Declaratory Statements - Referrals

1. 04.11.03 Diagnosis and Prescriptive Authority - Direct Access - If a diagnosis is made by the physician within 90 days, but no P.T. is ordered, and an evaluation of the patient determines that there is a need for physical therapy, the therapist sends the diagnosing physician a plan of care within 15 days. The physician replies by stating that he/she does not want physical therapy. Where are the legal obligations at this point?

   It is the Board's opinion that in the Louisiana Physical Therapy Practice Act, revisions for Physical Therapy Services without Prescription or Referral indicate that a physical therapist is allowed to treat patients by a physical therapy Plan of Care without physician approval. A physical therapist is only obligated to inform the Physician of such Plan of Care within 15 days, but not required to seek his approval.

   Please be advised that documentation standards must be met as outlined in Rules and Regulations as well as proof of a diagnosis made within 90 days.

2. 2410 of Practice Act - I have a few questions regarding procedures that I follow which are: 1. An Annual Evaluation 2. A plan is developed for each resident for the following year; 3. Objectives and goals are established for that year; 4. This plan is then signed by the physician; 5. Documentation of outcomes and attendance is kept on each resident whether in direct therapy or in group classes.

   It is the opinion of the Board that you are meeting all requirements in 2410. The population which you serve gives rise to a challenge in establishing goals and objectives and the Board realizes that many techniques may need to be used to accomplish these goals in a reasonable time frame.

3. Advance Practice Registered Nurse and Physician Assistant/ Referrals - Can a prescription for physical therapy be signed by a "nurse practitioner"?

   The Board requested information from the Louisiana State Board of Nursing with regards to this issue. The Board also received an inquiry with regards to whether a physicians assistant can make referrals for physical therapy. It was necessary to contact the Louisiana State Board of Medical Examiners with regards to the authority of a physicians assistant as per that Board's regulatory authority. With regards to the issue of the advanced practice registered nurse (ARPN), it is the Board's understanding that the State Board of Nursing is in the process of promulgating rules and regulations with regards to this issue. However, the Physical Therapy Board has taken the position that an advanced practice registered nurse (ARPN) has the legal authority to make a referral for physical therapy to a physical therapist. Likewise, the Board has taken the position that a physician assistant can refer a patient for physical therapy. There is no need for a co-signature from the attending physician with regards to the referral for physical therapy from a physician assistant or an ARPN. A physician assistant and an ARPN have the authority from their respective regulatory boards to make physical therapy referrals if internal protocol is established and complied with between the physician and these healthcare professionals. It is not required by the Physical Therapy Board for the physical therapist receiving such referral to verify the existence, or nature, or the internal protocol established between the physician and these healthcare professionals. The Physical Therapy Board's legal position as set forth in this letter with regards to physician assistants and advanced practice registered nurses is based upon its interpretation of LSA R.S. 37:2410A of the Louisiana Physical Therapy Practice Act which requires that physical therapy be implemented upon the prescription or referral of a person licensed to practice medicine. Based upon the laws allowing physician assistants and advanced practice registered nurses to refer for physical therapy enables the Board to legally and logically extend the term "license to practice medicine" in Section 2410A to extend to those healthcare professionals to whom such authority is legally delegated. Additionally, with regards to verbal orders, the following language is set forth in Rule 323A1: A prescription or referral is a written request for physical therapy signed by a qualified practitioner which may initially be a verbal order but must later be confirmed in writing. The verbal order shall be documented by the physical therapist in the patient's record. If the verbal order is not confirmed in writing, then the physical therapist shall send a written communication requesting a written prescription or referral to the prescribing practitioner within fifteen days of commencement of treatment or by the fifth treatment session, whichever occurs first. A copy of the written communication to the prescribing or referring practitioner must be maintained in the patient's record. "Practitioner" as referred to in Rule 323A1 is the individual licensed to practice medicine and not the physician assistant or advanced practice registered nurse. Therefore, your written communication must be followed directly to the attention of the physician.

4. Application or Titration of Oxygen - Can a PT perform application and titration of oxygen?

   It is the Board's opinion that application of oxygen as prescribed by a physician does not constitute a violation of the Practice Act. However, application or titration of oxygen outside of physician prescribed parameters, or changes in the prescription without physician approval, would be considered outside of the scope of practice as set forth in the Practice Act.

5. APRN - Referral - Is it required for nurse practitioners to have referrals for physical therapy co-signed by a physician? Additionally, what is the care for Physical Therapy Assistants on this issue?

   The Physical Therapy Board has taken the position that an advanced practice registered nurse (APRN) has the legal authority to make a referral for physical therapy to a physical therapist. Likewise, the Board has taken the position that a physician assistant can refer a patient for physical therapy.

   There is no need for a co-signature from the attending physician with regards to the referral for physical therapy from a physician assistant or an APRN. A physician assistant and an APRN have the authority from their respected regulatory boards to make physical therapy referrals if internal protocol is established and complied with between the physician and these healthcare professionals. It is not required by the Physical Therapy Board for the physical therapist receiving such referral to verify the existence, or nature, of the internal protocol established between the physician and these healthcare professionals.

   The physical Therapy Board's legal position with regards to physician assistants and advanced practice registered nurses is based upon its interpretation of LSA R.S. 37:2410A of the Louisiana Physical Therapy Practice Act which requires that a physical therapy be implemented upon the prescription or referral of a person licensed to practice medicine. Based upon the laws allowing physician assistants and advance practice registered nurses to refer for physical therapy enables the Board to legally and logically extend the term ?license to practice medicine? in Section 2410A to those healthcare professionals to whom such authority is legally delegated.

   Additionally, with regards to verbal orders, the following language is set forth in Rule 323AI:

   A prescription or referral is a written request for physical therapy signed by a qualified practitioner which may initially be verbal order but must later be confirmed in writing. The verbal order shall be documented by the physical therapist in the patient?s record. If the verbal order is not confirmed in writing, then the physical therapist shall send a written communication requesting a written prescription or referral to the prescribing practitioner within fifteen days of commencement of treatment or by the fifth treatment session, whichever occurs first. A copy of the written communication to the prescribing or referring practitioner must be maintained in the patient's records.

   ?Practitioner? as referred to in Rule 323AI is the individual licensed to practice medicine and not the physician assistant or advance practice registered nurse. Therefore, your written communication must be forwarded directly to the attention of the physician.

6. Athletic Event Volunteers - Do state licensed physical therapists need a physician referral for consultative contact with athletes where the physical therapists are consulting for pre-event and post-event massage, ice, heat, stretching, light (no weight) exercise, and electrical stimulation?

   The Board has determined that the pre-event procedures of massage, ice, superficial heat, stretching and warm-up exercises, and the post-event procedures of massage, ice superficial heat, stretching and cool down exercises fall within the concept of consultative services and in accordance with the Physical Therapy Practice Act and the Rules and Regulations promulgated by the Board and does not require a physician referral. However, post injury modalities such as electrical stimulation, prescriptive exercises, etc. shall not be performed without the referral or prescription from a physician. It is the understanding of the Board that a prescription for electrical stimulation will be obtained.

7. Buck's and Russell's Traction/Physician Order - Is it within the scope of practice for a PT to set up tractin for a lower extremity fracture, namely: Buck's traction and Russell's tractin? Additionally, can a PT "touch a patient without a physical therapy order?"

   In response to your first question, it is within the scope of the practice of physical therapy for a physical therapist to set up tractoin for lower extremity fracture namely; Buck's traction and Russell's tractin. It is recommended that the physical therapist have documented training in the application of traction set-ups that would reflect competency in this procedure. Additionally, you are correct in your understanding that while a PT may evaluate a patient to determine the need for physical therapy, it is necessary to have a physician's order to be able to lawfully implement treatment such as traction.

   Furthermore, your letter addresses a hypothetical doctor's order which states "Buck's traction, left lower extremity-five (5) pounds." The wording of this physician's order is proper to allow you to evaluate and implement traction pursuant to the Physical Therapy Practice Act and the Rules and Regulations promulaged by the board.

8. Case Manager accepting a verbal order for treatment - Can a case manager who is not a nurse accept a verbal order for PT from a physician and document in the medical record and PT begin treatment?

   The board determined it is not appropriate for a case manager who is not a nurse to accept a verbal order for PT from a physician and document in the medical record for physical therapy to begin treatment.

9. Casting Orthotics - No Script - Am I allowed to see a patient for evaluation and casting for a pair of orthotics without a script from the doctor? The patient is not coming for a course of physical therapy, only for an evaluation and casting of the feet which take one session.

   Pursuant to the Physical Therapy Practice Act and the Board's Rules, a referral is required for the scenario described because you are doing more than an evaluation. By casting and forwarding the impression to the laboratory, you are actually implementing physical therapy treatment.

10. Changes to POC on a daily note - If a PT writes a plan of care after an evaluation and the doctor signs the POC, can the PT then go back and change the same POC on a daily note without writing a new POC and getting a physicianýs signature approving the change? If the physiciansý signature is not required, can the PTA treat the patient with this change which is written only in the daily notes ý without the MD signature?

    In response to your question regarding changing the POC by documentation of a daily note, the board has opined this change can occur without obtaining signature of the physician. The PTA can treat the patient with the changes documented.

11. Chiropractor Referral - Can a PT accept a referral from a Chiropractor?

    Yes. The statute was changed by the Legislature in 2003.

12. Community Awareness Program - Referral Documentation - The Lafayette Community Healthcare Clinic has determined that it would be feasible to identify the diabetic population and determine whether or not their needs are being met concerning education and prevention of complications of their diabetes. The patients have no healthcare insurance and are seen by volunteers representing the various healthcare disciplines. 1) For group educational sessions is a physician referral necessary? 2) To perform a simple monofilament sensory test on any given patient to determine whether they belong in the high risk group is a physician referral requires and is an evaluation required? 3) To educate the patients in footwear and to inspect their actual shoes for patterns of wear or poor design is an evaluation required? 4) To educate patients on how to self-examine their feet is an evaluation required? 5) To be of service to this patient population, I believe it may be necessary to actually have a look at their feet, their shoes, and their sensation in order to educate them adequately in prevention measures. These of course will be videos, brochures, and mini-lectures addressing all the attendees in very general terms but what about when the questions become specific?

