Obtaining Physician Orders for PT services in School Systems?

Distinguished ERI Faculty Member, Debra Dickson asks a question of school therapists:

DEAR ERI COMMUNITY: We have a question regarding physician orders for PT services for children in school systems. Here in CT we are able to do 8 visits and then are required to obtain a script. We have 2 questions:
1. Is the same required when seeing a child in a school setting? Are school guidelines different? We have been unsuccessful in getting an answer from the State Board.
2. We have always gotten them, however, lately we have been servicing a school where parents do not show up for meetings and we have been unable to obtain a script or even a release of information so we can obtain a script ourselves. Has anyone else had this difficulty and do you stop seeing a child when the school team has recommended services? It seems we are in a legal dilemma as the IEP document is a legal document that must be fulfilled yet legally we are required to have the paperwork from the physician to fulfill those services. How have others handled this?

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24 Responses to Obtaining Physician Orders for PT services in School Systems?

  1. Kathryn Biel says:

    I also work in a district where there is poor parental involvement. The school district employs a district physician who reviews the reports, records, IEPs and sees the children for a brief evaluation. Based on that, they will sign our prescription forms which we fill out for them ahead of time. They review the frequency and make recommendations if they do not agree. This way, we can usually start seeing children in a timely manner and still be in compliance with the IEP. This has worked out very well.

  2. Kristen Suvick says:

    I haven’t been required to obtain a script to provide services in the state of PA as long as I’ve been working here in ’93. The first 19 years I worked for a private practice that worked under contracts for the county’s intermediate unit that provides all the special services. The past year i have worked for a company that provides special services for children in different private and cyber school settings. It has occurred to me over the years but has never arisen as an issue. Upon request by the school or parents I have done the evaluations, and determined goals, frequency and duration. They are approved, modified and implemented through an IEP. I’m also a bit of an old timer with a BS degree. I am going to contact the intermediate unit about this to see what might be on the horizon in my area. Great topic!


    • Janessa says:

      this is not only a legal issue..it is an ethical one..you NEED to have a prescription from a doctor to ensure that there are NO medical contraindications that would be necessary for you to know to treat this child. IT is imperative that a prescription be given..and of course you are protecting yourself..god forbid anything happens to the child that you did not know about because of a medical issue. It is very important to get a prescription no matter what the school or state says.

      • Genevieve says:

        You have to obtain a script if not no services it is not a gray area, what would you do in a medical setting same for school it is your license laws that answer these questions not the IEP. How are they getting signatures on the IEP that is when you have the parent sign saying you can contact the doctor directly for a script or right in the IEP PT services with script only.

  3. Patricia Hemdriks says:

    In my school system in NJ we also are not required to obtain scripts and haven’t had to in the past 5 years. That is partly due to the passage of direct access as well as the revamping of our school policies. In the past it was also an issue and sometimes very difficult to get appropriate scripts. But we would not treat without a script. We too had a school physician that would sign our scripts for us in emergencies once the child was seen by him. If you do not have access to a school physician, you may want to change your language to state that implementation (ie, Evals and treatments) are contingent upon receiving a script annually. That way you are being compliant with what is written on an Iep. It’s better to be safe than to lose your liscense.
    Hope that helps!

  4. Michilina Scala PT, DPT, PCS, c/NDT says:

    In 2006, a law was passed in Connecticut allowing patients to be evaluated and treated by a licensed physical therapist directly, without a physician’s referral. Previously, the State of Connecticut mandated that all patients needing physical therapy were required to obtain a referral or prescription from a medical doctor.

    Called Direct Access, the law allows patients to be examined and treated by a licensed physical therapist without first seeing their physician for a referral. It also allows physical therapists to examine, diagnose and treat patients – under most conditions – without first obtaining a physician’s referral.

    Currently, 47 states have a Direct Access mandate, and Connecticut was the 42nd state to adopt the law. In the State of Connecticut, certain medical conditions still require a referral from a physician. Additionally, some insurance plans may still require you to consult with a physician first, to confirm that you qualify for medical reimbursement.
    from http://www.robertsphysicaltherapy.com/Blog/BlogView.asp?BlogId=409687&CategoryID=2

    In NJ where I work in schools, we only get a consent from the parents at the beginning of the school year for treatment and it includes permission to contact the physician if there is any concern about the condition and no progress in PT. Insurance doesn’t cover treatment in school (unless district bills for medicaid reimbursement. In NJ we only have to contact a physician if no progress or change in 30 days. We do obtain prescriptions from the parents if the child is hospitalized, has surgery or a fracture etc.. a change in medical condition that would require a medical clearance to return to school and PT.

    I would check your practice act and legislation particularly in CT regarding your direct access privileges. Some states have different nuances to the law and I cannot speak to the details of your state. You are headed in the right direction to be fully informed.

