Orthopedic and sports-medicine referrals

This guide is for pediatric and adult physical therapy practices, and for occupational therapy practices that take hand and upper-extremity referrals. To earn orthopedic and sports-medicine referrals, show the office that your clinicians treat its patients competently, schedule them soon after surgery, take their insurance, follow the surgeon’s protocol and report back after the evaluation and at discharge.

The rules behind a referral differ by discipline, state and payer: direct access to physical therapy is set state by state, an OT practice answers to its own state’s practice act, and Medicare pays for outpatient PT and OT only under a plan of care that a physician or nonphysician practitioner certifies.⁠^1,2 Speech-language pathology referrals are outside this guide; the adult therapy referrals guide and the pediatrician referrals guide cover them.

What do orthopedic and sports-medicine offices need from a therapy practice?

Seven answers they can check: which of their patients you treat, how referrals arrive, how you work within the protocol, how soon you see a post-operative patient, which plans you take, who hears about an athlete’s progress, and when reports come back.

The general method, from the one-page sheet to follow-up, is in the pediatrician referrals guide and the adult therapy referrals guide.

Which orthopedic and sports-medicine offices refer to PT and hand therapy?

The ones whose patients match a service you deliver now, usually a short list rather than every orthopedic group in the area.

If a group runs its own therapy service, ask which patients it sends elsewhere: those who live far away, whose plan its therapists do not take, or who need a service it lacks, such as pediatric care or hand therapy. Infant referrals have their own routes, covered in NICU follow-up referrals and the pediatric PT growth guide.

Can an occupational therapy practice take orthopedic hand referrals?

Yes, when its clinicians have the experience: hand therapy belongs to both OT and PT. The Hand Therapy Certification Commission describes Certified Hand Therapists as licensed or certified OTs or PTs with at least three years of clinical experience, including 4,000 hours or more of direct practice in hand therapy, who have passed a comprehensive test in upper limb rehabilitation and recertify every five years; it reports that 88 percent of CHTs are occupational therapists, 11 percent physical therapists and 1 percent both.⁠⁸

Two rules differ for OT: Medicare counts the OT KX modifier threshold separately from PT and speech-language pathology.⁠⁹ Whether an OT may treat without a referral is answered by the state’s OT practice act, which defines the scope of practice, and by the payer contract, not by PT direct-access summaries.⁠¹⁰ A practice without a CHT can still offer upper-extremity care within its clinicians’ competence, described accurately and without the title.

How do you show competence with orthopedic and sports patients?

Name the populations, procedures and clinicians plainly, and attach real credentials where they exist. An office sending a 14-year-old after knee surgery wants to know who treats adolescents after that surgery, not that the practice “treats sports injuries,” and adult experience does not, by itself, show pediatric readiness.

Board certification is one way to show depth. APTA’s specialist certification program, governed by the American Board of Physical Therapy Specialties, certifies PTs in areas that include orthopedics, sports and pediatrics, and reports 25,306 orthopedic, 4,153 sports and 3,219 pediatric specialists certified as of July 2026.⁠^11,12,13 Its public directory lets health care professionals look a credential up.⁠¹⁴ The sports credential has a stated limit: ABPTS says it grants no additional rights or privileges, and its holders practice only within their state physical therapy practice act.⁠¹²

Where a clinician holds no specialist credential, describe the experience instead of borrowing a title. List only equipment the practice owns and uses, and if a protocol calls for a test or device you lack, say so before the patient is booked. The guide to choosing a specialty covers which services a team is ready to advertise.

Do patients need a referral to see a PT after an orthopedic injury?

For physical therapy it depends on the state and the payer, so check rather than assume. APTA’s summary of direct access by state reports that all 50 states, the District of Columbia and the U.S. Virgin Islands provide some form of direct access to physical therapist services, and that the specific provisions and limitations differ across jurisdictions.⁠¹ APTA describes each as having provisional or unrestricted direct access, with provisions tied to treatment without a referral persisting in a number of states.⁠¹⁵

Payment is a separate question. ChoosePT, APTA’s consumer site, notes that certain insurance plans may still require a referral, that some states may limit the duration or type of treatment without one, and that some insurers require a referral after a certain number of visits.⁠³ A patient who may legally book directly can still need a referral for payment.