    1) Pursuant to the Physical Therapy Practice Act and the Board's Rules, a physician referral is not required for group educational sessions.

    2) A referral is not required to perform an evaluation. Monofilament sensory testing is considered a part of the evaluation. Pursuant to the Physical Therapy Practice Act and the Board's Rules, a physical therapist may perform an initial physical therapy evaluation to determine the need for physical therapy and whether or not the patient belongs in the high risk group. Should you begin to implement treatment based on your physical therapy evaluation, a referral is required.

    3) The Board is of the opinion that pursuant to the Physical Therapy Practice Act and its Rules that an evaluation is not required. Such education as described in your question would fall under the context of consultation. Consultation or consultative services is defined in Rule 305 as providing information, advice or recommendations with respect to physical therapy, but does not include the administration of physical therapy treatment and, therefore, can be performed without referral or prescription.

    4) The Board is of the opinion that an evaluation is not required with regards to this factual scenario. Please refer to consultation or consultative services referenced in the Board's response above, more particularly Rule 305 as defined.

    5) The Board is of the opinion that pursuant to the Physical Therapy Practice Act and its Rules, the patient population may be educated as a group without the necessity of a legal referral. However, should individualized treatment be required, then the legal requirements of referral and evaluation are triggered. Additionally, if a one-on-one consultation for a specific condition occurs, and ultimately treatment is recommended then there is a need for evaluation which, of course, includes documentation.

13. Computer Generated Order for Outpatient PT - Can I accept a computer generated order for a PT sent to the outpatient clinic? What about physician approved protocols and standing orders?

    In order to answer this question, we should refer to the Rules and Regulations, Section 323 Documentation Standards. This section outlines and defines what must be contained in a physical therapy medical record.

    A. 1 of that section states: "A prescription or referral is a written request for physical therapy signed by a qualified practitioner which may initially be a verbal order but must be later confirmed in writing".

    The Board would therefore require that you receive a faxed or mailed copy of the written order signed by the patient's physician.

    Although this signed order may be in a patient's inpatient chart, as an outpatient clinic, you are starting a new chart with a new episode of care. The signed physician's order will start your new chart.

    Secondly, you must comply with all regulatory or accrediting agency requirements (JCAHO or other) and your facility Medical Staff By-laws pertaining to proper documentation of standing orders and protocols. The Board would require that each patient chart contain the referenced protocol or order for the equipment or device provided to the patients as part of your treatment plan. In addition, the patient's payor source may impose requirements that you would want to comply with.

14. Diagnostic Testing - EMG - Is it within the PT scope of practice for a PT to perform a surface EMG?

    Yes, a Physical Therapist may perform a surface EMG as part of an initial evaluation without a physician'?s referral. If a physical therapist is going to utilize the findings of the evaluation to implement a treatment plan, then the physical therapist shall obtain a referral for physical therapy prior to initiation of treatment. The physical therapist shall also report the results of the initial physical therapy evaluation to the referring physician, dentist, or podiatrist.

15. Direct Access - Medical Referrals in the School System - I wish to inquire the board on the topic of medical referrals in the school system.

    Legislation was passed in July 2003 which allows the treatment of children with a diagnosed developmental disability pursuant to the patient?s plan of care, without the referral of a physician.

    Your school system maybe be unaware of the Practice Act change or may have a reason for requiring the referral by policy. Any employer has a right to have policies that are stricter than the law. If they choose to continue with that policy, as an employee, you must follow their policy. Your options are to educate your employer about the practice act changes, or abide by their policies, or choose another employer if you feel strongly opposed to their policies.

16. Direct Access - Pediatric - I am a pediatric PT in Lake Charles. I understand that direct access has passed, and we can now see children with a diagnosed developmental delay. I have a question as to what constitutes a developmental delay. In particular: hydrocephalus, genetic disorders, syndromes, etc. Please let me know your opinion on these types of diagnosis.

    In response to your inquiry, the recently passed law states:

    2410 Practice D. A physical therapist licensed under this Chapter shall not perform physical therapy services without a prescription or referral from a person licensed to practice medicine, surgery, dentistry, podiatry, or chiropractic. However, a physical therapist licensed under this Chapter may perform physical therapy services without a prescription or referral under the following circumstances: (1) To Children with a diagnosed developmental disability pursuant to the patient's plan of care.

    The Physical Therapy Law does not specify what constitutes a developmental delay.

17. Direct Access - Pediatrics - I am a PT in the school system of Jeff Davis and Allen parishes. I have a question concerning the direct access regulations regarding pediatrics. I understand that I am able to treat a child with a diagnosis. My question is how recent does the diagnosis need to be dated?

    The Physical Therapy Law does not specify a time limitation for a diagnosis of developmental disability. The law as states:

    2418. C. Except as to an initial evaluation or consultation, as provided in Subsection B of this Section, physical therapy services may be performed without a prescription or by referral only under the following circumstances: (1) To a child with a diagnosed developmental disability pursuant to the patient's plan of care.

    The Physical Therapy Law does not specify what constitutes a developmental delay.

18. Direct Access - Practice without Referral - I am writing the Board to inquire about practice without referral in the school system.

    In the Physical Therapy Statute and in the Rules when a physical therapist is treating a child as defined with a diagnosed developmental disability, then a referral is not required. The IEP or IFSP contain the diagnosed condition and plan of care within the educational setting. The rule pertaining to ?individuals with previously diagnosed conditions? does not apply in the school system scenario. It is recommended that a PT perform an initial evaluation with a plan of care and measurable PT goals following all documentation standards when treating children in the schools under practice without referral.

19. Discharge Disagree with Physician - 1) Does the setting have any bearing on the physical therapist discharging PT services even if the doctor disagrees? Is the physical therapist in an LTAC required to keep a patient in PT if the doctor insists even if the physical therapist has determined that there are no attainable goals? 2) Does my title of a physical therapist limit me from supervising a maintenance program?

    1) To answer your question you must look to the La PT Rules and Regulations as well as the APTA Code of Conduct. Under the Rules and Regulations section 327 E. 5 unprofessional conduct is described as "initiation or continuation of physical therapy services that are contraindicated or cannot reasonable result in a beneficial outcome." If you have determined that a patient has received the maximum benefit from PT services then it would be unprofessional to continue treatment.

    Additionally, the LSBPTE adopts the APTA Code of Ethics. In the Code of Ethics section 4.1 Professional Responsibility is outlined as follows:

    B. regardless of practice setting, a physical therapist has primary responsibility for the physical therapy care of a patient and shall make independent judgments regarding that care consistent with accepted professional standards. H. A physical therapist shall determine when a patient/client will no longer benefit from PT services.

    2) It is appropriate for a patient to be referred to a restorative nursing program following discontinuation of PT services. This program is no longer physical therapy and is under the direction of nursing services. There is nothing within the PT Practice Act or Rules and Regulations which would prohibit you from supervising the staff that are providing this services as long as it is not being designated as physical therapy and you are simply providing a management function of supervision of personnel.

20. Discharge - Physician Order - Is it correct that Medicare regulations state that a therapist cannot discharge a patient from his or her services without a physician's order?

    At the outset, please keep in mind that Medicare regulations deal primarily with reimbursement issues. The Physical Therapy Practice Act and the Board's Rules govern the practice of physical therapy in Louisiana which includes Medicare and non-Medicare patients. You are correct in your interpretation of the Physical Therapy Practice Act and the Board's Rules which require that a physical therapist discontinue physical therapy services that are contraindicated or can not reasonably result in a beneficial outcome. To do otherwise, does place the physical therapist's license in jeopardy of being sanctioned by the Board for a violation of the law.

21. Duration of Rx - This question concerns the need for an additional prescription upon expiration of the duration of treatment versus the fulfillment of the prescribed number of treatments.

    As a prescription is written, it indicates: 1). the frequency of treatments; and 2). the duration of treatments. In the course of the physical therapy treatment, fulfillment of either the number of visits prescribed or the time frame of the prescription fulfills the validity of the prescription. After fulfillment of a prescription, if the physical therapist or the patient believes that continued treatment is warranted, then either the physical therapist or the patient must obtain a prescription for continued treatment.

22. Eval - fabricate - bill prosthetics - orthotics - Can a PT perform prosthetic fabrication?

    Prosthetic fabrication is not within the scope of Practice of Physical Therapy within the State of Louisiana. Prosthetics are required to have certain education and training, and are certified by the Board of Orthotists and Prosthetics to evaluate, fabricate, and bill for prosthetics.

    A Physical Therapist may evaluate, fabricate and bill for an orthotic device for which he/she may have the competence, which is within the Scope of Practice of Physical Therapy within the State of Louisiana. However, a physical therapist is not qualified as an orthotist.

23. Eval for DME - Exercise Program - 1) If a patient is referred to physical therapy for issuance of durable medical equipment (i.e. home cervical traction unit, TENS unit, shoulder pulley) for a specific medical condition, is it necessary for the P.T. to perform an evaluation to determine if any precautions or contraindications exit and instruct the patient in a safe use of this device - or - can the physical therapy clinic issue the device without a therapist seeing the patient? The clinic is a outpatient clinic not a DME supplier. 2) We would also like to know if a physical therapist must evaluate patients who are referred for instruction in a home exercise program to address a specific medical condition - or - can a physical therapist instruct the patient in the prescribed exercises without performing and evaluating?

    1) An evaluation of the patient must be completed by the physical therapist to determine precautions and contraindications.

    2) Education and instructions must be provided to the patient prior to issuance of DME or Home Exercise Programs.