  5. Vicki says:

    In Texas we can only eval without a script. This applies to all settings. Years ago I would go back to ard and put therapy on hold if I couldn’t get a release or a script. Now we put a statement in the ard packet that “per PT licensing laws all PT services beyond an evaluation require a physician’s signature”. That way if we don’t get a script we’re legal not to provide services.

  6. Eva Durand says:

    I would have you check your state medicaid regulations. Some of these children may be eligible and your school district may be submitting their names for reimbursement. If that is the case please be certain what is required to be in compliance.

  7. Liz says:

    I work for an agency in New York City that sees preschool and school age kiddos at a center based location. Recently I went to a meeting about the updates on Medicaid and the person who runs the part of the DOE who deals wth billing told us this: while we have to make the effort to obtain a prescription ( leave a paper trail: emails, letters with a copy in their chart) if we cannot get the parent to bring in a script, we should Not stop seeing the child. He went on to say the most important thing to do is to ensure the child receives the services he/she is recommended and to not stop because you have been unable to attain a script. If you are ever audited, you just have to be able to show that you have put in your due diligence in attempting to obtain one. On a side note, if you do, it should include the following things: child’s name and DOB, the discipline they are recommending ( each PT OT and ST need separate scripts) the frequency and duration (2×45 min), a length of time (x 12 months), a date the prescription was issued and most importantly, a diagnosis, it could be an ICD-9 code or something like impaired coordination or receptive speech delays. I hope this helped!

  8. Lauren says:

    Great question! I have worked in school districts in CA and FL. We have not been required to have a physician prescription just to see a child for PT rx in the school setting. However, if your district bills Medicaid for the services, a prescription is required. I believe that you can still see the child to be in compliance with the IEP, but you cannot bill for the services, if there is no prescription. Hope that helps!

  9. al says:

    Yes, I have been in this situation. This is, of course, state dependent. If state law says you need a prescription, this is no different at school. Parents should sign a release when signing the iep. If you don’t have it to get a prescription, you cannot see the child, heartbreaking as that is. If you see the child, your license is in jeopardy. Keep detailed documentation to why the conditions of the iep have not been met, your attempts to reach family, etc.

  10. Holly McElhinny says:

    In Pennsylvania, a PT prescription is required to deliver PT services in schools, as it is in all locations. If a therapist holds a direct access certification, some amount of visits are allowed before a script is required, but it is not enough to cover a school year of service. A script is NOT required to perform PT evaluations. You are correct, this is a legal dilemma as our Practice act/laws and the administration of FAPE do not mesh on this issue. I have been advised by both educational and legal experts that if a script cannot be obtained within 30 days, an IEP meeting should be held to address the issue as to why the family is unable to obtain the prescription. If cost or availability is an issue for the family, the district may be obligated to provide access and payement for a physician exam if PT is necessary to provide FAPE for the student. If the team determines that PT is not required or the family refuses to provide the prescription even with assistance, PT must be removed from the IEP through the revision process, with information regarding reasoning for this added into the present levels. As director of a school based OT/PT department, we have a comprehesive policy and set of procedures to address the issue of obtaining PT prescriptions.

  11. Mandy says:

    Posting from Yvonne:
    I worked at an acute care hospital and outpatient clinic from the hospital, yes we get the referrals from the doctor but to continue its difficult to get an update script because these doctors do not work at the office everyday sometimes they work there once a month, what I do I mailed the POC and I send a copy of POC wih the caregiver to continue with PT intervention Thanks Yvonne

  12. Nancy says:

    As a school-based PT in upstate NY, our District and BOCES (who I previously worked for) require PTs and OTs to obtain prescriptions that correspond to the frequency and duration listed on the IEP, and include the dates the IEP begins and ends. This also supports the District’s ability to bill Medicaid. If we are unable to obtain prescriptions, for any reason, an IEP review is completed to remove the PT/OT service. Obtaining a script is rarely, if ever, an issue. Even though NYS has direct access, our District, BOCES and Medicaid all require prescriptions to begin the service. Similiarly, our county requires prescriptions for evaluations, and another one for treatment of our preschool population. I am sure this is so the county can receive reimbursement for the evaluation.

    I agree with the above response, that the prescription ensures the physician has completed a physical of the child, and is aware of any medical conditions that I might not be made aware of. Better safe than sorry, in the long run.

    • Nancy says:

      One more thought: Be sure you document and date your multiple efforts to obtain the prescription, just in case you are audited. You then have information to support discontinuing the service.

  13. Mark Raum says:

    In NJ do not need them

  14. Donna Agnew says:

    1. I have worked in schools for the past 36 years in 7 states. I always follow the state practice act regardless of the setting.
    2. I currently work in NY state. Parents must sign the IEP or 504 plan in order for them to be in effect. This includes parent permission for PT services. If a parent doesn’t sign, they don’t get serviced. Parents are informed that PT is a prescriptive service and that the school physician will provide this unless they want to get the referral themselves. In June of each year, we prepare the physician referrals for the next school year and send them to the school physician for their signature. In the fall, most schools schedule a time for the school doc to be available at the school to look at new students and sign referrals.
    I feel I must also add that in NY state you CANNOT provide physical therapy to a child without a physicians referral after an initial evaluative period. Liz above is risking her license.

