Telehealth Physical Therapy (PT) – Your Guide

Telehealth physical therapy: it’s on everyone’s mind right now. COVID-19 has flung our world onto its side—but, it has one silver lining: it is serving as the kick in the pants we’ve needed for our profession to get serious about telehealth PT.

Now, more than ever, people are reaching out to ask me questions like:

– “What is telehealth vs. an e-visit?”
– “Can I practice as a telehealth physical therapist or assistant?”
– “How do I start a telehealth PT business?”
– “What telehealth PT companies are out there and are they hiring?”
– “Does Medicare reimburse for telehealth PT?”

True to these unpredictable times, the answers to your questions are changing daily. I am doing my best to keep this article current and reflective of the latest information about telehealth physical therapy.

Let’s start with the basics and go from there.

What is telehealth physical therapy (PT)?

Simply put, “telehealth physical therapy” (or “virtual physical therapy”) refers to physical therapy services that are provided over a technology platform, rather than by in-person means.

Other phrases referring to telehealth physical therapy might include (depending on your specific role):
telemedicine physical therapy | telePT | teletherapy | telerehab | telemedicine physical therapy | online physical therapy virtual physical therapy | remote physical therapy

How is telehealth physical therapy delivered?

There are four ways to deliver telehealth PT services (source):

1. Live video. This is also referred to as “synchronous” format, and uses live interaction between two parties over video. It’s also sometimes called “real-time.” This type of delivery is ideal for evaluations and treatments. 
2. Store-and-forward. This is sometimes called “asynchronous” format. This involves the transfer of health history and/or medical records over secure electronic means. This type of delivery is best for sending x-rays, progress notes, etc. This delivery is scalable, and can also be used for subscription model delivery of services.
3. Remote patient monitoring (RPM): This involves the remote monitoring of patients’ health and medical data over secure electronic means. This type of delivery is ideal for monitoring patients’ blood pressure and/or blood glucose measurements, steps per day, etc.
4. Mobile health (mHealth): This involves healthcare services, education, and public health notifications being delivered over cellphones, tablets, and other electronic devices. This type of delivery is ideal for alerting patients to updates to their HEP, as well as the closure of roads near a clinic, a possible disease outbreak, etc. Examples of this are WebPT’s HEP software and MedBridge’s HEP program.

Why should PTs use virtual physical therapy?

Right now, we’re facing unprecedented times. With “social distancing” becoming the norm, each state is facing the difficult decision of whether or not physical therapy is considered “essential.” And, as we all know, “essential” is a loaded term. Nobody would argue that PTs are essential to triaging musculoskeletal injuries and ensuring safe discharge planning—which keeps our hospitals streamlined and best prepared to face the onslaught of COVID-19 patients.

However, most of us can probably agree that a mild ankle sprain won’t exactly require immediate in-person attention from an outpatient orthopedic physical therapist.

Then, there’s that gray area of our vulnerable post-CVA patients whose homes need evaluating. After all, the last thing they need right now is a fall, sending them right back into the COVID-19 hot zone.

Frankly, we’re at a crossroads, and it’s the ideal time—albeit under terrible circumstances—to get our act together as a profession, and to serve patients to our best ability with the primary intent of, first and foremost, doing no harm.

Telehealth physical therapy as tool for education.

While manual therapy is still an important component to our treatments, it’s certainly not the be-all-end-all. In fact, many of us can attest to the fact that too much manual therapy makes our patients dependent upon us, when what they really need is to be up and moving. As patient education and pain science are increasingly influencing our treatment choices—and ineffective treatment modalities are falling out of favor—we PTs are finding that our role as movement experts relies less and less on patients being physically in the clinic for treatments.

Our primary duty as PTs, aside from doing no harm to our patients, is to educate them. Teletherapy is the perfect way to educate patients who otherwise couldn’t access care. Whether they’re under shelter-in-place orders or simply unable to make it to appointments under normal circumstances, there are tons of options to use telehealth PT as an educational tool.

Teletherapy as a method of convenience.

We live in an on-demand society. People want what they want, when they want it. Even before COVID-19 began dominating our daily lives, people were changing how they approached life. Patients are trending toward wanting immediate care, and they don’t want to wait weeks for an appointment, especially if they only need exercise prescription and general education/guidance.