24. Faxed Referral/Prescription - Are signed referrals or prescriptions by the appropriate health care providers which are faxed acceptable to implement physical therapy services?

    The Board is of the opinion that pursuant to the Physical Therapy Practice Act, LSA R.S. 37:24 10A, and the Board's Rules, it is acceptable for a physical therapist to implement physical therapy treatment pursuant to a faxed copy of a prescription or referral signed by a person licensed to practice medicine, surgery, dentistry, chiropractic or podiatry.

    As you are aware, an initial evaluation or consultation of a screening nature to determine the need for physical therapy may be performed by a physical therapist without referral, but implementation of physical therapy treatment to individuals for a specific condition or conditions shall be based on a prescription or referral.

    Also, due to recent legislative amendments to other healthcare laws, a prescription or referral may also be received from a physician assistant or advanced practice registered nurse as stated by the Board in an earlier Declaratory Statement.

25. Faxed Referral - Prescription - Are signed referrals or prescriptions by the appropriate health care providers which are faxed to you are acceptable to implement physical therapy services?

    The Board is of the opinion that pursuant to the Physical Therapy Practice Act, LSA R.S. 37:24 10A, and the Board's Rules, it is acceptable for a physical therapist to implement physical therapy treatment pursuant to a faxed copy of a prescription or referral signed by a person licensed to practice medicine, surgery, dentistry or podiatry. As you are aware, an initial evaluation or consultation of a screening nature to determine the need for physical therapy may be performed by a physical therapist without referral, but implementation of physical therapy treatment to individuals for a specific condition of conditions shall be based on prescription or referral. Also, due to recent legislative amendments to other healthcare laws, a prescription or referral may also be received from a physician assistant or advanced practice registered nurse.

26. FCE Order - Is a physicians order necessary or can it be done at the request of an Attorney, Judge, or Employer?

    The Board determined that no physician order is necessary. An evaluation can be done without a Physician order. The request for a Functional Capacity Evaluation can be done by an Attorney, Judge, or Employer.

27. Frequency of Treatment /Physician Order - The inquiry involves a situation where it is the professional opinion that, based upon a physical therapy evaluation, the patient should receive a decrease in the treatment frequency ordered by the physician. Particularly stated, the question is whether the physical therapist must follow the physician's orders with regards to treatment frequency if the frequency contradicts the physical therapist's professional judgment based upon his evaluation.

    The Board is mandated by law to regulate the practice of physical therapy so as to protect the consuming public. The main tools used by the Board are the Physical Therapy Practice Act, LSA R.S. 37:2401 et seq., and the Board's Rules promulgated in accordance thereto, Title 46, Rules 103 et seq. A physical therapist is required by law to perform an initial physical therapy evaluation in order to determine the need for physical therapy and determination of a physical therapy treatment plan. See LSA R.S.37:2410A. "Initial physical therapy evaluation" is defined in Section 2401 (1)(d) of the Practice Act which is reproduced for your convenience as follows: the physical therapy assessment and resulting interpretation of a patient's condition through use of patient history, signs, symptoms, objective tests, or measurements to determine neuromusculoskeletal and biomechanical dysfunctions to determine the need for physical therapy. The conclusions of such initial physical therapy evaluation may be reported to the patient and may be used to establish treatment goals. The results of an initial physical therapy evaluation or physical therapy consultation shall be reported to the referring or treating physician, dentist, chiropractor or podiatrist. Furthermore, pursuant to the Board's delegated authority, it promulgated Rule 305 with regards to Special Definitions wherein it further defines physical therapy evaluation as follows: the evaluation of a patient by the use of physical and mental findings, objective tests and measurements, patient history, and their interpretation, to determine muscoloskeletal and biomechanical limitations, to determine his suitability for and the potential efficacy of physical therapy and the establishment or modification of treatment goals and a physical therapy treatment program.

    With regards to the obligation of the licensed physical therapist, I refer to you Section 2413 A (7) of the Practice Act which states that a physical therapist can have his license suspended, revoked or otherwise disciplined for engaging in unprofessional conduct. Unprofessional conduct shall include departure from, or failure to conform to, the minimal standards of acceptable and prevailing physical therapy practice, in which proceeding actual injury to a patient need not be established.

    The Board further clarified "unprofessional conduct" as set forth in Rule 327 E to include the following: . . . 5. initiation or continuation of physical therapy services that are contraindicated or cannot reasonably result in a beneficial outcome; or 6. abuse or exploitation of the physical therapy provider patient relationship for the purpose of securing personal compensation, gratification, or benefit unrelated to the provision of physical therapy services.

    In response to the inquiry, a physical therapist is mandated by the Practice Act and the Board's Rules not to perform physical therapy treatment to a patient, whether it be a modality or treatment frequency, which in your professional opinion does not benefit the patient. For you to do otherwise, subjects your license to sanction by the Board after adequate notice and a hearing.

    From a practical standpoint, it is highly suggested that when a situation like this arises that you communicate directly with the referring practitioner with your opinion in order to insure the patient is receiving appropriate treatment. In the event the physician refuses to yield, please be advised that should you violate the Practice Act and the Board?s Rules, your license will be subject to sanction as referenced above.

28. Frequency of Treatment - Phys Order - Is the physical therapist required to follow the physician's professional judgment based upon his evaluation?

    The Board is mandated by law to regulate the practice of physical therapy so as to protect the consuming public. The main tools used by the Board are the Physical Therapy Practice Act, LSA R.S. 37:2401 et seq., and the Board?s Rules promulgated in accordance thereto, Title 46, Rules 103 et seq. A physical therapist is required by law to perform an initial physical therapy evaluation in order to determine the need for physical therapy and determination of a physical therapy treatment plan. See LSA R.S. 37:2410A.

    Initial physical therapy evaluation is defined in Section 2401 (1)(d) of the Practice Act which is reproduced for your convenience as follows:

    the physical therapy assessment and resulting interpretation of a patient?s condition through use of patient history, signs, symptoms, objective tests, or measurements to determine neuromusculoskeletal and biochemical dysfunctions to determine the need for physical therapy. The conclusions of such initial physical therapy evaluation may be reported to the patient and may be used to establish treatment goals. The results of an initial physical therapy evaluation or physical therapy consultation shall be reported to the referring or treating physician, dentist, or podiatrist.

    Furthermore, pursuant to the Board's delegated authority, it is promulgated Rule 305 with regards to Special Definitions wherein it further defines physical therapy evaluation as follows:

    the evaluation of a patient by use of physical therapy and mental findings, objective tests and measurements, patient history, and their interpretation, to determine musculoskeletal and biomechanical limitations, to determine his suitability for and the potential efficacy of physical therapy and the establishment or modification of treatment goals and a physical therapy treatment program.

    With regards to the obligation of the licensed physical therapist, I refer to you Section 2413 A (7) of the Practice Act which states that a physical therapist can have his license suspended, revoked, or otherwise disciplined for engaging in unprofessional conduct. Unprofessional conduct shall include departure from, or failure to conform to, the minimal standards of acceptable and prevailing physical therapy practices, in which proceeding actually injury to a patient need not be established. The Board further clarified ?unprofessional conduct? as set forth in Rule 327 E to include the following:

    5. initiation or continuation of physical therapy services that are contraindicated or cannot reasonably result in a beneficial outcome; or

    6. abuse or exploitation of the physical therapy provider patient relationship for the purpose of securing personal compensation, gratification, or benefit unrelated to the provision of physical therapy services.

    In response to your inquiry, you are mandated by the Practice Act and the Board's Rules not to perform physical therapy treatment to a patient, whether it is a modality or treatment frequency, which in your professional opinion does not benefit the patient. For you do otherwise, subjects your license to sanction by the board after adequate notice and a hearing. From a practical standpoint, it is highly suggested that when a situation like this arises that you communicate directly with the referring practitioner with your opinion in order to insure the patient is receiving appropriate treatment. In the event the physician refuses to yield, please be advised that should you violate the Practice Act and the Board's Rules, your license will be subject to sanction as referenced above.

29. Frequency of Visits - Is it within regulations to set the frequency of visits as a range for example: 3 to 5 times per week, after a physical therapy evaluation in developing a plan of care?

    A physical therapist is required to perform an initial evaluation and set up a written treatment plan on each patient prior to implementation of any treatment or the delegation of any portion of the treatment. It is the Boards opinion that it is within the scope of practice of the physical therapist to set the frequency of visits as a range of 3 - 5 visits, assuring that the patient's medical status warrants the range of treatment frequency. Documentation of patient response and progress would also warrant the possible range of treatments required.

30. Goals met for discharge - What is the course of action for a physical therapist working on a rehab unit when the therapist feels that the patient has reached the highest level of functional mobility possible and the rehab doctor insists on keeping the patient? Or if the PT feels that therapy can be continued on an outpatient or home health basis rather than an inpatient stay? Doctor's reasoning for keeping a patient under these circumstances includes political ties within the hospital and "not angering another doctor" due to need for referrals. One patient was kept approximately 6 weeks functioning at a supervision level and ambulating approximately 400-500' with supervision. The therapist, both PT and OT stated strongly at all interdisciplinary team meetings their feelings (also documenting). What happens if this medical record is called into question by Medicare? Are the therapists held responsible for continued care which they felt was unnecessary? Can the therapists legally discharge the patient from their services and place that patient on a maintenance therapy program?

    To answer the question, one must review several documents, including the Louisiana Physical Therapy Practice Act and Rules and Regulations, the Code of Ethics of the American Physical Therapy Association, as well as possibly Medicare billing guidelines. The Rules and Regulations (Section 327, E, 5 on page 26) describe "unprofessional conduct" as the "initiation or continuation of physical therapy services that are contraindicated or cannot reasonably result in a beneficial outcome." Further, Section 2413 of the Louisiana Physical Therapy Act outlines refusal, suspension, or revocation of license. Specifically, Section 2413A, 7 states

    "Has been found guilty of unprofessional conduct. Unprofessional conduct shall include departure from, or failure to conform to, the minimal standards of acceptable and prevailing physical therapy practice, in which proceeding actual injury to a patient need not be established."