    • Nancy says:

      I agree with you. However, what do you do when parents don’t attend the Annual Review? Or when the annual review occurs in Feb or March, or anytime during the school year? Our District rand BOCES requires our scripts go from the start of the current IEP, to the end of the IEP. Do you experience this? Just curious…..

  15. Vicki Nephew says:

    In NY there is direct access for PT, but we are required to have scripts to see children in a school setting. We need to obtain parental consent and a script to evaluate, then if services are recommended another script is obtained for services (which needs to correspond to what the IEP says…this & script to evaluate are also required by Medicaid). We also have a “school” doctor who is able to do “face to face” initial visits (another Medicaid requirement) & signs our scripts for ongoing services each year. Parents could also opt to go through their family doctor, but most do not since the school does all of the work. Sometimes it takes a bit to get the parental consent if the parents aren’t involved, but once that is done the rest is based on therapist, CSE committee & doctors, so unless the parent refuses services, getting the script & getting started isn’t usually too prolonged.

  16. Joanne Mortimer says:

    I have worked as an employee of a very large school district in Rhode Island for 22 years. up until about 5 years ago we told parents that without a yearly prescription we could not service their child , despite the, having an IEP ( we are licensed under the department of health NOT education ). Subsequently, in discussion with early intervention therapists at a local agency, we were told that they did not seek orders because they didn’t need to. We ( represents myself and 3 other PTs ) were surprised and didn’t quite think that was right. Meanwhile, the practice act in the state changed to evaluate and treat for 90 days without a referral and if continued treatment was necessary a referral is needed. SO, one of my school PT colleagues contacted the state board and was told that ” we did not need prescriptions for school based PT” . MY thought was THEY COULDN’T POSSIBLY KNOW WHAT WE DO IN SCHOOL !!! That said, we no longer require prescriptions. by the way, because many physicians were not knowing what to write or some orthos were writing like we were an outpatient clinic, we came up with our own form to mail out that was very functional and in a checklist format, that we only asked for their signature. Basically, we told them what we were doing, Asked for their signature, / approval and that was our prescription. We do not send them out anymore on a routine basis. I do require a prescription to resume therapy after surgery, and we have a form we send ( it includes precautions, procedure done etc. and ather things related to returning to school function. the 4 therapists developed the form for the district. Also, I will send one out for a medically fragile child, or any diagnosis that may have possible contraindications or precautions ( eg. OI , osteoporosis , ortho procedures etc… Thus far, I think we only have an email from the Board ( Physical Therapy Board for the state of Rhode Island). I need to get a copy of it and see if should be discussed again and be formalized. I guess for now, this is a state to state thing by your governing board, just as the legislation regarding practice without referral is. sorry don’t know now to use my spell check in this format on my iPad yet!

  17. Kathy Stranger says:

    I’m in Idaho. A doctor’s presciption is required for school based services if Medicaid is being billed for services – PT, OT, ST, nursing services,and personal care services. If the student does not have Medicaid a physician’s order is not needed. However, in our district, for any student who has an IEP with any of the above services on it, we obtain a prescription from their doctor .

    Our school district has one person that manages the “medical” paperwork for all IEP’s (about 1000) students – Medicaid billing, SDR’s, and doctor’s signatures. At the IEP, the physician information is obtained from the parent. It is the responsibility of the case manager to fax that page to this person and she then sends it to the doctor’s offices. She is very organized and very efficient. She has established wonderful rapport with the doctor’s offices and a system that works to get the prescriptions needed for the above services about 98% of the time.
    There are rare times when getting the parent to the meeting is difficult. In those cases, the team can and does, establish the IEP and provide services even if the parent does not show after 3 attempts. The IEP is either home or mailed as often as needed, and the physician information is finally obtained. There have been a couple of occasions where the parent does NOT allow the school district to bill Medicaid or contact the physician. We cannot deny services that a student needs. The student is still provided services based on the information the team has to allow the student to “access their special education program”.

  18. Mandy says:

    Posting from Mickie:
    It all depends on the requirements from each state’s board of physical therapy examiners rules/regulations. we would need a information such as diagnosis, and contraindications from the doctor, or ok to continue to resume PT after a hospitalization or significant change in functional gross motor status. In the school setting, we do not provide a medical model of therapy services.

  19. Beth says:

    In VT, school based therapists do not need an MD script. I believe the above is documented in our state practice act. If I worked in a state that required an MD script for school based services, I would NOT provide an “IEP’d service” without a script as my Practice Act and ultimately my license take precedent over the IEP. Legally it is the school district’s responsibility to provide all IEP services and therefore the district’s responsibility to obtain any/all required documentation. If the family is not cooperative, perhaps social servcies should be contacted as this could be seen as neglect…..

  20. Jane Allen says:

    We do not need them to provide services in schools in MA.

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