Many other medical providers, including radiologists, psychiatrists, and dermatologists, have recognized this fact, and have been providing telemedicine for years. And, since the COVID-19 has truly begun dominating our lives, even more medical providers have stepped into the role of telemedicine providers.

Telehealth PT as a solution for access.

Frankly, these days, convenience is a fairly moot point. At this point, we really need to think about how we can serve our patients best during these challenging times. And that means providing them the best possible access to care they might not otherwise get.

With so many clinics closed or using reduced hours, we have to remember that people are still having strokes. They are still falling. They still need to know how to keep their homes safe to prevent future falls. We must ask ourselves: can post-CVA and post-fall patients still access therapists and assistants so they can ask safety-related questions? Will lack of access land many of these patients right back in the hot zone of the hospital, where they’re MORE at risk?

We NEED to be leaning into telehealth now.

Here are a few common use cases:

• Prevention of readmission through home safety evals and mobility screens
• Post-discharge checkups and safety screens
• Advanced intake of subjective history
• Wellness and preventative services to avoid hospitalizations
• Consulting with other practitioners (think McKenzie screens, CrossFit/yoga instructors, or pelvic floor consults)
• Post-surgical monitoring and rehabilitation
• Q and A to prevent hospital readmissions and future injuries

All this aside, let’s assume life resumes to its normal clip within a few months. There’s STILL what Ellen Morello, PT, DPT, Clinical Program Manager at Physera, calls “a PT desert.” And, by that, she means wide swaths of land where patients have very little access to skilled PT.

The following image, produced by Dan Merl (head of data science at Physera), shows how many PTs there are per 1000 people.

What does the evidence say about telehealth PT?

What’s in favor vs. what isn’t doesn’t always matter if the evidence argues otherwise. It turns out that our magical healing hands may only be a small part of the puzzle.

• A UC Irvine School of Medicine study recently revealed that telehealth PT was as effective as in-clinic therapy for improving upper extremity motor control post-CVA. (source)
• According to Mani et al., there is a high level of agreement between an in-clinic PT diagnosis and a diagnosis obtained via telehealth using a remote diagnosis and a functional movement screen (FMS) (source)
• A review of 75 systematic reviews and 71 Cochrane reviews revealed that the most effective interventions for low back pain (LBP) are patient self management, psychosocial interventions, and therapeutic exercise (source)

Is telehealth PT legal?

YES, telehealth physical therapy is completely legal. However, every state is different, so you can visit the Center for Connected Health Policy to learn your own state’s rules and regulations, as well as get a better understanding of your state’s parity laws*, if applicable. Plus, standards of practice still hold when you practice telehealth, including:

• Informed consent
• Abiding by HIPAA
• Protecting patient privacy

*Some states have parity laws, which require payers to reimburse for teletherapy at the same rate they would for in-person care. Be sure to know if your state does.

How to become a telehealth PT or PTA

If you’re a licensed PT (or PTA), you can practice telehealth. You can join one of the emerging telehealth provider practices as a therapy provider, or you can launch your own telehealth PT practice by using telehealth software and doing your own marketing. Here’s how to get started, either way:

1. Decide whether you want to fly solo or join a company.

This is a big decision based on your own life goals. There are pros and cons to each approach.

2. Get licensed where you intend to practice.

In any case, you’ll need a license to treat your patient(s) where they live. This might sound like a deal-breaker, but a PT compact has been established for this reason. The PT compact is an agreement between member states to enable eligible PTs to work in multiple states under a single agreement.

…If you’re joining an existing practice

…Explore the telehealth PT companies that are hiring

Here are some companies I know of that offer telehealth physical therapy jobs. I update this list frequently, so you might see it changing as companies shift, change names/practices, etc. If you come across any others, please let me know in the comments below*!