Medicare has no order requirement but does require certification: CMS’s Benefit Policy Manual states that there is no Medicare requirement for an order and that payment depends on the certification of the plan of care.⁠⁴ Even so, an orthopedic referral carries the surgeon’s protocol and precautions, so when a post-operative patient books directly, request the protocol before treatment begins.

What does Medicare require when an orthopedic office refers a patient?

A written plan of care that a physician or nonphysician practitioner certifies. The Part B conditions for outpatient PT and OT refer to a patient under the care of a doctor of medicine, osteopathy or podiatric medicine, and to a written plan meeting 42 CFR 410.61.⁠^16,17 The certification states that the patient was under the care of a physician, nurse practitioner, clinical nurse specialist or physician assistant.⁠²

The plan does not have to come from the surgeon. It may be established by a physician, by the PT or OT who furnishes the services, or by a nurse practitioner, clinical nurse specialist or physician assistant, and it states the type, amount, frequency and duration of the services, the diagnosis and the anticipated goals.⁠¹⁸ When the therapist establishes it, a physician or one of those practitioners with knowledge of the case signs the certification, and recertification is required at least every 90 days.⁠²

Timing matters. CMS’s fact sheet calls for the initial certification as a dated signature or verbal order within 30 calendar days of the first day of treatment, including the evaluation.⁠⁵ Since January 1, 2025, the physician’s dated signature on a written order can substitute for the signature on a therapist’s initial plan that has not come back within 30 days, but only when the order identifies the physician and patient and states the type of therapy needed, and the record shows the plan was delivered to that physician within 30 days of the evaluation; it does not apply to recertifications.⁠⁵ So ask each office for a signed, dated order naming PT or OT, and send the plan in a way you can prove.

1. The claim. It carries the certifying provider’s name and NPI, so the referral record needs the certifying physician’s NPI, often the surgeon’s.⁠⁵
2. The certifier. A doctor of podiatric medicine may certify within the scope state law allows podiatry; a chiropractor may not certify or recertify a therapy plan of care.⁠⁴
3. The next post-operative visit. A certifying physician, often the surgeon, who requires a visit before therapy continues should certify only until that date; CMS treats later services as lacking a certified plan.⁠⁴
4. The patient’s liability. When a therapist in private practice cannot produce a certification, CMS says the denial results in beneficiary liability and recommends making the patient aware of the need for certification.⁠⁴

These are Original Medicare rules; check each Medicare Advantage, Medicaid and commercial plan’s own referral and authorization rules, and see the credentialing guide for participation.

How does the Medicare KX threshold affect long post-operative care?

It adds a documentation step once a patient’s therapy spending for the year passes it. For 2026, CMS sets the KX modifier threshold at $2,480 for PT and speech-language pathology combined and $2,480 for OT; claims above it without the modifier are denied, and targeted medical review applies at $3,000.⁠⁹ The modifier indicates medically necessary services justified by documentation in the record.⁠¹⁶

Because PT and speech-language pathology share one amount, a patient who had outpatient speech therapy this year reaches the PT threshold sooner; ask at intake about therapy elsewhere this year.⁠⁹

Who decides the post-operative protocol when a surgeon refers a patient?

The surgeon does: the protocol and its precautions belong to the surgeon, and the practice follows them. Within them, the therapist evaluates and writes the plan of care, because evaluation and treatment decisions stay with the qualified clinician. APTA’s Code of Ethics asks physical therapists to strive for independent and objective professional judgment in the patient’s best interests, and to communicate with, collaborate with or refer to other health care professionals when necessary.⁠¹⁹ For OTs, Medicare’s plan rules likewise name the OT who furnishes the services among those who may establish the plan.⁠¹⁸

Medicare draws the line on changes: when a physician has established or certified the plan, CMS states that the therapist may not significantly alter it without the physician’s documented approval, and treats a change in long-term goals as significant.⁠⁴ Progressing within the protocol is the therapist’s work; changing what it allows is a conversation with the surgeon.

