Medicare.gov says of HMO plans: "In most cases, you have to get a referral to use a specialist in HMO Plans." That page is silent on physical therapy, so look up the plan's rules for outpatient physical therapy before the first visit.

Timed billing and treatment notes have their own 8-minute rule guide. The annual therapy threshold is covered in the KX modifier guide.

Do private insurers require a referral for physical therapy?

Some do, even where state law does not. The state laws above say so themselves. Texas makes the patient acknowledge that their health insurance "may not include coverage" for the PT's services. New York requires a written notice that physical therapy may not be covered without a referral.

Rules differ from plan to plan within the same insurer, so check the patient's own plan. The steps below are suggested practice, not a legal or payer requirement. The point is to find out before the first visit, rather than from a denied claim.

• Ask for the patient's insurance details when they book.
• Verify benefits with the plan. Does physical therapy need a referral or prior authorization, or both? Is there a visit limit?
• Give the patient the answer in writing before treatment. Include what they would pay if the plan does not cover the visit.
• If a referral is needed, ask the patient's physician for it before treatment starts.
• Note the date of each call and the name of the person you spoke to. Write down what they told you.

What does the evidence say about direct access?

One systematic review, by Ojha and colleagues in Physical Therapy in 2014, looked at patients with musculoskeletal injuries. It compared episodes of care that began by direct access with episodes that began with a physician referral. It included 8 studies, all at levels 3 to 4 on the Centre for Evidence-Based Medicine scale. The authors reported "statistically significant and clinically meaningful findings across studies that satisfaction and outcomes were superior, and numbers of physical therapy visits, imaging ordered, medications prescribed, and additional non-physical therapy appointments were less" in the direct access groups. They also wrote: "There was no evidence for harm."

The authors named the limits themselves: "lack of group randomization, potential for selection bias, and limited generalizability." Patients who choose direct access may not be like those who are referred. APTA's 2025 report on direct access is a different kind of source, an advocacy resource. It sums up evidence on patient safety and functional outcomes, and on patient satisfaction, among other topics. APTA intends it for use with payers, regulators and facilities.

When must a PT refer on?

Treating without a referral means you may be the first clinician to see the problem. Screening for conditions that need a doctor, and sometimes an ambulance, belongs in every first visit. It is not an optional extra. Florida puts the duty in its statute: "The physical therapist shall refer the patient to or consult with a practitioner of record if the patient's condition is found to be outside the scope of physical therapy."

Red flags are only a starting point. The International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) framework for serious spinal pathology, published by Finucane and colleagues in JOSPT in 2020, states that there is "an absence of high-quality evidence for the diagnostic accuracy of most red flags." The framework aims to give clinicians a clinical reasoning pathway that makes the role of red flags clearer.

The steps below are suggested practice, not a legal requirement:

1. Ask the screening questions on day one and write down the answers. Record the negatives too.
2. Repeat the screen if the picture changes: pain that is new, a change in its pattern, or symptoms that stop responding the way you expected.
3. Know your routes before you need them: emergency services, same-day medical care, and a routine letter to the patient's physician.
4. When you refer, note your findings, what you told the patient and where you sent them.
5. If the patient has not improved as expected by the time you set, reassess. Consider referral rather than carrying on.

These are the warning signs our condition pages give patients, in the same words. Each one means medical care, not a physical therapy appointment:

1. Emergency: pain, tingling, numbness or weakness in both legs, numbness or altered feeling around your genitals or bottom, or new trouble peeing or controlling your bladder or bowels. The same applies if you lose feeling in one leg. Call emergency services or go to an emergency department straight away. These can be signs of pressure on the nerves at the base of the spine (cauda equina syndrome).
2. Emergency: back or leg pain that started after a serious accident, such as a car crash or a fall from a height, or back pain with chest pain. Call emergency services.
3. Chest pain or tightness, which may spread to your arm, neck or jaw, or shoulder or arm pain that comes with shortness of breath, sweating or feeling sick. This can be a heart attack. Call emergency services straight away.
4. Emergency: you have had a fall or an injury and now have severe hip pain, or you cannot walk or put weight on the leg. Call emergency services or go to an emergency department. This can be a sign of a broken hip (hip fracture).
5. A calf or thigh that is newly swollen, warm, tender, red or darker than usual, has swollen veins that are sore to touch, or has a throbbing or cramping pain that does not fit your injury or condition, or that feels different from normal muscle soreness after exercise. This can be a sign of a blood clot (deep vein thrombosis), especially after surgery, an injury, time in a cast or boot, a long trip or a spell of being much less mobile than usual. Get medical advice the same day. If you are also short of breath or have chest pain, call emergency services.
6. A leg or foot that is getting weaker, for example your foot drags, catches on the ground or slaps down when you walk (foot drop). Get medical advice the same day. If the weakness is getting worse by the hour, go to an emergency department.
7. Emergency: any sign of a stroke, even if it goes away. That means a face that droops on one side, an arm you cannot lift or keep up, slurred or muddled speech, weakness or numbness on one side of your body or face, sudden blurred vision, double vision or loss of sight, trouble swallowing, sudden dizziness with unsteadiness or falling over, a sudden severe headache, or a sudden fall where your legs give way but you do not black out (a drop attack). Call emergency services straight away.
8. Emergency: a new headache, or new pain on one side of your face, jaw or neck, with a drooping eyelid or a smaller pupil on the same side, or with a new pulsing or whooshing sound in one ear that keeps time with your heartbeat. Call emergency services or go to an emergency department straight away, and do not drive yourself. This can be a tear in an artery in the neck (cervical artery dissection), which can lead to a stroke.

This list is not complete. Each condition page has the full set for its body area. The low back pain page adds fever and weight loss, a history of cancer, and pain at night. The neck pain page covers signs of pressure on the spinal cord in the neck.

Setting up a direct access workflow in your clinic

A direct access patient takes a little more organizing up front. This sequence is suggested practice; your state law and each payer's rules come first:

1. At booking: record the insurance, check whether the plan needs a referral or prior authorization, and tell the patient.
2. Before the first visit: have the patient sign any disclosure your state requires, and note the start date if your state has a day or visit limit.
3. At the evaluation: screen for red flags and document the answers. Then decide whether physical therapy is right for this problem.
4. After the evaluation: write the plan of care. For Medicare patients, send it to the patient's physician or NPP straight away, and record the date and how you sent it.
5. During treatment: count the days or visits against your state's limit. Get the referral or sign-off before you reach it.
6. At discharge or referral: write briefly to the patient's physician about your findings and treatment.

Steps 4 and 6 are easier with a clear SOAP note, because the physician reads the same reasoning you recorded.

Home exercise between visits

When a state gives you a short direct access window, much of the patient's progress has to happen at home. Put the home exercise program (HEP) in the plan with its dose. Then hand the patient exactly that program, so what they do at home matches what you wrote.

In PocketPhysio, each exercise in the program carries your numbers (sets and reps, or a hold time) plus a short cue typed in your own words. Each one also has its own video, with a voice guide the patient can listen to instead of reading. You can text or email the program, share the link yourself, or put it in the patient's Pocket Physio Care app. WhatsApp works too. For exercise choice and dose, read the guide on writing a home exercise program.

For patients: seeing a PT without a referral

You can book with a physical therapist directly in every state. Your state may limit how long treatment goes on before a doctor needs to be involved. Before you book, call your insurance plan and ask whether physical therapy needs a referral or prior authorization under your plan. If you have a Medicare Advantage HMO, ask the plan too.

Bring a list of your medicines, your past operations and any scans or test results. The PT will ask about your general health as well as the painful area, because some symptoms need a doctor first. If the PT suggests you see a doctor, that is part of good care. It is not a refusal to help.