• Agile Virtual PT (virtual PT company that contracts out to work with other clinics, too)
• CityPT (ortho PT)
• eLuma (k-12 special education – PT/OT/SLP and some assistants)
• E-Therapy (school-based telehealth – PT/OT/SLP)
• Maven (PT and OT in numerous specialties)
• Physera (adult musculoskeletal – PT)
• ProCare therapy (school-based PT, OT, SLP)
• Rehab Smarter (all ages – PT/OT)
• SWORD Health (adult musculoskeletal – PT)
• Talkpath Live (all ages – PT/OT/SLP and maybe assistants)
• Virtual Physical Therapists (Mckenzie certification and or concussion/vestibular training required – PT)
• WizeCare (PT)

*Please note, there are additional companies like Hinge Health and The Joint Academy, which do hire PTs, but do not necessarily use them to the full extent of licensure.

…Create a telehealth resume and telehealth cover letter

You’ll want to really beef up any clinical experience you have, as well as any experience using technology, educating patients/mentoring SPTs, etc. Ensure your resume and cover letter are free from typos, as you’ll be relying on e-communications more than ever as a telehealth PT. You’d better make yourself look good. 🙂

Telehealth resume for PT, OT, and SLP professionals

Telehealth-friendly keywords to include in your resume include:

• Deliver
• Communicate
• Collaborate
• Interpret
• Demonstrate
• Remote
• Technology

If you’re experienced in SFMA, McKenzie Method, or any other functional movement screens or specialized training, definitely highlight that on your resume. Specific ther-ex, vestibular, and/or differential diagnosis con-ed training will also help.

…If you’re starting your own practice:

…Pick a good telehealth PT platform

Some of the following organizations offer software solutions for PTs*:

• Anywhere Healthcare
• BetterPT
• BlueJay (This is the only telehealth platform I have tried. I found it very user friendly!)
• BlinkSession
• Doctor Care 247
• doxy.me
• eVisit
• Hello Note
• In Hand Health 
• PTEverywhere
• Simple Practice
• TheraNest
• TheraPlatform
• Updox
• VSee
• Zoom for Healthcare

*Please note, there are enterprise-level companies offering telehealth platforms that cater to larger organizations, including Health Recovery Solutions, Force Therapeutics, etc.

…Determine whether you want to be cash-based or collect insurance

Until recently, it was easier to be cash-based, unless you really understood insurance rules and parity laws. These days, the COVID-19 crisis has led many third-party payers to begin reimbursing for teletherapy.

Also, many states have dictated that teletherapy PTs can get reimbursed for telePT delivered to Medicaid patients. You’ll need to check with your specific state for details.

Billing nuances to consider for telehealth PT

1. Private insurance rules and reimbursement rates vary, and they also vary across state lines. I have linked to resources at the end of the article to help you learn more. Unfortunately, there is currently no comprehensive list of third-party insurances that reimburse for physical therapy telehealth services, and such a list would be nearly impossible to keep current at this time.
2. Private insurers often want a written explanation of why telehealth was used. Always keep a record of the services you perform and your rationale for using telehealth vs. in-person visits.
3. Currently, there are no CPT codes specific to billing for telehealth physical therapy. Many CPT codes require direct one-on-one patient contact, so telehealth services may not be covered unless there is an agreement with the payer. However, again, check with your insurance partners to know how things are being handled during the coronavirus crisis.
   These are changing quickly, so check the resource documents at the end of the article for latest info!
4. Understand billing terminology and nuances. An addendum is often required to be added to the CPT code to denote service was provided through telehealth. Be sure to check your own insurers’ guidelines.
   >>> Use correct terminology for sites.
   The originating site is where the patient is located.
   The distance site is where you are located.
   >>> Use Place of Service (POS) codes appropriately
   “02” for actual telehealth services
   “11” for e-visit services from an office (including phone visits from an office)
   “12” for e-visit services from your home (including phone visits from your home)
   >>> Use modifiers properly.
   95 = services were delivered synchronously (or in real time for telephone visits, but not e-visits)
   GQ = services were delivered asynchronously (this is mostly a form of telehealth getting phased out)
   CR = services were catastrophe- or disaster-related (must use this modifier for Medicare’s new e-visit codes)
   The above codes are subject to change, so check the resource documents at the end of the article for latest info!
   Much of this came from the WebPT webinar; cheers and thanks for the info, WebPT!

Does Medicare reimburse for telehealth PT?