• Get the protocol in writing, with its version or date, and keep a file for each surgeon who refers.
• When none arrives, ask for it before the first treatment session rather than substituting one from elsewhere.
• Record each protocol question, who answered it and what was decided.

What should an orthopedic referral include before the first visit?

Enough to start safely and bill correctly: who the patient is, what was done and when, what the surgeon allows, who pays and where reports go. Agree on the list with each office once.

Ask for the records the protocol depends on. Under HIPAA, a covered entity may disclose protected health information for the treatment activities of a health care provider, treatment includes referring a patient from one provider to another, and the minimum necessary standard does not apply to disclosures to or requests by a provider for treatment.⁠^20,21,22 Those rules bind covered entities, including a provider that transmits health information electronically in a covered transaction.⁠²³ Keep referral documents out of marketing files.

How fast should a practice schedule patients after orthopedic surgery?

As fast as the surgeon’s protocol needs, and only as fast as the practice can deliver every time. Ask each office when its protocols expect the first visit, measure your own days from referral to first visit, and put that measured figure on the referral sheet.

The evaluation is one appointment; the plan of care is many, so check that the follow-on visits fit hours a recovering patient can attend before accepting the referral.

• Hold evaluation slots each week for post-operative patients, released at a fixed point if unused.
• Ask the office to send the referral before surgery when the date is known, so the first visit is booked before the patient goes home.
• Match the clinician to the patient’s age and procedure first, and the open slot second.
• When you cannot meet the protocol’s timing, tell the office at once so it can refer elsewhere.

Do not advertise next-day post-operative appointments unless the measured figure supports it. The intake call script and the waitlist guide cover the first call and a full schedule.

How should a practice report back to the referring orthopedic office?

After the evaluation, when the plan changes or a problem appears, before each post-operative visit, and at discharge, through the route the office chose. The evaluation report carries the plan of care, which for Medicare patients needs a dated certification within 30 calendar days of the first day of treatment, so keep proof of delivery.⁠⁵ The progress report Medicare requires at least once every 10 treatment days is a ready-made update before a post-operative visit.⁠⁵

When a patient does not schedule or stops attending, tell the office; coordinating care with the referring provider is treatment under HIPAA’s definition.⁠²¹

How should a PT practice handle return to sport for adolescent athletes?

Treat return to sport as a process the practice reports on, not a date it promises, and agree at the start on who makes the clearance decision. The 2016 consensus statement from the First World Congress in Sports Physical Therapy describes return to sport as a continuum alongside recovery and rehabilitation rather than a decision taken at the end, says those decisions are made by clinicians, athletes and coaches, ideally collaboratively, and notes that research evidence to support them in clinical practice is scarce.⁠⁶

So describe the tests the practice runs, send results with the clinician’s interpretation, and do not market return-to-sport timelines. Ask the office whether it wants a recommendation or results only, and who signs any participation form a school, club or league requires.

An adolescent needs a clinician who treats adolescents and a family that is part of the plan. HIPAA treats a parent or guardian with authority under applicable law as an unemancipated minor’s personal representative, with exceptions such as care the minor may lawfully obtain without a parent’s consent, and state law can permit or prohibit disclosure to a parent.⁠²² Keep the athlete in every conversation about goals.

Who can receive an injured athlete’s therapy information?

The patient, a minor’s parent as personal representative, and other providers treating the athlete; a coach generally needs a signed authorization. HIPAA permits disclosure for a health care provider’s treatment activities, and a provider includes anyone who furnishes health care in the normal course of business, which can include an athletic trainer caring for the athlete.⁠^20,23 A coach or league official is not furnishing health care, and outside the Rule’s permissions a covered entity needs a valid authorization to disclose protected health information.⁠²⁴ Name each recipient and what they may receive in a signed authorization at intake, and send a team only what it covers.