The short version

Direct access to physical therapy is allowed in some form in all 50 states, plus the District of Columbia and the U.S. Virgin Islands, according to APTA as of July 1, 2025. A number of states attach conditions. Examples are the Texas limit of 30 consecutive calendar days, the Florida sign-off after 30 days, and the New York limit of ten visits or thirty days with three years in practice.

Original Medicare needs no order, but a physician or NPP still has to certify the plan of care, and the manual treats that as timely when it is dated within the first 30 days of treatment, evaluation included. Private plans and Medicare Advantage HMOs may still require a referral, so check before the first visit. Screen every direct access patient for red flags and keep a record. If what you find does not fit physical therapy, refer.

References

1. American Physical Therapy Association. Direct Access Advocacy. No date shown. Accessed September 28, 2026. https://www.apta.org/advocacy/issues/direct-access-advocacy
2. American Physical Therapy Association. Direct Access by State. Published September 4, 2024, current as of July 2025 (state summary for APTA account holders). Accessed September 28, 2026. https://www.apta.org/advocacy/issues/direct-access-advocacy/direct-access-by-state
3. American Physical Therapy Association. State of Direct Access to Physical Therapist Services: A Report from the American Physical Therapy Association. June 25, 2025. Accessed September 28, 2026. https://www.apta.org/apta-and-you/news-publications/reports/2025/state-of-direct-access-to-physical-therapist-services
4. Texas Occupations Code section 453.301, Practice by Physical Therapist (as amended by Acts 2025, 89th Leg., R.S., Ch. 1090 (H.B. 4099), effective September 1, 2025). Texas Constitution and Statutes, Texas Legislature. Accessed September 28, 2026. https://statutes.capitol.texas.gov/Docs/OC/htm/OC.453.htm
5. Florida Statutes section 486.021(11)(a), Definitions, practice of physical therapy (2026 Florida Statutes; history to s. 1, ch. 2020-128). Accessed September 28, 2026. http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0400-0499/0486/Sections/0486.021.html
6. New York Education Law section 6731, paragraph (d). New York State Senate Open Legislation, most recent revision shown dated September 22, 2014. Accessed September 28, 2026. https://www.nysenate.gov/legislation/laws/EDN/6731
7. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual (Publication 100-02), Chapter 15: Covered Medical and Other Health Services (table of contents Revision 13889, issued July 30, 2026). Section 220.1, Conditions of Coverage and Payment for Outpatient Physical Therapy, Occupational Therapy, or Speech-Language Pathology Services (Revision 255, effective January 1, 2019); section 220.1.1, Care of a Physician/Nonphysician Practitioner (NPP) (Revision 179, effective January 7, 2014); section 220.1.3, Certification and Recertification of Need for Treatment and Therapy Plans of Care (Revision 88, effective January 1, 2008); section 220.3, Documentation Requirements for Therapy Services (Revision 255, effective January 1, 2019); section 230.1, Practice of Physical Therapy. Accessed September 28, 2026. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf
8. Code of Federal Regulations. 42 CFR 424.24, Requirements for medical and other health services furnished by providers under Medicare Part B, paragraph (c) (as amended at 89 FR 98565, Dec. 9, 2024, the CY 2025 Physician Fee Schedule final rule, effective January 1, 2025). Electronic Code of Federal Regulations. Accessed September 28, 2026. https://www.ecfr.gov/current/title-42/section-424.24
9. Medicare.gov. Health Maintenance Organizations (HMOs). Accessed September 28, 2026. https://www.medicare.gov/health-drug-plans/health-plans/your-coverage-options/HMO
10. Ojha HA, Snyder RS, Davenport TE. Direct access compared with referred physical therapy episodes of care: a systematic review. Physical Therapy. 2014;94(1):14-30. doi:10.2522/ptj.20130096
11. Finucane LM, Downie A, Mercer C, et al. International framework for red flags for potential serious spinal pathologies. Journal of Orthopaedic and Sports Physical Therapy. 2020;50(7):350-372. doi:10.2519/jospt.2020.9971

Written and checked by the PocketPhysio editorial team. Last updated 2026-09-28.