    Additionally, the Louisiana Physical Therapy Practice Act and Rules and Regulations hold each licensee for the Code of Ethics of the American Physical Therapy Association (Subpart 2, Section 305, Special Definition; Practice of Physical Therapy, B. "Minimal Standards of acceptable and prevailing physical therapy practice shall include but not be limited to the American Physical Therapy Association Code of Ethics").

    It is the responsibility of the physical therapist to discharge a patient once the patient has met all treatment goals and there is no reasonable expectation for reasonable improvement. The physical therapist may establish a maintenance program for the patient, which should be carried out under the auspices of nursing services.

    Additionally, if a physical therapist within the state of Louisiana is convicted of fraud, the physical therapists' license would be subject to Disciplinary Actions by the LSBPTE as outlined in the Rules and Regulations Section 327E on page 26.

    You may wish to review any appropriate documentation from the Medicare Manual for inpatient hospital and rehab services. The Board does not have jurisdiction over these areas.

    The physical therapist must exercise prudent judgment in physical therapy services, the initiation, and competition of such services.

31. Initial Eval Screening - Does the initial evaluation or consultation to determine the need for physical therapy allow the therapist to lay hands on the patient?

    The initial evaluation or consultation does allow for the evaluation of a patient (including hands on assessment) without referral from a physician. There are no restrictions of the evaluation/consultation process by the law. However, your facility may have policies for patient care that are more restrictive than the law. Please be aware that documentation of your patient screening should be completed in the patient's records, which would reflect your assessment.

32. Interdisciplinary Team Staffing - I have a question regarding the use of PTA's on a rehab unit. We have a 30-bed in-pt rehab unit that is currently staffed with 2 PTs and 2 PTAs and techs. One PT and one PTA form a team that is responsible for 15 patients. The PT and PTA work jointly in treatment and care of those patients, so that each is familiar with all aspects of each patients care. Each Monday there is an interdisciplinary team staffing which is attended by all team members (except the physician) where goals, needs, and equipment are discussed (this is attended by both PT and PTA together). Later in the week a second starring is held with the physician present to report PT status and update the M.D. Given the large number of PTs that can be staffed at one time, this removes the PTs from the clinical setting for extended time. My question is if the PT and PTA have conferred prior to this staffing and the PT has determined equipment and d/c recommendations, can the PTA do the actual reporting? The PTA will not be responsible for making any decisions or judgments, but is strictly to report. The PTs are available to step in when necessary or report back at a later time. Having the PTAs do those staffings that are uncomplicated allows the PTs to be in the clinic more often. Also, on those specific days when the PT is out, the PT and PTA can confer ahead of time and the PTA can report. Our approach to rehab teams of PT and PTA is to have both team members networking closely together with the PT making the decisions and the PTA assisting in the care.

    The Board addressed your situation in an earlier Declaratory Statement which was published in the Summer 1995 Newsletter. Please be advised that the Board is of the opinion that the Declaratory Statement is still valid. After reviewing the scenario, the physical therapist assistant may report what is stated in the record, but can not change nor comment on the content of the record. Additionally, the physical therapist assistant's role will be to report to the physical therapist the information he or she obtained from the interdisciplinary team staffing.

33. Long Term Acute Care Facility Practice Guideline/Evaluation and Treatment - A maintenance/restorative program is being established for inpatients who no longer meet the requirements for skilled services, but need ROM, general maintenance, walking, etc. These patients will be discharged from therapy services and the program will be established by the physical therapist and carried out by aides/technicians. More particularly the inquiry is as follows: If these patients at a later time need family training (ROM, transfers, etc.) but there has been no change in functional status or potential, can training be performed as a part of "consultation" without a reorder or does this require new orders? Does it matter if this service is being billed or not? Also, the same question applies if the patient needs equipment (b/s commode, etc.) for home or a night splint, for ex. does it matter if the splint is applied by an orthotist and not by a P.T.?

    The Board is of the opinion that if the patient is discharged and placed on a maintenance/restorative program and, thereafter, there is the need for the physical therapist to re-enter the case or provide equipment, it is necessary to obtain a new order from the physician. With regards to the Physical Therapy Practice Act and the Board's Rules, the opinion of the Board will not change whether the service is billed or not. You may wish to check Medicare Guidelines with regards to whether or not an order is needed if the patient will be billed for the service as opposed to the service being rendered complimentary. In further response to your inquiry if the physical therapist sets up the program and the program is carried out at home by an aide/technician, then the aide/technician becomes the caregiver. The physical therapist can teach the restorative program to the family or the caregiver. A new order would be needed from the physician for the physical therapist to thereafter attend to the patient to establish a new plan of care since the earlier plan of care would no longer be in effect. With regards to your question concerning the equipment, splint, etc., whichever healthcare provider is addressed in the order is the provider who should implement the service. Please keep in mind that an order is needed for such service.

34. Iontophoresis Order - Does a doctor's order stating evaluate and treat encompass iontophoresis? Does the term modalities in an order also allow iontophoresis? Does the administration of iontophoresis require an order specific for it because it involves administering medication?

    A doctor's orders stating "evaluate and treat" does encompass iontophoresis. The term "modalities" in an order does allow iontophoresis. If the physician orders "evaluate and treat," then the physical therapist has the discretion to decide the plan of care after performing an initial evaluation. However, if the order is specific as to the medication, then the physical therapist must get approval from the physician should the physical therapist recommend something different than what is specified in the order.

35. LTAC Facility Practice Guidelines - Eval & Treat - A maintenance/restorative program is being established for inpatients who no longer meet the requirements for skilled services, but need ROM, general maintenance, walking, etc. These patients will be discharged from physical therapy services and the program will be established by the physical therapist and carried out by aides/technicians. If these patients at a later time need family training (ROM, transfers, etc.) but there has been no change in functional status or potential, can training be performed as part of the "consultation" without a reorder or does this require new orders? Does it matter if these services are being billed or not? Also, the same question applies if the patient needs equipment (b/s commode, etc.) for home or a night splint, for example, does it matter if the splint is applied by an orthotist and not by a PT?

    The Board is of the opinion that if the patient is discharged and placed on a maintenance/restorative program and, thereafter there is need for the physical therapist to re-enter the case or provide equipment, it is necessary to obtain a new order from the physician. With regards to the Physical Therapy Practice Act and the Boards Rules, the opinion of the Board will not change whether the services is billed or not. You may wish to check Medicare guidelines with regards to whether or not an order is needed if the patient will be billed for the service as opposed to the service being rendered complimentary.

    If the physical therapist sets up the program and the program is carried out at home by an aide/technician, then the aide/technician becomes the caregiver. The physical therapist can teach the restorative program to the family or caregiver. A new order would be needed from the physician for the physical therapist to thereafter attend to the patient to establish a new plan of care since the earlier plan of care would no longer be in effect.

    With regards to your question concerning the equipment, splint, etc. whichever healthcare provider is addressed in the order is the provider who should implement the service. Please keep in mind that an order is needed for such service.

36. Lymphedema Compression or Drainage - Can a physical therapist suggest that a compression garment might be helpful, or that a patient should contact her physician requesting physical or occupational therapy intervention for manual lymphatic drainage or compression bandaging?

    Pursuant to the Physical Therapy Practice Act, more particularly LSA R.S. 37:2410A, an initial evaluation or consultation of a screening nature to determine the need for physical therapy may be performed by a physical therapist, without a referral or prescription, but implementation of physical therapy treatment to individuals for their specific condition shall be based upon the prescription or referral of a person licensed to practice medicine, surgery, dentistry or podiatry. The Board is of the opinion that the proposed role as set forth in the inquiry is not a violation of the Physical Therapy Practice Act or the Board's Rules. Therefore, you may provide education regarding lymphedema prevention. However, please be advised that you cannot implement physical therapy treatment without the proper referral or prescription.

    In response to the specific question, the Board is of the opinion that a P.T. may suggest that a compression garment might be helpful or that a patient should contact her physician regarding physical or occupational therapy intervention for manual lymphatic drainage or compression bandaging. Such actions on your part are in the nature of education or consultation. Please be advised that the Board's opinion set forth in this response is limited to the factual scenario. In the event the facts are altered, the Board reserves the right to amend its opinion accordingly.

37. Lymphedema Recommendations for Treatment - Can a physical therapist make recommendations for treatment?

    Yes. A physical therapist can make recommendations for treatment.

    Pursuant to the Physical Therapy Practice Act, more particularly LSA R.S. 37:2410A, an initial evaluation or consultation of a screening nature to determine the need for physical therapy may be performed by a physical therapist, without a referral or prescription, but implementation of physical therapy treatment to individuals for their specific condition shall be based upon the prescription or referral of a person licensed to practice medicine, surgery, dentistry or podiatry. The Board is of the opinion that the proposed role as set forth in the inquiry is not a violation of the Physical Therapy Practice Act or the Board's Rules. Therefore, you may provide education regarding lymphedema prevention. However, please be advised that you cannot implement physical therapy treatment without the proper referral or prescription.

38. Lymphedema Prevention Education - A social worker with a Cancer Center asked a therapist to provide assessments for women at risk with lymphedema. The proposed role is to identify women who need treatment and refer them to their physicians. Can the therapist provide education to these women regarding lymphedema prevention? This information is not patient-specific, and is not based on evaluation findings. It would be the same for all clients.