Which arrangements with orthopedic groups need a legal review first?

Any arrangement in which something of value passes between the practice and a referral source, in either direction. The federal Anti-Kickback Statute prohibits the knowing and willful payment of remuneration to induce or reward referrals of services payable by federal health care programs, on both sides of the payment; OIG states that remuneration includes anything of value, such as free rent, and that the prohibition applies to all sources of referrals.⁠²⁵

Orthopedic groups bring in a second law. The physician self-referral law prohibits a physician from referring Medicare patients for designated health services, which include PT, OT and outpatient speech-language pathology, to an entity with which the physician or an immediate family member has an ownership or compensation relationship, unless an exception’s requirements are met.⁠⁷ OIG calls it a strict liability statute, so intent does not need to be proven.⁠²⁵ Its lease exceptions also rule out rent for office space or equipment set by a per-unit-of-service formula, to the extent it reflects patients the lessor refers.⁠⁷ Have counsel review these before anyone signs:

• Renting space, staff time or equipment from or to an orthopedic group, or placing a therapist in a surgeon’s clinic
• Medical director or consulting fees paid to a physician who refers
• Sponsorship or “preferred provider” fees paid to a group, team or league in return for steering patients
• Free services to a referral source, such as bracing in its clinic
• Any referral target, written or unwritten, in either direction

APTA’s Code of Ethics sets the professional standard alongside the law: physical therapists shall not accept gifts or other considerations that influence or appear to influence their judgment, nor enter into arrangements that prevent them from meeting their obligations to patients.⁠¹⁹

How do you introduce a practice to an orthopedic or sports office?

With a short letter to the person who handles referrals, built from the capability statement and your measured figures; the pediatrician referrals guide has the phone script and follow-up timing.

Replace every bracket with a fact you can stand behind. If the clinic has claimed and activated its DrSensory listing, make the specialties, ages and conditions on it match this letter (claiming and optimizing a profile); a listing describes the clinic and is not an endorsement.

What does a well-run sports-medicine referral look like in practice?

One where the practice matches the athlete to the right clinician, settles information sharing before anyone asks, and takes protocol questions to the surgeon the day they come up.

What should a practice record about each orthopedic referral source?

One record per office, holding the facts and decisions the relationship runs on; a blank field is an open decision, not an assumed yes.

Keep patient identifiers out of this record; the referrals themselves belong in the practice’s protected system.

Which numbers show whether an orthopedic referral route works?

The ones that measure the handoff, not the volume: days to first visit, referrals arriving with a protocol and signed order, days to send the evaluation report, plans returned signed within 30 days, and discharge summaries sent.⁠⁵ Review why referrals did not fit, and fix the sheet or the schedule before looking for more offices.

