Coverage for the clinic and the care.

Direct access: the 45-day, 12-visit line

California lets patients start physical therapy without a referral, but Business and Professions Code 2620.1 attaches conditions. Treatment can't continue beyond 45 calendar days or 12 visits, whichever occurs first, unless a physician and surgeon or a podiatrist has put a dated signature on the therapist's plan of care approving it. That approval has to include an in-person or telehealth examination and evaluation of the patient by the physician and surgeon or podiatrist. The limit doesn't apply when the therapist provides only wellness services, or to services under an individualized family service plan or individualized education plan for someone with no medical diagnosis.

Before treating a direct-access patient, the therapist must give a notice that is:

• given orally and in writing, in at least 14-point type, and signed by the patient
• clear that the patient is receiving direct physical therapy treatment services, and that after 45 calendar days or 12 visits, whichever occurs first, treatment can continue only with a physician and surgeon's or podiatrist's dated signature approving the plan of care after an in-person or telehealth examination
• closed with a "Patient's Signature/Date" line

The same section requires the therapist to refer the patient to a physician and surgeon, dentist, podiatrist or chiropractor when signs or symptoms point to a condition beyond physical therapy's scope, or when the patient isn't progressing toward documented treatment goals. With the patient's written authorization, the therapist must notify the patient's physician and surgeon, if any, and the therapist must disclose any financial interest in treating the patient.

If a treatment outcome is ever disputed, the signed notice, the visit count and the dated plan of care are the records that show these steps happened, so keep them where they can be pulled quickly. Direct access rules vary by state, and a group treating patients in more than one state needs each state's rules on hand. Section 2620.1 also says it does not require a health plan, insurer or workers' compensation plan to cover direct-access treatment.

The chart rules, and Medicare's

California's records rule, 16 CCR 1398.13, requires the physical therapist to document and sign in the patient record:

• examination and re-examination
• evaluation and reevaluation
• diagnosis, prognosis and intervention
• the treatment plan and any modification of the plan of care
• each treatment provided by the physical therapist or a physical therapy aide
• the discharge summary

A PTA documents and signs any treatment the PTA provides. For any care, the record must show the date and nature of the service and the name and title of each person who provided it, including that person's role. Electronic signatures are sufficient.

Medicare adds its own layer. Under 42 CFR 424.24(c), the initial certification of an outpatient therapy plan must be obtained as soon as possible after the plan is established, and recertification is required at least every 90 days. When a therapist establishes the plan, the certification doesn't need the signature of a physician, nurse practitioner, physician assistant or clinical nurse specialist who knows the case if that practitioner's written order or referral is in the record and the therapist has documented delivering the plan to them within 30 days of completing the initial evaluation. CMS also sets a KX modifier threshold for Medicare claims of $2,480 for PT and speech-language pathology services combined for calendar year 2026. CMS describes the modifier as confirmation that services are medically necessary as justified by documentation in the medical record, and claims over the threshold without it are denied.

Charts written to meet these rules are also what a defense attorney works from. A billing audit is a different risk from a malpractice claim, so ask what your professional liability form says about regulatory and billing proceedings before you need it.

Official sources

• Cal. Bus. & Prof. Code 2620.1 (direct access)
• Cal. Bus. & Prof. Code 2622 (PTA and aide limits)
• Cal. Bus. & Prof. Code 2630.3 (physical therapist assistants)
• 16 CCR 1398.44 (PTA supervision)
• 16 CCR 1399 (requirements for use of aides)
• 16 CCR 1398.13 (patient record documentation)
• 42 CFR 424.24 (certification of outpatient therapy plans)
• CMS: Therapy Services (KX modifier thresholds)