    Pursuant to the Physical Therapy Practice Act, more particularly LSA R.S. 37:2410A, an initial evaluation or consultation of a screening nature to determine the need for physical therapy may be performed by a physical therapist, without a referral or prescription, but implementation of physical therapy treatment to individuals for their specific condition shall be based upon the prescription or referral of a person licensed to practice medicine, surgery, dentistry or podiatry. The Board is of the opinion that the proposed role as set forth in the inquiry is not a violation of the Physical Therapy Practice Act or the Board's Rules. Therefore, you may provide education regarding lymphedema prevention. However, please be advised that you cannot implement physical therapy treatment without the proper referral or prescription.

39. Midwife - I work as a women's health therapist for HealthSouth. One of my major referral sources is a nurse midwife who works with an OBGyn. A question has arisen as to whether or not it is acceptable to receive referrals from this source. 1 would appreciate your response enabling us to ensure that we are practicing under APTA guidelines.

    The Louisiana Physical Therapy Practice Act requires a prescription or a referral for treatment from a person licensed to practice medicine, surgery, dentistry or podiatry as defined in LA R.S. 37:240 1 (b). Additionally, during the Summer of 2001, the Louisiana State Board of Physical Therapy Examiners issued a Declaratory Statement in regards to Advance Practice Registered Nurse and Physician Assistant Referrals:

    With regards to the issue of the advanced practice registered nurse (APRN), it is the Board's understanding that the State Board of Nursing is in the process of promulgating rules and regulations with regards to this issue. However, the Physical Therapy Board has taken the position that an advanced practice registered nurse (APRN) has the legal authority to make a referral for physical therapy to a physical therapist. Likewise, the Board has taken the position that a physician assistant can refer a patient for physical therapy.

    It is the understanding of the board that as long as a midwife is an Advanced Practice Registered Nurse, then you may accept a referral from this individual. The individual will be identified as an Advanced Practice Registered Nurse by the Louisiana State Board of Nursing. Please be advised that not all "midwives" are Advanced Practice Registered Nurses as defined by the Louisiana State Board of Nursing.

40. On the Field Direct Access - I'm a PT in Monroe, LA. I have a question about what PT's can and can't do on the field. I want to take responsibility of handling a local high school's Friday night football game. According to our practice act and the new limited direct access, am I able to eval and treat on the field? What other regulations do I need to know? I have had extensive training in first response from Red Cross through North American Sports Medicine Institute and will sit for a Sports Therapy Certification through NASMI in June. Please provide any helpful information I may need.

    Please be advised that in the situation described it would be appropriate for a P.T. to deliver first aide and/or evaluate the student. However, treatment is not appropriate. Your understanding of the Practice Act and "new limited direct access" is not completely accurate. The Practice Act does allow for evaluation without a referral, however, the direct access component of the Practice Act requires a diagnosis from a person licensed to practice medicine, surgery, dentistry, podiatry, or chiropractic within 90 days in order for treatment to be rendered.

    In the situation described on the football field, a P.T. would be evaluation an acute injury and would not have a diagnosis. Therefore, the P.T. would not be able the render treatment as outlined by the Practice Act. If a physician was on the field and a diagnosis was made by the physician, then treatment may be rendered.

41. Orders for "P.T." or "P.T. Eval" - If an order is written for "P.T.," "P.T. eval" or "P.T. consult," would that cover just the evaluation or would it also cover treatment to be rendered? The concern is that the order must also say "and treat" in order for the patient to receive actual treatment. If that were the case, I would have to contact the physician to get the go ahead to continue with treatment after I've completed the eval.

    The Board is of the opinion that the order stating "P.T." is a valid prescription. Pursuant to the Physical Therapy Practice Act and the Board?s Rules, you must perform an initial evaluation which shall be reported to the prescribing physician. You may implement physical therapy treatment pursuant to this prescription. With regards to the order that states "P.T. eval," it is uncertain whether the prescribing physician wants only an evaluation or whether he is approving a plan of care. It is suggested by the Board that you perform your initial evaluation and obtain approval of your plan of care from the prescribing physician before beginning physical therapy treatment. In regards to the order stating "P.T. consult," the Board considers such order a referral which requires you to perform an initial evaluation and report or consult with the prescribing physician concerning your recommendations. Should you receive an order and are in doubt as to the context of the wording, it is suggested that you contact the prescribing physician for further clarification. In any event, you are authorized, and obligated, by the Physical Therapy Practice Act and the Board's Rules to perform an initial evaluation to determine the need for physical therapy and establish a treatment plan. Pursuant to the law, you are also required to report your evaluation to the prescribing physician. An open line of communication between the prescribing physician and the physical therapist should resolve most of the issues which you have presented.

42. Orders / Goals Achieved - Should the PT proceed with discharge planning once a patient's goals are achieved?

    It is a violation of the Physical Therapy Practice Act, Rules and Regulations of the Board, as well as the code of Ethics and Standards of Practice of American Physical Therapy Association which the Board has adopted for a PT or PTA to continue treating a patient once goals have been achieved. To do otherwise, would potentially be considered exploitation of the provider/patient relationship. Additionally, billing for physical therapy when there are no established goals could be construed as fraud regarding Medicare, worker's compensation health insurance, etc. types of claims.

43. Out-of-State Referral - Can a P.T. accept an out of state referral?

    Yes Physical Therapists licensed and practicing in the state of Louisiana can accept an out of state prescription/referral from a physician licensed to practice medicine in the United States.

44. Part C Adult Population - Question 1: I work at a private pediatric outpatient clinic. Am I, as a licensed physical therapist, allowed to treat a child with a life long and/or developmental delay diagnosis such as Cerebral Palsy without a prescription? Do I need to obtain an initial prescription from the child?s physical prior to being able to treat this child throughout his or her growth years? What diagnoses are considered to be in this category? Is there an age limit at which I can no longer see a patient for a childhood diagnosis? Question 2: I have just signed up to be a Part C provider for 0 to 3 year old children. In a package I received it was stated that physical therapists no longer need a prescription to provide PT services to children diagnosed with a developmental disability pursuant to the plan of care (IFSP). Is this accurate? Can we still get reimbursed without a prescription through Part C funding? What documentation is required for me to demonstrate that I am seeing a patient in accordance to his or her IFSP without a prescription? Question 3: In regards to the adult population, what documentation is required for me to show proof that a patient has seen a doctor in the last 90 days? Verbal order? Patient?s statement? Question 4: Assume I receive a prescription from a physician that reads Physical Therapy Exercises once per week for 2 weeks for a specific diagnosis. If I feel it is most beneficial to the patient can I increase therapy twice per week? Can I see the patient for 3 weeks? If for this patient's specific diagnosis I feel that a particular modality would be beneficial, can I provide that modality to my patient even though I have a prescription that does not include?

    Answer 1: The Physical Therapy Law does not specify a time limitation for a diagnosis of developmental disability. Recently passed law as stated: 2410 Practice D. A physical therapist licensed under this Chapter shall not perform physical therapy services without a prescription or referral from a person licensed to practice medicine, surgery, dentistry, podiatry, or chiropractic. However, a physical therapist licensed under this Chapter may perform physical therapy services without a prescription or referral under the following circumstances: (1) To Children with a diagnosed developmental disability pursuant to the patient?s plan of care.

    The Board has not written rules and regulations addressing the recent changes in the Physical Therapy Law. The board will begin the Promulgation process of Rules and Regulations addressing the recent changes in the law in the near future. It Is recommended that a physical therapist providing treatment to a patient with a developmental disability diagnosis, exercise diligence to assure that any provision of physical therapy enhances the improvement of the educational opportunities of the patient.

    Answer 2: The Board is not familiar with the IFSP. Does the IFSP have a written diagnosis and is it a Plan-of-Care? The Board recommends that you check with Part C funding in regards to the reimbursement issues and documentation requirements.

    Answer 3: Documentation for proof that a patient has seen the physician in the last 90 days has not been defined at this point, evidence of documentation is required.

    Answer 4: If a physical therapist is seeing a patient upon a prescription referral, then the physical therapist should adhere to the Plan of Care based upon the prescription. If a physical therapist determines that there needs to be changes to the Plan-of-Care, then the physical therapist should contact the referring physician to modify the plan of care prior to implementing any changes in the patient's treatment.

45. Part C Prescriptions - We have recently begun taking patients in our clinic through Part C (birth to age 3 populations). There has been much confusion in this area concerning prescriptions for PT. The Family Service Coordinators state the IFSP stands as a prescription. We are of the understanding that we have to have a prescription for the PT for all patient populations. Could you please clarify the correct way to handle this? It is our greatest desire to serve this population, whoever, it is of the utmost importance to perform our services ethically and legally.

    In response to your inquiry, the Board is not familiar with the IFSP. The Board questions if the IFSP has a written diagnosis and a physician signature? As well, does the IFSP outline or prescribe a treatment protocol or plan of care? The preceding questions should allow a therapist to determine if the IFSP will stand as a prescription.

    Please be advised that the recent changes in the Practice Act allow direct access to the treatment of children with a diagnosed developmental disability pursuant to the patient?s plan of care as written:

    2410 Practice D. A physical therapist licensed under this Chapter shall not perform physical therapy services without a prescription or referral from a person licensed to practice medicine, surgery, dentistry, podiatry, or chiropractic. However, a physical therapist licensed under this Chapter may perform physical therapy services without a prescription or referral under the following circumstances: (1) To Children with a diagnosed developmental disability pursuant to the patient?s plan of care.

46. Physician Referrals and Triennial Evaluations - Can physician referrals coincide with triennial evaluations in the school system setting?

    The Board extensively researched the Guidelines and processes established for Special Education. The Board has agreed to allow the physician referral to coincide with the triennial evaluation as long as the physician clearly understands that the orders will be in effect until the three (3) year re-evaluation. The Board also discerned that new physician orders would be required if the child has any medical complication or surgeries in between the triennial evaluation. The Board also feels that the therapist should notify the physician if therapy services are discontinued during the annual Individualized Education Program or I.E.P.. All existing standards and criteria for identifying children eligible for special education and/or related services in Bulletin 1508 also apply.