Sources

1. American Physical Therapy Association. Levels of Patient Access to Physical Therapists Services in the U.S. (Direct Access by State, APTA resource dated September 4, 2024, with state data current as of July 2025). Checked October 23, 2026.
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   “While all 50 states, the District of Columbia and the U.S. Virgin Islands, provide some form of direct access to physical therapist services, the specific provisions and limitations differ across jurisdictions.”; “For a detailed overview of the language (if any) regarding direct access in each state’s practice act, please refer to the summary starting on page 2”.
2. Electronic Code of Federal Regulations. 42 CFR 424.24, Requirements for medical and other health services furnished by providers under Medicare Part B (paragraph (c), outpatient physical therapy, occupational therapy, and speech-language pathology services; eCFR, current through October 21, 2026). Checked October 23, 2026.
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   “The services were furnished while the individual was under the care of a physician, nurse practitioner, clinical nurse specialist, or physician assistant.”; “If the plan of treatment is established by a physical therapist, occupational therapist, or speech-language pathologist, the certification must be signed by a physician or by a nurse practitioner, clinical nurse specialist, or physician assistant who has knowledge of the case, except as specified in paragraph (c)(5) of this section.”; “Recertification is required at least every 90 days.”; “No references to an order or referral in this subsection shall be construed to require an order or referral for outpatient physical therapy, occupational therapy, or speech-language pathology services.”.
3. American Physical Therapy Association, ChoosePT. Physician Referral Not Needed: You Can See a Physical Therapist First (APTA staff; expert review March 11, 2026, revised March 23, 2026). Checked October 23, 2026.
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   “Certain insurance plans may still require a referral. Some states may limit the duration or type of treatment that can be provided without one.”; “some health systems and insurers still have outdated policies that require a referral after a certain number of physical therapy visits or for certain treatments”.
4. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services (Pub. 100-02, Rev. 13889, issued July 30, 2026; sections 220.1.1 to 220.1.3). Checked October 23, 2026.
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   “Although there is no Medicare requirement for an order, when documented in the medical record, an order provides evidence that the patient both needs therapy services and is under the care of a physician.”; “Payment is dependent on the certification of the plan of care rather than the order”; “the therapist may not significantly alter a plan of treatment established or certified by a physician/NPP without their documented written or verbal approval”; “A change in long-term goals, (for example if a new condition was to be treated) would be a significant change.”; “If the physician wishes to restrict the patient’s treatment beyond a certain date when a visit is required, the physician should certify a plan only until the date of the visit. After that date, services will not be considered reasonable and necessary due to lack of a certified plan.”; “Certifications and recertifications by doctors of podiatric medicine must be consistent with the scope of the professional services provided by a doctor of podiatric medicine as authorized by applicable state law.”; “Chiropractors may not certify or recertify plans of care for therapy services.”; “if the service is provided by a supplier (in the office of the physician/NPP, or therapist) a technical denial due to absence of a certification results in beneficiary liability. For that reason, it is recommended that the patient be made aware of the need for certification and the consequences of its absence.”.
5. Centers for Medicare & Medicaid Services, Medicare Learning Network. Complying with Outpatient Rehabilitation Therapy Documentation Requirements (MLN Fact Sheet MLN905365, September 2025). Checked October 23, 2026.
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   “POC-certifying provider’s name and NPI is on the claim”; “The physician or NPP certifies the initial POC with a dated signature or verbal order within 30 calendar days from the first day of treatment, including evaluation. The physician or NPP must sign and date verbal orders within 14 calendar days.”; “Starting January 1, 2025, for therapist-established POCs, the physician’s or NPP’s dated signature on the order or referral may be substituted for a signature on the initial POC if that physician or NPP hasn’t signed and returned the patient’s POC to the therapist within 30 calendar days of the initial evaluation. This applies only when the patient’s physician or NPP signs and dates the written order or referral, including information to identify the physician or NPP as well as the patient, and indicates the type of therapy needed”; “along with further evidence that the POC was delivered to the physician or NPP within 30 calendar days of the therapist’s initial evaluation. This policy doesn’t apply to recertifications or to POCs in a CORF.”; “The physician or NPP signs recertifications documenting the need for continued or modified therapy whenever a significant POC modification becomes evident, or at least every 90 calendar days after treatment starts.”; “The physician or NPP completes recertification sooner when the plan duration is less than 90 calendar days unless a certification delay occurs.”; “Progress reports justify medical necessity and require information like timing (at least once every 10 treatment days)”.