Glory be…it has finally happened! As of 4/29/2020, Medicare announced that PT, OT, and SLP are covered services in the time of COVID-19. Now, this could change. It might not. Just keep in mind that everything is changing on a near-daily basis at this point!

Keep in mind that these changes also impact outpatient billing of Medicare Part B, but we’re not quire sure how this update will affect inpatient or hospital outpatient providers. So, more hurry up and wait 🙂 Here is a reference sheet with the codes you’d need to use for billing.

Things are changing on a near-daily basis, so please check the resources section at the end of this article for the latest info!

…Develop a viable business plan

Right now, patients are a bit of a captive audience. With so much social distancing, some telehealth PTs can probably get away with being …less than strategic…with their business plans if they act quickly. That said, I always recommend any business owner think long-term. At some point, we will resume to our normal, pathogen-passing lifestyles, and telehealth PTs with poor initial business plans might flounder. Here are some tips:

• Niche down. Going at a niche seems to be the best initial strategy. A niche allows you to create a very specific type of patient base that you can target with your marketing efforts. This works much better than tossing lots of money at marketing to a broad swath of patients, and hoping that you run across a few who decide to take a chance.
  Patient niches include: dancers, runners, cyclists, gymnasts, young moms, patients with chronic CVAs, etc.
  Speciality niches include: ortho, neuro, injury-specific, etc.
• Nail down your patient acquisition strategy. Will you be building a therapy blog to attract patients? Will you be marketing via YouTube videos?
• Determine your UVP. Your unique value proposition (UVP) will set you apart from the competition. Determine what makes you special and worth working with. Extensive education? Friendly, discreet care? Convenient access?

…Consult with a telehealth PT compliance professional

Because of the nuances involved with adopting telehealth so early in the game, it is always a good idea to consult with a telehealth physical therapy expert—notably, one who understands legal and internet technology (IT) considerations.

Nancy Beckley, MBA, CHC recommends a platform that is HIPAA complaint—with evidence that the platform has complied with HIPAA Privacy, Security and Breach Notification Rules—and a set process for offering a Business Associate Agreement (BAA) as appropriate. 

Rules, regulations, and legal considerations of teletherapy

One of the things I’m most asked is: “Is telehealth PT legal?” Again, the answer is yes. And, while we’ve covered quite a few of the rules and regulations above, it’s always good to have an attorney weigh in!

I was able to speak about teletherapy with attorney Erin Jackson, Managing Partner of Jackson LLP Healthcare Lawyers. She is extremely passionate about providing this alternative practice setting for PTs, and was eager to weigh in. Here are her thoughts:

• Insurance companies may have requirements—distinct from legal requirements—concerning the frequency, duration, and type of visits that can be conducted via telehealth.
• It’s crucial that providers using telehealth have an up-to-date HIPAA privacy policies and procedures manual. The greater a provider’s reliance on technology, the greater the risk of breach.
• Some states have legislation or regulations which speak to telehealth issues. (This is likely changing every day with COVID-19.)
• Always check your state legislation regarding direct access considerations.
• Many states have an in-person visit requirement for telehealth-based provider-patient relationships, meaning that it may not be possible to operate a fully telehealth-based practice.
• A PT is still held to the same scope of practice and duty of care. If you can’t offer the same caliber of treatment, the same attention to detail, and the same assessments of functionality as you offer to in-office patients, then telehealth isn’t appropriate for that patient.

The laws surrounding telehealth often lag behind technology, patient demands, and provider capabilities.That’s why it’s essential to stay on top of legal compliance.

Telehealth PT CEUs and continuing education

Technically, you don’t need any additional education to become a telehealth PT—but, certain skills will make you a much more effective remote therapist.

Examples of helpful training include:

• McKenzie Certification
• Pain science education
• Total Motion Release (TMR)
• Selective Functional Movement Assessment (SFMA)

Many companies look for therapists who can demonstrate a commitment to evidence-based care. Basic educational strategies and treatment with exercise prescription can help many patients feel better.