47. Prescriptions - The question is regarding Physical Therapy Prescriptions with a prescribed duration of 3 times per week for 3 weeks. The example stated that the prescription was dated 12/3/01 and the patient evaluation was 12/10/01. The questions were: #1 When will the prescription expire?; and #2 Can the patient be treated beyond the three weeks to complete the nine visits?

    It is the Boards opinion that the 3 weeks begins with the date of the Evaluation and would expire 21 days post. It would not allow for treatment to continue after the expiration or the 9 visits without consultation and a new referral from the Physician. The Practice Act, specifically 2410, governs this opinion. A Physical Therapist treats by referral and if the referral states time and duration, then we must follow the referral. If a therapist deems that discontinuing care prior to, or continuing after the prescribed duration, then the physician should be consulted.

    You should also be aware that even though you may comply with the Board's regulations, you will also need to comply with third party payor regulations for reimbursement. Medicare, Medicaid, or Commercial Insurance may have stricterrequirements.

48. Prescription - 30 day - I have a patient's prescription dated 10/1 for a treatment of (6) six weeks, but the patient's first visit starts on 10/16. When does the six (6) weeks start?

    The Board considers the six (6) weeks to start with your first visit and initial evaluation. You should be aware; however, payors such as Medicare, Medicaid, or Commercial Insurance may have stricter requirements. For example, Medicare considers the start date as the date the prescription is written and requires 30 day recertification by the physician. Medicare would not accept a six (6) week treatment order.

    Even if you are in compliance with the Board's regulations, you will also need to comply with third party payor regulations in order to get paid.

49. Prescription expiration - Does a prescription for physical therapy ever expire by law? If so, what is the time frame?

    The Physical Therapy Practice Act does not specify the length of time that a prescription is valid. If the physician specifies the length of time the prescription is valid, then the prescription is valid for that period of time provided that the patient continues to have ongoing, attainable therapeutic goals. If the physician does not specify the duration of the prescription, the physical therapist is required to establish a plan of care with therapeutic goals, including the recommended frequency and duration of treatment. The Practice Act requires you to forward a copy of the initial physical therapy evaluation and plan of care to the referring or treating physician, dentist, podiatrist, or chiropractor. You should also be aware that entities other than the Board have specific requirements regarding the duration of treatment. For example, Medicare requires a physician re-certification every thirty (30) days. Also, please note that with regards to a prescription which is dated thirty (30) days prior to the actual date the patient presents himself for physical therapy, it is recommended by the Board that you contact the physician with regards to the possibility of a "stale" prescription. You may perform an initial evaluation to determine the need for physical therapy prior to contacting the physician in order to more fully discuss the patient's needs.

50. Prescription Insurance - Scenario: I treated a patient in the hospital for some time. She began as a very dependant person and left the hospital requiring mod-min assistance primarily for transfers and gait. She returned home with home health who has now decided her treatment. She currently is using a rolling walker and began to use a cane. She presents difficulty getting into bed and out of a car (or low level surfaces). Her bathroom independence is limited by space, balance, and strength. She continues to be limited to her bedroom because she is not independent enough to be assisted by her husband. Questions: As an independent PT, can I treat this patient with a physician's script? (She has requested my services). Private pay? - not via insurance company. Can I use a notebook for official documentation - with evaluation, goals, and designated time frame? Is this considered "wellness?" Can you relay information at the cost of insurance for me?

    The Board carefully reviewed your inquiry. It is of the opinion that the services you have described are not considered wellness or preventative services. This would not be considered wellness at this person had an acute medical diagnosis or condition from which she has not yet fully recovered. This patient still has active physical therapy goals. You can perform the services you described with a prescription from an authorized health care provider, such as a physician. Please refer to Section 2410A of the Practice Act which requires that you must have a prescription, or referral from a person licensed to practice medicine, surgery, dentistry, chiropractic or podiatry in order to implement physical therapy treatment to individuals for their specific condition or conditions.

    With regards to reimbursement, you may properly bill private pay including third party payors and/or Medicare, if appropriate. The patient can pay you privately; however, you should ensure that the patient has exhausted her medical benefits through the home health agency. If the patient is a Medicare patient and services qualify for payment under Medicare, then you can not bill the patient directly for the services. You should review pertinent Medicare guidelines.

    With regards to malpractice insurance, neither the Practice Act nor the Board's Rules require that a physical therapist or physical therapist assistant maintain professional liability insurance. However, it is strongly recommended that you obtain medical malpractice insurance coverage in the event a claim is filed in a civil suit and you are required to compensate someone for his damages. The Board can not recommend medical malpractice insurance carriers nor can it provide you with the costs of such professional liability insurance. It is recommended that you contact the Louisiana Physical Therapy Association in order to obtain some direction in this area.

    In reference to your use of a notebook for documentation purposes, such a practice is not prohibited by the Physical Therapy Practice Act or the Board's Rules, more particularly Rule 323 regarding documentation. Should you use this method of documentation, it is recommended that a notebook be used with securely fastened pages upon which the medical information is noted. You are also required to send a copy of your evaluation to the referring physician.

51. Prescription for tennis participatants - I realize that I am unable to treat without an M.D. order in my clinic, but is this for insurance reimbursement reasons? If tennis participants were to be private pay for physical therapy services, would I then be able to treat without an M.D. order?

    The practice act reads as follows regarding the practice of physical therapy without referral: 5) (a) To an individual for a previously diagnosed condition or conditions for which physical therapy services are appropriate after informing the health care provider rendering the diagnosis. The diagnosis shall have been made within the previous ninety days. The physical therapist shall provide the health care provider who rendered such diagnosis with a plan of care for physical therapy services within the first fifteen days of physical therapy intervention. Insurance reimbursement does not have anything to do with the rules regarding treatment without referral. In regards to the specific situation described at a local tennis club, the physical therapist would be within the scope of practice to provide wellness services to the members. However, if any of these participants have a medical problem with a medical diagnosis, then this would be considered physical therapy treatment and not wellness. I would recommend reviewing the portions of the practice act regarding direct access and wellness, and possibly attending one of the jurisprudence courses offered by the board

    The portion on wellness found in the rules section 305. Special Definitions is as follows: Preventative Services ý the use of physical therapy knowledge and skills by a physical therapist to provide education or activities in a wellness setting for the purpose of injury prevention, reduction of stress and/or the promotion of fitness, but does not include the administrations of physical therapy treatment and, therefore, can be performed without referral or prescription.

52. PTA requesting an order - May a Physical Therapist Assistant contact the physician to request an order?

    The physical therapist assistant may not solicit a verbal order. It is necessary for the physical therapist to request such an order.

53. PT Eval and Goals - THis facility currently has Pulmonary/Respiratory Therapists, Occupational Therapists and COTAs, and Physical Therapists and PTAs who work in this environment. At this time, two specific questions have arisen: 1) Pursuant to the PT Practice Act and Board rules, can a Physical Therapist initiate/complete a Pulmonary Rehab evaluation per MD order if the order states "Pulmonary Rehab Eval.?" Or, must the MD order state "Physical Therapy for Pulmonary Rehab?" 2) If a patient has been evaluated and is being seen for pulmonary rehab by a Pulmonary/Respiratory Therapist, can a PT/PTA carryout the treatment plan, document on that, and charge for skilled PT intervention in absence of that Pulmonary/Respiratory Therapist?

    In response to the first question, the Board is of the opinion that the referral for a Pulmonary Rehab Evaluation to a Physical Therapist must be written as a referral for physical therapy.

    In response to the second question, the Physical Therapy Practice Act mandates that a physical therapist can only implement a Treatment Plan, document and charge for such services after an evaluation has been completed by a duly licensed physical therapist.

54. PT Unable to see all patient load - Is a PT's license in jeopardy if they are unable to see patients as ordered by the MD? Example: if MD orders PT BID or TID, and the PT, due to staff shortages is only able to see that patient daily, is the PT's license in jeopardy?

    The Statutes or the Rules and Regulations do not address MD orders or patient care in the event of staff shortages. This is a problem that is experienced by most facilities at some point in operation for either daily coverage or weekend coverage. It is the opinion of the Board that a PT's license would not be in jeopardy if Hospital Policies and Procedures addressing staff shortages and Patient Care coverage are adopted. It may be beneficial that therapists' documentation address frequency and/or duration as per the policies during staff shortage periods.

55. Referrals by APRN's and PA's - With regards to the issue of the advanced practice registered nurse (APRN), it is the Board's understanding that the State Board of Nursing is in the process of promulgating rules and regulations with regards to this issue. However, the Physical Therapy Board has taken the position that an advanced practice registered nurse (APRN) has the legal authority to make a referral for physical therapy to a physical therapist. Likewise, the Board has taken the position that a physician assistant can refer a patient for physical therapy.

    There is no need for a co-signature from the attending physician with regards to the referral for physical therapy from a physician assistant or an APRN. A physician assistant and an APRN have the authority from their respective regulatory boards to make physical therapy referrals if internal protocol is established and complied with between the physician and these healthcare professionals. It is not required by the Physical Therapy Board for the physical therapist receiving such referral to verify the existence, or nature, of the internal protocol established between the physician and these healthcare professionals. The Physical Therapy Board?s legal position as set forth in this letter with regards to physician assistants and advanced practice registered nurses is based upon its interpretation of LSA R.S. 37:2410A of the Louisiana Physical Therapy Practice Act which requires that physical therapy be implemented upon the prescription or referral of a person licensed to practice medicine. Based upon the laws allowing physician assistants and advanced practice registered nurses to refer for physical therapy enables the Board to legally and logically extend the term "license to practice medicine" in Section 2410A to those healthcare professionals to whom such authority is legally delegated. Additionally, with regards to verbal orders, the following language is set forth in Rule 323AI: A prescription or referral is a written request for physical therapy signed by a qualified practitioner which may initially be a verbal order but must later be confirmed in writing. The verbal order shall be documented by the physical therapist in the patient"s record. If the verbal order is not confirmed in writing, then the physical therapist shall send a written communication requesting a written prescription or referral to the prescribing practitioner within fifteen days of commencement of treatment or by the fifth treatment session, whichever occurs first. A copy of the written communication to the prescribing or referring practitioner must be maintained in the patient"s record. "Practitioner" as referred to in Rule 323A1 is the individual licensed to practice medicine and not the physician assistant or advanced practice registered nurse. Therefore, your written communication must be forwarded directly to the attention of the physician.