6. Ardern CL, Glasgow P, Schneiders A, et al. 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern (British Journal of Sports Medicine 2016;50(14):853–864; DOI 10.1136/bjsports-2016-096278; PMID 27226389; abstract as shown on Europe PMC). Checked October 23, 2026.
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   “Return to sport decisions are made every day by clinicians, athletes and coaches, ideally in a collaborative way.”; “Return to sport is not a decision taken in isolation at the end of the recovery and rehabilitation process. Instead, return to sport should be viewed as a continuum, paralleled with recovery and rehabilitation.”; “Research evidence to support return to sport decisions in clinical practice is scarce.”.
7. Centers for Medicare & Medicaid Services. Physician Self-Referral (CMS web page on section 1877 of the Social Security Act). Checked October 23, 2026.
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   “Prohibits a physician from making referrals for certain designated health services payable by Medicare to an entity with which he or she (or an immediate family member) has a financial relationship, unless the requirements of an applicable exception are satisfied”; “A financial relationship may be an ownership or investment interest in the entity or a compensation arrangement with the entity.”; “Physical therapy services. Occupational therapy services. Outpatient speech-language pathology services.”; “the rental charges for the lease of office space or equipment are not determined using a formula based on per-unit of service rental charges, to the extent that such charges reflect services provided to patients referred by the lessor to the lessee”.
8. Hand Therapy Certification Commission. The CHT Credential (HTCC web page). Checked October 23, 2026.
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   “CHTs are certified or licensed occupational therapists or physical therapists who, through advanced education, clinical experience, and independent study, have become proficient in the treatment of pathological upper limb conditions resulting from trauma, disease, or congenital or acquired deformity.”; “A CHT has a minimum of three years of clinical experience, including 4,000 hours or more in direct practice in hand therapy, and has successfully passed a comprehensive test of advanced clinical skills and theory in upper limb rehabilitation.”; “every CHT is required to demonstrate continued professional development and competency by recertifying every five years”; “Occupational Therapists = 88%”; “Physical Therapists = 11%”; “CHTs who are both OT & PT = 1%”.
9. Centers for Medicare & Medicaid Services. Therapy Services (CMS web page; its Bipartisan Budget Act section last revised in February 2026 for the CY 2026 thresholds). Checked October 23, 2026.
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   “there is one amount for PT and SLP services combined and a separate amount for OT services”; “Claims for services over the KX modifier threshold amounts without the KX modifier are denied.”; “For CY 2026 this KX modifier threshold amount is: $2,480 for PT and SLP services combined, and $2,480 for OT services.”; “the MR threshold is $3,000 for PT and SLP services and $3,000 for OT services”.
10. American Occupational Therapy Association. Occupational therapy scope of practice (AOTA practice essentials). “An occupational therapist’s or occupational therapy assistant’s scope of practice is defined in state law. Scope of practice describes the domain of practice and delineates the services that the OT practitioner is deemed qualified to perform and permitted under the law.” Checked October 23, 2026.
11. American Physical Therapy Association, APTA Specialist Certification governed by the American Board of Physical Therapy Specialties. Orthopaedics (ABPTS specialty page). “The purpose of the Orthopaedic Clinical Specialist (OCS) certification is to formally recognize physical therapists who demonstrate advanced clinical competence in orthopaedic physical therapy.”; “As of July 2026, ABPTS has certified 25,306 orthopaedics specialists.”. Checked October 23, 2026.
12. American Physical Therapy Association, APTA Specialist Certification governed by the American Board of Physical Therapy Specialties. Become a Board-Certified Sports Clinical Specialist (ABPTS specialty page). Checked October 23, 2026.
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    “As of July 2026, ABPTS has certified 4,153 sports specialists.”; “If you are board certified in sports physical therapy, you are permitted to practice only within the scope of your state physical therapy practice act. Board certification does not grant you any additional rights or privileges.”; “The state practice act dictates who is permitted to provide services at athletic venues, based on the state of licensure and the physical location of the venue. Board certification in sports physical therapy does not necessarily permit you to cover athletic venues; you may be required to have additional certification as an emergency medical responder or certified athletic trainer.”.
13. American Physical Therapy Association, APTA Specialist Certification governed by the American Board of Physical Therapy Specialties. Become a Board-Certified Pediatric Clinical Specialist (ABPTS specialty page). Checked October 23, 2026.
