Reading your state's direct access limit before you sign a cash PT lease

How many visits can you treat without a referral?

Across the four states read below, from ten visits to no ceiling at all, and a state not among them can sit outside that range in either direction. The number lives in your state's physical therapy practice act, and in those four it takes one of four shapes: a visit count, a calendar-day count, both running together with whichever arrives first ending the period, or no ceiling at all for a defined set of conditions.

California writes the two-number version: a physical therapist there may treat without a referral for 45 calendar days or 12 visits, whichever occurs first 1Ref 1California State Legislature (2024).Business and Professions Code Section 2620.1.California's 45-calendar-day or 12-visit direct-access ceiling, whichever occurs first; the dated physician signature approving the plan of care required to continue past it; and the oral and written notice in at least 14-point type, signed by the patient, required before direct treatment begins.. New York writes the same shape with smaller numbers, ten visits or thirty days, whichever occurs first, and adds a qualification the therapist has to meet before using it at all 2Ref 2New York State Legislature (2024).Education Law Section 6731 — Practice of physical therapy.New York's ten-visit or thirty-day direct-access ceiling, whichever occurs first; the three-year full-time practice experience a physical therapist must hold to treat without a referral; and the duplicate written notice signed and dated by both parties, with one copy retained by the patient.. Florida counts days alone, requiring review and signature by a practitioner of record beyond 30 days for a condition not previously assessed by a practitioner of record, and its section names no visit ceiling 3Ref 3Florida Legislature (2024).Florida Statutes Section 486.021 — Physical therapy practice; exceptions.Florida's time-only threshold: review and signature by a practitioner of record required beyond 30 days for a condition not previously assessed by a practitioner of record, with no separate visit-count ceiling in that section. Used as the example of a state that caps by days alone.. Washington removes the requirement instead of capping it, since consultation and periodic review are not required for treatment of neuromuscular or musculoskeletal conditions 4Ref 4Washington State Legislature (2024).RCW 18.74.012 — Consultation and periodic review not required, when.Washington's removal of the consultation and periodic review requirement for treatment of neuromuscular or musculoskeletal conditions. Used only as the example of a state with no numeric visit or day cap for those condition types..

direct access covers all four of those arrangements, which is why a number quoted in a continuing education slide is worth nothing until you have found it in your own state's code. The unit differs, the number differs, and in New York the eligibility to use it at all differs.

Where the number lives in your own state's code

In your state legislature's own text, under the physical therapy practice act, in the section on treatment without a referral. Search the state code for the practice act chapter and read the section headed for referral or direct treatment. Five things decide what the cap costs you, and only the first is the number everyone quotes.

Read the statute rather than a summary of it. A state board's website may simply link back to the legislature's text instead of restating it, and where a board does add its own regulation, that regulation sits on top of the statute rather than in place of it. Write the five answers on one page with the section number at the top, because that page is what you will hand to a bookkeeper, a landlord's attorney, or the next therapist you hire.

The notice form, and who may use direct access at all

Before the first visit, in writing, in a form the statute describes. California requires the therapist to give the notice orally and in writing, in at least 14-point type, signed by the patient 1Ref 1California State Legislature (2024).Business and Professions Code Section 2620.1.California's 45-calendar-day or 12-visit direct-access ceiling, whichever occurs first; the dated physician signature approving the plan of care required to continue past it; and the oral and written notice in at least 14-point type, signed by the patient, required before direct treatment begins.. New York requires it in duplicate, signed and dated by both the physical therapist and the patient, with one copy retained by the patient 2Ref 2New York State Legislature (2024).Education Law Section 6731 — Practice of physical therapy.New York's ten-visit or thirty-day direct-access ceiling, whichever occurs first; the three-year full-time practice experience a physical therapist must hold to treat without a referral; and the duplicate written notice signed and dated by both parties, with one copy retained by the patient.. Neither is a courtesy disclosure you can fold into the intake packet later.

New York also decides who may use direct access before it decides for how long. A therapist there qualifies only after having practiced physical therapy on a full-time basis equivalent to not less than three years 2Ref 2New York State Legislature (2024).Education Law Section 6731 — Practice of physical therapy.New York's ten-visit or thirty-day direct-access ceiling, whichever occurs first; the three-year full-time practice experience a physical therapist must hold to treat without a referral; and the duplicate written notice signed and dated by both parties, with one copy retained by the patient.. A new graduate opening a cash practice in New York is reading a different sentence in the same section than a therapist ten years in, and it is the sentence that comes first.

Neither requirement produces a bill, so neither appears in a pro forma, and both decide whether the visits counted in one can be delivered the way they were counted.

What the cap does to a cash lease

It bounds the episode, which is the unit a lease has to be paid out of. A cap of 12 visits or 45 days is a ceiling on what one patient can be worth before a physician's signature enters the picture, and a lease is a fixed monthly number that does not care how many episodes ended early. Run the arithmetic in that order.