56. Referral for FCE - Is a physician referral required for Functional Capacity Evaluation, Ergonomic Analysis, Work Conditioning, and Work Hardening?

    It is the Board's opinion that as per the P.T. Practice Act an FCE is an evaluation and there is no need for a physician's prescription or referral. Concerning an Ergonomic Analysis, the Board is of the opinion that the law does not require a physician referral in as much as this type of service is of a consultative nature, i.e.; an evaluation of a person's work and/or living environment. With regards to work conditioning and work hardening, it is necessary to have a physician referral in order to perform these treatment services.

57. Referrals - Ionto - 1) What are the state regulations on ordering/dispensing oxygen patients for PT? Is a prescription needed for ordering oxygen? 2) Is a prescription needed for Ionto/phonophoresis? Can these be dispensed to patients without a specific script from an MD? 3) Same question in references to wound care drugs?

    1) The Physical Therapy Practice Act does not authorize the ordering of oxygen or the dispensing of oxygen to patients for physical therapy without a referral from a physician.

    2) The patients may be evaluated and treatment implemented which includes Ionto/phonophoresis under Direct Access (patients must have a diagnosis for physical therapy intervention within 90 days). The physical therapist must forward a plan of care to the diagnosing physician within 15 days of implementation of treatment.

    3) We assume you are referencing prescriptive drugs. Prescriptions require a physician order. The patient may be seen under direct access for wound care, however, the physician order for drugs remains.

58. Registration of facilities administering PT - Do facilities administering physical therapy have to be registered with the Board?

    Such facilities do not have to be registered with the Board. It is recommended that you contact the Louisiana Department of Health and Hospitals with regards to any other inquiries concerning this issue.

59. Rehab Physiatrist and Nursing Home Patients - A rehab without a physiatrist is admitting patients who may be independent with functions; the doctor still orders physical therapy. Can the P.T. discharge the patient if he thinks they are not appropriate? Is it proper for the DON to interfere with the P.T.'s judgment not to discharge?

    As a physical therapist you have a responsibility to perform an initial evaluation of each patient to establish an appropriate treatment plan and goals to be achieved. If no appropriate intervention is felt necessary, then this should be communicated to the ordering physician and no therapy intervention undertaken without agreement that an appropriate therapy indication is present.

    Absolutely, it is not appropriate for any administrative personnel to interfere with clinical decisions of appropriate treatment or discharge.

60. Rx - Documentation - How does direct access relate to the patient?s diagnosis and subsequent treatment?

    The patient's diagnosis can be established by a number of methods, but must have been made by a Health Care Provider (physician) within the previous 90 days. Bills, copies of the physicians note stating the diagnosis, and insurance papers with associated diagnosis codes from the physician?s office are all acceptable means of establishing a diagnosis.

    Please note that once a plan of care has been established, this must be provided to the Health Care Provider within 15 days of initiation of treatment. Please refer to section 2410 D of the Louisiana Physical Therapy Practice Act for a full explanation.

61. Rx for Re-consult - I am currently working in an acute care setting, level one trauma center. I have a question on when a new referral from a physician is needed for treatment. It has always been an unwritten rule with our rehabilitation department that when a patient has a change in status either because of a major surgery or a medical change in status requiring admittance to the ICU that we have discharged the patient and asked for a re-consult when appropriate. Our doctors are now asking for documentation of why we need a re-consult. I have looked in the Louisiana Practice Act and on the APTA website and cannot find anything related to this. Does the Board have a stance on when new consults are needed/required such as in this case?

    The Board has no laws or Rules and Regulations that specifically address discontinuation of therapy when the patients medical status declines or when a patient has surgery. As practicing therapists, most of us know who have worked in hospitals have followed the same procedure that you currently do.

    I would suggest that you look to JCAHO Standards and Medical Staff or Hospital Bylaws for guidance and answers to your questions.

62. Short Term Rehabilitation - Therapists were told by one physician-Medical Director of free standing short term rehab, to place these patients not appropriate on functional maintenance programs. What exactly is this in a short term rehab? How do you charge and document for this? Is this really skilled treatment, when we are told to continue weight training/strengthening with patients that are exhibiting normal/functional strength?

    The Board is of the opinion that no legitimate situation exists whereby a patient is placed on a maintenance program when involved in an inpatient rehab situation. In other words, when the patient no longer has realistic goals, there is no skill treatment and services are not billable as such. To do otherwise would be a violation of the Physical Therapy Practice Act and the Board's Rules, as well as other healthcare laws such as Medicare, etc.

63. Taping Athletes' Joints - Can a physical therapist properly provide taping of athletes' joints prior to athletic competition as injury prevention without a physician's order?

    The Board is of the opinion that the taping of an athletes' joints prior to athletic competition as injury prevention is in the nature of a consultative service which does not require a physicians order as per the Physical Therapy Practice Act, more particularly LSA R.S. 37:2410A. Therefore, such services constitute the practice of physical therapy, but does not require a physician's order.

64. Treatment Discharge 1 - If a physical therapist is told by its Rehab Manager (a speech therapist) to evaluate a resident with Medicare Part B insurance, and is told by the Manager to recommend treatment for two weeks as a "trial therapy" for the patient, but the physical therapist does not believe it would result in any improvement to the patient, what should the physical therapist do?

    Pursuant to the Physical Therapy Practice Act, LSA R.S. 37:2410A, a physical therapist may conduct an initial evaluation to determine the need for physical therapy without a physician's prescription or referral. However, it must be noted that to implement physical therapy treatment, a referral or prescription is needed from a surgeon, dentist, podiatrist, chiropractor, or physician. More pertinent to your inquiry, a physical therapist can only recommend physical therapy treatment if in fact such treatment would help improve the patient's condition. To do otherwise, would be recommending treatment which exploits the provider-patient relationship as well as perhaps contraindicated. Such action on the part of the physical therapist would be in violation of the Physical Therapy Practice Act and the Board's Rules, which includes the Code of Ethics, and as a result subjects the physical therapist's license to sanction by the Board. Please review Section 37:2413A(7) of the Practice Act regarding "unprofessional conduct" and Board Rule 327 E, which further defines unprofessional conduct quoted, in pertinent part, as follows:

    5. initiation or continuation of physical therapy services that are contraindicated or cannot reasonably result in a beneficial outcome; or

    6. abuse or exploitation of the physical therapy provider patient relationship for the purpose of securing personal compensation, gratification, or benefit unrelated to the provision of physical therapy services.

    Additionally, for a physical therapist to recommend that a resident receive physical therapy treatment which is not appropriate and then bill Medicare Part B insurance, would in all probability be viewed as Medicare fraud.

65. Treatment Discharge 2 - If a physical therapist believes a patient has exhibited maximum functional gains, and believes no further therapy would change the patient's status, and the physical therapist discharge summary notes no additional progress for 2-3 weeks prior to discharge, but the rehab manager (a speech therapist) questions the discharge (and other similar discharges) as inappropriate and directs continues treatment for an additional two weeks, what should the physical therapist do?

    Please refer to the Board's Response to Question 1. Additionally, once a patient has reached maximum medical improvement and physical therapy can no longer benefit such individual, it is the physical therapists obligation to discharge the patient. For a physical therapist to continue treatment which is inappropriate would be a violation of the Physical Practice Act, LSA R.S. 37:2413A (7), regarding unprofessional conduct and Rule 327E.

66. Treatment Discharge 3 - If a rehab manager tells a physical therapist to do a split QD (with the physical therapist seeing the resident in the morning and the physical therapist assistant treating the same patient in the afternoon) to a Medicare Part B patient, and the physical therapist believe such afternoon treatments would be unnecessary and unjustified, what should the physical therapist do?

    A "split" can be done as long as the physical therapist and physical therapist assistant is complying with the Physical Therapy Practice Act and the Board's Rules with regards to supervision, more particularly Rule 321 regarding the appropriate practice setting. Furthermore, the split can be done if the treatment is proper and has realistic goals in compliance with the Practice Act and the Board's Rules. Please be advised that pursuant to Rule 305, the supervising physical therapist is ultimately responsible for the treatment plan of the patient.

67. Treatment Discharge 4 - If a physical therapist does a screening of a new Medicare Part A admit, and the physical therapist is of the opinion that the resident is not appropriate for physical therapy treatment, and advises the nursing personnel of this opinion, but the nursing personnel subsequently write a telephone order for physical therapy evaluation and treatment, what should the physical therapist do, and how can the physical therapist address such ethical questions at work without jeopardizing his position/job?

    Please see the Board's Responses to Treatment Questions 1-3. You describe an unfortunate situation, however, it is much more career oriented for to physical therapist to protect his license for future employment. In other words, you will be able to find other employment with a current license that has not been sanctioned by the Board should you lose your current job for obeying the law.

68. Treatment Session - Plan of Care - In reference to regulation regarding supervision of PTAs (section 321). Is it necessary for the PT to treat the patient for the entire determined treatment session or can they treat them for the amount of time determined to be sufficient to update the goals and plan of care?