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    “The pediatric specialty area within the physical therapy profession includes treatment of traumatic, developmental, and systemic disorders that relate specifically to children.”; “As of July 2026, ABPTS has certified 3,219 pediatric specialists.”.
14. American Physical Therapy Association, APTA Specialist Certification governed by the American Board of Physical Therapy Specialties. Directory of Board-Certified Physical Therapist Specialists (ABPTS directory page). Checked October 23, 2026.
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    “The directory of board-certified specialists is a portal that allows consumers, physical therapists, physical therapist assistants, and other health care professionals to find PTs that have achieved specialist certification from the American Board of Physical Therapy Specialties.”.
15. American Physical Therapy Association. Direct Access Advocacy (APTA advocacy issue page). Checked October 23, 2026.
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    “As of July 1, 2025, all 50 states, the District of Columbia, and the U.S. Virgin Islands have either provisional or unrestricted direct access to physical therapist services for evaluation and treatment.”; “Even though patients may go directly to a physical therapist without a referral, some provisions tied to treatment absent a referral still persist in a number of states”.
16. Electronic Code of Federal Regulations. 42 CFR 410.60, Outpatient physical therapy services: Conditions (eCFR, current through October 21, 2026). Checked October 23, 2026.
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    “Medicare Part B pays for outpatient physical therapy services only if they are furnished by an individual meeting the qualifications in part 484 of this chapter for a physical therapist or an appropriately supervised physical therapist assistant but only under the following conditions”; “(1) They are furnished to a beneficiary while he or she is under the care of a physician who is a doctor of medicine, osteopathy, or podiatric medicine. (2) They are furnished under a written plan of treatment that meets the requirements of § 410.61.”; “applied as a threshold above which claims for physical therapy and speech-language pathology services must include the KX modifier (the KX modifier threshold) to indicate that the service is medically necessary and justified by appropriate documentation in the medical record; and claims for services above the KX modifier threshold that do not include the KX modifier are denied”.
17. Electronic Code of Federal Regulations. 42 CFR 410.59, Outpatient occupational therapy services: Conditions (eCFR, current through October 21, 2026). Checked October 23, 2026.
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    “Medicare Part B pays for outpatient occupational therapy services only if they are furnished by an individual meeting the qualifications in part 484 of this chapter for an occupational therapist or an appropriately supervised occupational therapy assistant but only under the following conditions”; “(1) They are furnished to a beneficiary while he or she is under the care of a physician who is a doctor of medicine, osteopathy, or podiatric medicine. (2) They are furnished under a written plan of treatment that meets the requirements of § 410.61.”; “applied as a threshold above which claims for occupational therapy services must include the KX modifier (the KX modifier threshold)”.
18. Electronic Code of Federal Regulations. 42 CFR 410.61, Plan of treatment requirements for outpatient rehabilitation services (eCFR, current through October 21, 2026). Checked October 23, 2026.
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    “The plan is established before treatment is begun by one of the following: (1) A physician. (2) A physical therapist who furnishes the physical therapy services. (3) A speech-language pathologist who furnishes the speech-language pathology services. (4) An occupational therapist who furnishes the occupational therapy services. (5) A nurse practitioner, a clinical nurse specialist, or a physician assistant.”; “The plan prescribes the type, amount, frequency, and duration of the physical therapy, occupational therapy, or speech-language pathology services to be furnished to the individual, and indicates the diagnosis and anticipated goals.”.
19. American Physical Therapy Association. Code of Ethics for the Physical Therapy Profession (PDF). Checked October 23, 2026.
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    “Physical therapists and physical therapist assistants shall not exceed their professional, jurisdictional, and personal scopes of practice and shall communicate with, collaborate with, or refer to a peer or other health care professionals when necessary.”; “Physical therapists shall strive to demonstrate independent and objective professional judgment and make decisions in the patient’s or client’s best interests in all settings.”; “Physical therapists and physical therapist assistants shall not, at any time, accept gifts or other considerations that influence or give an appearance of influencing their professional judgment and decision-making.”; “Physical therapists and physical therapist assistants shall not knowingly enter into or continue any employment or other arrangements that prevent them from fulfilling professional and ethical obligations to patients and clients.”.