Telehealth PT CEUs on MedBridge and PhysicalTherapy.com

Many organizations are releasing continuing education courses for PTs, which is nice because you can learn the ropes of telehealth and earn CEUs at the same time. Two of my favorite providers are MedBridge and PhysicalTherapy.com, due to their ease of use and affordability. By using my discount codes for these platforms, you save money and help support the free content at TNCPT. Thank you for your support!

I’m so excited to share that MedBridge Education now offers a Telehealth certificate program! So, if you’re interested in gaining CEUs while you work toward an actual certification to put on your resume, check out this program!

Below, find some excellent individual courses, some of which are included in the aforementioned cert program.

• Telehealth: An Introduction to Virtual Care (MedBridge)
• Starting Out in Telepractice (MedBridge)
• Specialty Work With Telepractice (MedBridge)
• Virtual Pediatric Therapy: Assessment and Intervention Using Telehealth as a Service Delivery Model (MedBridge)
• Telehealth: Innovations in Care (PhysicalTherapy.com – use code NCPTBonus13 for a free month)
• TeleRehabilitation: Demystifying the Use of Technology to Deliver Physical Therapy (PhysicalTherapy.com)

What does telehealth PT delivery look like?

The evaluation

• Past medical history (PMH) + subjective 
• Screen for red flags and note tests that require in-person attention
• Functional movement screen

The treatment

• Patient education
• Therapeutic exercise
• In-office treatments as indicated

What’s it like to be a telehealth PT?

Many of you are probably wondering whether you’ll even enjoy being a telehealth provider. It’s wise to consider the pros and cons when weighing this decision.

Pros

• Flexibility. Can you imagine how nice it’d be to treat patients from anywhere that had an internet connection?!
• Predictable hours. Generally speaking, you can still have predictable hours when you know you’ll be working vs. not working.
• Using your degree. One of the hardest parts of leaving direct patient care is feeling like you’re not really using your degree. As a telehealth PT, you’re using your degree to its fullest!
• Work from home.  Enough said 🙂

Cons

• Difficult patient acquisition. As mentioned above, getting patients is the hardest part. Just like many PTs are disinterested in teletherapy because they don’t understand it, plenty of patients shy away from telehealth PT because they don’t understand it, or don’t even know it exists as an option.
• Lots of sitting. The nice part is that you’re also up and about to demonstrate exercises, so you’re not quite as sedentary as you’d be at other jobs.
• Confusing and rapidly changing rules and reimbursements. This would drive anyone a bit bonkers.
• Uncertainty. It’s a new form of therapy, and there aren’t set, established practices yet. It’s a bit like the wild west, which can be considered a pro, since there is a lot of opportunity! It’s also hard to find full-time, benefited roles in teletherapy…at least so far.

What does a successful telehealth physical therapist look like?

• Enjoys patient education – You don’t have those magic hands as your secret weapon to get patients better, so you’ll be relying on your communication and education skills.
• Does not rely on manual therapy alone – For this reason, having sound evaluation and assessment skills, as well as strong patient-education skills, will help you succeed at telehealth.
• Is articulate – When you deliver care remotely, it’s essential to be clear with communications.
• Is licensed in the state(s) in which they plan to provide therapy – PTs and PTAs can treat as they normally do per a state practice act (with PTAs treating with oversight by a PT). The same goes for OTs and COTAs and SLPs. But if you’re planning to treat a patient in Missouri, you need to have a clinical license (PT, PTA, OT, COTA, SLP, etc.) to practice in Missouri.
• Enjoys patient care – While telehealth PT is incredibly flexible and rewarding, it’s still patient care, so it’s not exactly non-clinical; it can be considered more of an alternative career for physical therapists. You’ll be providing physical therapy services remotely, so if you truly do not enjoy patient care, you might want to consider something else.
• Has a niche – Whether it’s running, pediatrics, cardiopulmonary, yoga, CrossFit, vestibular, or cycling, patients will be more likely to use your services if you’re considered an an expert in your niche.

What is a typical telehealth physical therapy salary?

Most teletherapists do not get a salary, but are paid an hourly wage. That’s because most remote care is delivered on a PRN basis. However, now that many clinics are incorporating telehealth into their existing practice models, this could change soon. If that’s the case, you can likely expect pay to align with what a staff therapist would make. However, keep in mind that if your patient load is primarily Medicare-based, you will likely be swapping out e-visits for in-person visits, at least until Medicare reimburses actual telehealth visits. So, you might make less than a staff therapist.