Set the price floor from your own costs first. Multiply it by the number of visits your state allows before a signature is required, and you have the ceiling on one unreferred episode. Divide the lease and the rest of your fixed monthly costs by that figure and you have the minimum number of new episodes a month the space has to produce to break even. If that number is one you have never hit in a month of your working life, the square footage in front of you is already sized for the second location.

But the cap ends the referral-free period, not the treatment. California lets the same course continue on a dated physician signature approving the plan of care 1Ref 1California State Legislature (2024).Business and Professions Code Section 2620.1.California's 45-calendar-day or 12-visit direct-access ceiling, whichever occurs first; the dated physician signature approving the plan of care required to continue past it; and the oral and written notice in at least 14-point type, signed by the patient, required before direct treatment begins., which converts a clinical decision into a scheduling dependency: someone outside your practice has to sign something inside your week, on a calendar day the statute already fixed.

The state's permission and the payer's rule are separate questions

They are separate, and answering one does not answer the other. A state can permit treatment with no referral while a payer still requires a plan of treatment on its own terms. Medicare's outpatient rehabilitation rule requires a written plan of treatment before treatment begins, and it lets a physical therapist establish that plan rather than only a physician 5Ref 5Centers for Medicare & Medicaid Services / Code of Federal Regulations (2023).42 CFR Section 410.61 — Plan of treatment requirements for outpatient rehabilitation services.The point that a payer's own plan-of-treatment requirement is separate from a state's referral-free permission: Medicare requires a written plan of treatment before outpatient therapy begins, and a physical therapist may establish that plan. No certification-timeline figure is drawn from it.. Reading a payer contract for its own referral language is the same exercise with every other payer.

Cash-only does not settle the Medicare question either. Medicare recognizes a specific list of practitioners who may sign a private contract with a beneficiary and formally opt out for a two-year period: physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, certified nurse-midwives, clinical psychologists, clinical social workers, and registered dietitians or nutrition professionals, alongside a narrow definition of physician covering doctors of medicine, osteopathy, dentistry, podiatry and optometry 6Ref 6Centers for Medicare & Medicaid Services (HHS) (2023).42 CFR Part 405, Subpart D — Private Contracts (§§405.400 Definitions, 405.405 General rules, 405.410 Conditions for properly opting-out, 405.415 Requirements of the private contract, 405.420).The enumerated practitioner types eligible to sign a Medicare private contract and opt out for a two-year period, the narrow definition of physician, and the fact that physical therapist appears on neither list.. Physical therapist appears on neither list. That absence is why a cash physical therapy practice takes the Medicare question to a health care attorney before the doors open, rather than after the first Medicare-eligible patient asks for a receipt.

Paying for a referral is a separate statute

Do not pay for the physician relationship the cap forces on you. A state can prohibit paying or receiving a commission, benefit, bonus, rebate, kickback or bribe for a patient referral without limiting that prohibition to Medicare or Medicaid patients, which puts a purely cash-pay referral arrangement inside the statute. Florida's patient brokering law is written that way 7Ref 7Florida Legislature (2026).Florida Statute 817.505 — Patient brokering prohibited; exceptions; penalties.One named-state example of a referral-payment prohibition that is not limited to Medicare or Medicaid patients, and therefore reaches a purely cash-pay referral relationship that the federal anti-kickback statute's own text does not..

Florida is one named example rather than a national rule, and a prohibition written that broadly reaches a cash-pay referral relationship the federal anti-kickback statute's own text does not 7Ref 7Florida Legislature (2026).Florida Statute 817.505 — Patient brokering prohibited; exceptions; penalties.One named-state example of a referral-payment prohibition that is not limited to Medicare or Medicaid patients, and therefore reaches a purely cash-pay referral relationship that the federal anti-kickback statute's own text does not.. A cash practice therefore cannot reason from the absence of federal money to the absence of a rule. Read your own state's chapter, and take any arrangement that moves money toward a referral source to a health care attorney before the first payment rather than after it.

What to read before you sign

Four documents, in this order: your state's practice act section on treatment without a referral, the notice form that section requires, any payer contract you have signed or intend to sign, and the lease itself. Read the first three before you agree to the fourth, because the lease is the only one of them with a term measured in years.

Two lookups sit beside this one and neither is answered by the section you just read. If any visit happens by video, which state's law reaches that visit is the rule under everything a multi-state practice does, and it is settled separately from the cap. If you are leaving an employer to sign this lease, state caps on clinician non-competes live in their own chapter of their own code, and the enrolled text is the thing to read rather than a summary of it.

Keep the one-page answer with the lease file. When a landlord asks for a personal guarantee on a five-year term, that page is what tells you how much of the term your own license lets you plan for.