20. Electronic Code of Federal Regulations. 45 CFR 164.506, Uses and disclosures to carry out treatment, payment, or health care operations (HIPAA Privacy Rule; eCFR, current through October 21, 2026). “A covered entity may disclose protected health information for treatment activities of a health care provider.”. Checked October 23, 2026.
21. Electronic Code of Federal Regulations. 45 CFR 164.501, Definitions (HIPAA Privacy Rule; eCFR, current through October 21, 2026). Checked October 23, 2026.
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    “Treatment means the provision, coordination, or management of health care and related services by one or more health care providers, including the coordination or management of health care by a health care provider with a third party; consultation between health care providers relating to a patient; or the referral of a patient for health care from one health care provider to another.”.
22. Electronic Code of Federal Regulations. 45 CFR 164.502, Uses and disclosures of protected health information: General rules (HIPAA Privacy Rule; eCFR, current through October 21, 2026). Checked October 23, 2026.
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    “This requirement does not apply to: (i) Disclosures to or requests by a health care provider for treatment”; “If under applicable law a parent, guardian, or other person acting in loco parentis has authority to act on behalf of an individual who is an unemancipated minor in making decisions related to health care, a covered entity must treat such person as a personal representative under this subchapter, with respect to protected health information relevant to such personal representation, except that such person may not be a personal representative of an unemancipated minor, and the minor has the authority to act as an individual, with respect to protected health information pertaining to a health care service, if”; “The minor may lawfully obtain such health care service without the consent of a parent, guardian, or other person acting in loco parentis, and the minor, a court, or another person authorized by law consents to such health care service”; “If, and to the extent, prohibited by an applicable provision of State or other law, including applicable case law, a covered entity may not disclose, or provide access in accordance with § 164.524 to, protected health information about an unemancipated minor to a parent, guardian, or other person acting in loco parentis”.
23. Electronic Code of Federal Regulations. 45 CFR 160.103, Definitions (HIPAA Administrative Simplification; eCFR, current through October 21, 2026). Checked October 23, 2026.
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    “Covered entity means: (1) A health plan. (2) A health care clearinghouse. (3) A health care provider who transmits any health information in electronic form in connection with a transaction covered by this subchapter.”; “Health care provider means a provider of services (as defined in section 1861(u) of the Act, 42 U.S.C. 1395x(u)), a provider of medical or health services (as defined in section 1861(s) of the Act, 42 U.S.C. 1395x(s)), and any other person or organization who furnishes, bills, or is paid for health care in the normal course of business.”.
24. Electronic Code of Federal Regulations. 45 CFR 164.508, Uses and disclosures for which an authorization is required (HIPAA Privacy Rule; eCFR, current through October 21, 2026). “Except as otherwise permitted or required by this subchapter, a covered entity may not use or disclose protected health information without an authorization that is valid under this section.”. Checked October 23, 2026.
25. U.S. Department of Health and Human Services, Office of Inspector General. Fraud & Abuse Laws (A Roadmap for New Physicians). Checked October 23, 2026.
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    “The AKS is a criminal law that prohibits the knowing and willful payment of “remuneration” to induce or reward patient referrals or the generation of business involving any item or service payable by the Federal health care programs”; “Remuneration includes anything of value and can take many forms besides cash, such as free rent, expensive hotel stays and meals, and excessive compensation for medical directorships or consultancies.”; “The statute covers the payers of kickbacks-those who offer or pay remuneration- as well as the recipients of kickbacks-those who solicit or receive remuneration.”; “The kickback prohibition applies to all sources of referrals, even patients.”; “The Stark law is a strict liability statute, which means proof of specific intent to violate the law is not required.”.
26. Hand Therapy Certification Commission. Eligibility Requirements (CHT examination eligibility). Checked October 23, 2026.
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    “You must be an occupational therapist or physical therapist with a current professional credential.”; “You must have been certified or licensed for a minimum of three years, based on date of issue of the certificate or license.”; “You must have accrued a minimum of 4,000 hours of Direct Practice Experience in hand therapy as described below.”.

Medical disclaimer. This page is for general educational purposes and does not constitute medical advice, diagnosis, or treatment. It is general guidance on running a therapy practice, not legal, compliance, billing or financial advice. Its worked example is hypothetical; state practice acts, payer contracts and each surgeon’s protocols govern actual care.