    Rule 321A(2)(c) provides that with regards to the requirement of periodic supervision of physical services rendered by a licensed physical therapist assistant, the supervising physical therapist "shall treat and reassess the patient on at least every sixth (6th) visit but not less than once per month." It is the Board's opinion that in order to properly reassess, the physical therapist must be involved in the entire treatment session of the patient. Pursuant to Rule 323A(4) regarding documentation standards, reassessment is defined to mean the written documentation which includes all elements of a progress note as well as the interpretation of objective findings with a revision of goals and treatment plan as indicated. Therefore, the Board is of the opinion that reassess only based upon the sixth (6th) visit without being involved In the entire treatment session does not comply with the intent and wording of Rule 321A(2)(c). The Physical Therapy Practice Act and Rules promulgated by the Board have been written, and are enforced, to insure the safety, health, and welfare of the public receiving physical therapy services. To that end, the Board must implement the Practice Act and its Rules so as to provide the best standard of care for the patients.

69. Treatment without MD order. - Question 1: I do realize that I am unable to treat without an M.D. order in my clinic, but is this for insurance reimbursement reasons? Question 2: If there tennis participants were to be private pay for physical therapy services, would I then be able to treat without an M.D. order?

    Answer 1: The practice act reads as follows regarding the practice of physical therapy without referral:

    5)(a) To an individual for a previously diagnosed condition or conditions for which physical therapy services are appropriate after informing the health care provider rendering the diagnosis. The diagnosis shall have been made within the previous ninety days. The physical therapist shall provide the health care provider who rendered such diagnosis with a plan of care for physical therapy services within the first fifteen days of physical therapy intervention.

    Insurance reimbursement does not have anything to do with the rules regarding treatment without referral.

    Answer 2: Once again, please refer to the practice act as quoted above. The source of payment does not matter, and therefore the rules for treatment without referral remain unchanged.

    In regards to the specific situation you have described at a local tennis club, you would be within the scope of practice to provide wellness services to the members; however, if any of these participants have a medical problem with a medical diagnosis, then this would be considered physical therapy treatment and not wellness.

    I would recommend reviewing the portions of the practice act regarding direct access and wellness, and possibly attending one of the jurisprudence courses offered by the board in your area. The portion on practice and referrals is below:

    2410 Practice No person licensed under this Chapter shall practice physical therapy or act as a physical therapist, except upon the prescription or referral of a person licensed to practice medicine, surgery, dentistry, podiatry, or chiropractor. Initial evaluation or consultation of a screening nature to determine the need for physical therapy may be performed by a physical therapist without referral, but implementation of physical therapy treatment individuals for their specific condition or conditions shall be based on the prescription or referral of a person licensed to practice medicine, surgery, dentistry, chiropractor, or podiatry. B. A person not licensed as a physical therapist or physical therapist assistant in accordance with this Chapter may be employed in a hospital, institution, clinic, physician's office, or athletic training room to administer treatment under the direction and supervision of a license physician; however, the treatment administered shall not be identified a physical therapy, and further provided that such persons administering such treatment shall not hold themselves out, nor be held by others as physical therapists or physical therapists assistants. C. (1) A person licensed under this Chapter as a physical therapist assistant shall only perform treatments under the direction and supervision of a licensed physical therapist. The duties assigned to the physical therapist assistant shall be commensurate with the physical therapist assistant's education and training. (2) A physical therapist assistant?s duties shall not include interpretation or implementation of referrals or prescriptions, performance of evaluations, or the determination or major modification of treatment programs. (3) A physical therapist assistant shall in no way hold himself out to be a physical therapist and shall make known to patients his title as a licensed physical therapist assistant. D. A physical therapist licensed under this Chapter shall not perform physical therapy services without a prescription or referral from a person licensed to practice medicine, surgery, dentistry, podiatry, or chiropractic. However, a physical therapist licensed under this Chapter may perform physical therapy services without a prescription or referral under the following circumstances: (1) To Children with a diagnosed developmental disability pursuant to the patient's plan of care. (2) As part of a home health care agency pursuant to the patient?s plan of care. (3) To a patient in a nursing home pursuant to the patient's plan of care. (4) 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. (5) (a) To an individual for a previously diagnosed condition or conditions for which physical therapy services are appropriate after informing the health care provider rendering the diagnosis. The diagnosis shall have been made within the previous ninety days. The physical therapist shall provide the health care provider who rendered such diagnosis with a plan of care for physical therapy services within the first fifteen days of physical therapy intervention. (b) Nothing in this Chapter shall be construed to create liability of any kind for the health care provider rendering the diagnosis pursuant to this Subsection for a condition, illness, or injury that manifested itself after such diagnosis or for any alleged damages as a result of physical therapy services performed without a prescription or referral from a person licensed to practice medicine, surgery, dentistry, podiatry, or chiropractic. E. Physical therapy service performed without a prescription or referral from a person licensed to practice medicine, surgery, dentistry, podiatry, or chiropractic shall not be construed to mandate coverage for physical therapy services under any health care plan, insurance policy, or workers? compensation or circumvent any requirement for pre-authorization of services in accordance with any health care plan, insurance policy, or workers' compensation.

    The portion on wellness found in the Rules and Regulations is as follows:

    Preventative Services - the use of physical therapy knowledge and skills by a physical therapist to provide education or activities in a wellness setting for the purpose of injury prevention, reduction of stress and/or the promotion of fitness, but does not include the administrations of physical therapy treatment, and therefore, can be performed without referral or prescription.

70. Triennial Eval - Can physician referrals coincide with triennial evaluations in the school system setting?

    The Board extensively researched the guidelines and processes established for Special Education. The Board has agreed to allow the physician referral to coincide with the triennial evaluation as long as the physician clearly understands that the orders will be in effect until the three (3) year re-evaluation. The Board also discerned that new physician orders would be required if the child has any medical complication or surgeries in between the triennial evaluation. The Board also feels that the therapist should notify the physician if therapy services are discontinued during the annual Individualized Education Program or I.E.P. All existing standards and criteria for identifying children eligible for special education and/or related services in Bulletin 1608 also apply.

71. Verbal order initiated by physician - Could the physical therapist assistant accept a verbal order from a physician if the physician initiates the contact? If the answer is yes, should the assistant record the verbal order in the patient's chart?

    The assistant may accept the verbal order from the physician if the physician initiates the contact but physical therapy can not be implemented nor changes with regards to physical therapy without the physical therapists knowledge and the physical therapist actually implementing the change and/or formulating the treatment plan. Additionally, your attention is addressed to the APTA's Guide for Professional Conduct No. 1.2A, B and C, which are listed below. 1 Confidential Information A. Information relating to the physical therapist-patient relationship is confidential and may not be communicated to a third party not involved in that patients care without the prior written consent of the patient subject to applicable law. B. Information derived from a component-sponsored peer review shall be held confidential by the reviewer unless written permission to release the information is obtained from the physical therapist who was reviewed. C. Information derived from the working relationships of physical therapists shall be held confidential by all parties.

    The verbal order must be recorded in the patient s record by the attending physical therapist.

72. Verbal Orders - NRSG Name - MD Signature Stamp - Can a script for the physical therapist read v.o. and the nurse's name with the physician's signature stamped on the script?

    Pursuant to Rule 323A (1), a nurse can write a verbal order on a prescription for physical therapy and the physical therapist can initiate physical therapy treatment after performing an evaluation. Furthermore, pursuant to the cited Rule, the verbal order must later be confirmed in writing by the physician. Rule 323A (1) requires that the verbal order be documented by the physical therapist in the patient's record.

    With regards to your question concerning the use of a physician's signature stamp, I have researched the issue and contacted the Board of Medical Examiners and the Board of Pharmacy. It is our understanding that the Board of Medical Examiners does not prohibit the use of a physician's signature stamp. Additionally, the Physical Therapy Practice Act and the Board's Rules do not prohibit the use of a physician's signature stamp. Please be mindful of the requirements contained in Rule 323 referenced above regarding verbal orders.

    It is also recommended that you review the policy of your organization regarding its position on verbal orders. In the event the position set forth in hospital policy regarding verbal orders is more strict that Rule 323A (1), then the hospital policy will govern the use of physician's signature stamp.

    Also, please be aware that most third party payors, including Medicare, do not accept a physician's signature stamp with regards to reimbursement.

73. Verbal Order Signed by M.D. - What is the timeframe required to receive signed orders to cover verbal orders from physicians?

    The Board's Rules, Section 323A (1) DOCUMENTATION STANDARDS describes the therapist's responsibility in taking and documenting a verbal order, and requesting a written order within 15 days of commencement of treatment or by the fifth treatment session, whichever occurs first. The therapist must retain a copy of the written communication to the physician in the patient's medical record.

    The Board has no jurisdiction over physicians and therefore cannot write Rules that will force a physician to provide a written order to the therapist in a specified time frame.

    As stated, the hospital has set timeframes in Hospital Bylaws for physicians signing verbal orders. Any organization may set these timeframes and it is their right and obligation to do so. JCAHO also requires this in their Standards.

74. Verbal Orders from Nurse - Can a nurse accept a verbal order for P.T. from a physician, and then pass on the order to the physical therapist?

    The answer to this question is yes. The nurse may take the verbal order and then document it in the medical record for co-signature by the physician. The physical therapist can begin treatment based on the verbal order.

75. Wheelchair Evaluation - Is it permissible pursuant to the Physical Therapy Practice Act and Rules and Regulations of the Board for you to evaluate a patient for a wheelchair?

    The Board is of the opinion that the evaluation of a patient for a wheelchair is permissible and within the scope of the practice of physical therapy as stated in the Physical Therapy Practice Act, LSA R.S. 37:2410A. The evaluation of a patient for a wheelchair is covered by the provision that "an initial evaluation or consultation of a screening nature to determine the need for physical therapy may be performed by a PT without referral, but the implementation of physical therapy treatment to individuals for their specific condition or conditions shall be based on the prescription or referral of a person licensed practice medicine, surgery, dentistry, or podiatry." Therefore, the evaluation of a patient for a wheel chair would constitute an initial evaluation or consultation of a screening nature and is legally permissible pursuant to the Physical Therapy Practice Act and Rules and Regulations of the Board.