Experienced PRN telehealth physical therapists typically can earn about $50-75/hour. However, with the coronavirus dramatically shaking up the market, these rates could easily change!

Career paths for the telehealth PT professional

Because telehealth PT is such a new career niche, only time will tell us what common career paths will be.

Here are just a few that we’re seeing:

• Telehealth PT/A → lead telehealth PT → virtual rehab manager (which likely includes a customer success angle)
• Telehealth PT/A with niche focus → solo telehealth PT with niche independent practice → sell clinic to larger clinic
• Telehealth PT/A → telehealth consultant→ program manager
• Telehealth PT/A → clinical trainer → training manager
• Telehealth PT/A → sales trainer → sales specialist → sales manager

Another thought is to parlay that tech experience into entrepreneurial endeavors, or work for a digital health company as a clinical trainer or implementation specialist.

Telehealth physical therapy in larger systems

For those of you working in larger hospital systems, COVID-19 might have sped up the process of incorporating telehealth into your care delivery. However, the larger the system, the more challenging it can be to make this move.

Devra Sheldon, PT, MSPT, NCS works at Schwab Rehabilitation Hospital (part of Sinai Health System) in Chicago, which serves many low-income patients who have a tough time getting to appointments. Sheldon has done extensive research into telehealth as a tool for better management of low income populations who have numerous barriers to care, but these barriers can often include lack of the smartphones and tablets used to deliver the very care we wish to provide. So far, this has precluded telehealth from being integrated into their delivery model.

Sheldon is hopeful that hospitals will eventually negotiate with payers and get the ball rolling on insurance reimbursing telehealth for therapy. As an employee of a low-income hospital, she spends a lot of time on the phone and emailing with patients. This time is not reimbursed, even though it’s valuable care. “I believe Telehealth could be very valuable with not just low-income patients, but all patients with persistent pain by evaluating flare ups, reviewing self management strategies, pacing and more,” she explains.

Top resources for teletherapy

Still want more information about telehealth physical therapy? Here are some great resources for continued learning!

• APTA’s Telehealth Page – The best resource for telehealth information from the APTA.
• APTA’s Telehealth PT Directory – Add yourself to the list if you’d like!
• AOTA’s Coronavirus Page – The most current resource for coronavirus-related info from the AOTA.
• APTA Facebook live with Physera team – Also features Ellen Morello, PT, DPT.
• Canadian Physiotherapy Association’s Position on Telehealth – Great page for Canadian PT/As.
• Center for Connected Health Policy – This is where you can look up telehealth rules state-by-state.
• Coronavirus and PT – The most current resource for coronavirus-related info from the APTA.
• FSBPT – Federation of State Boards of Physical Therapy: resource for state rules/regs around telehealth.
• HIPAA and Telehealth – Free APTA webinar.
• Medicare’s new ruling – For COVID-19 PT/OT/SLP telehealth reimbursement.
• Medicare’s coding guidelines – For teletherapy and telepractice.
• OT Potential’s Article on Telehealth Occupational Therapy – Great resource for OTs interested in telehealth.
• Private Practice Section of APTA – Probably the most robust/current source of COVID-19 and telehealth PT.
• PT Compact – See which states are members (or in the process of becoming members) of the compact.
• SWORD Health’s webinars. These cover about combining telePT with AI (artificial intelligence)
• Telehealth and the COVID-19 crisis – Features Ellen Morello, PT, DPT of Physera (mentioned above).
• UpDoc Media’s white paper on digital health practice – By Ben Fung, PT, DPT, MBA and his team.
• WebPT’s free resource on COVID-19 and continuity of care – Must sign up to email list to receive it.
• WebPT’s free webinar on how to get paid for telehealth – Must sign up to email list to view this webinar.
• WebPT’s free downloadable guide to practicing telehealth – Must sign up for their email list to access.

This article was updated last on 5/21/2020. Please reach out with questions or corrections. This is a rapidly evolving topic, and I appreciate any help I can get!

Online physical therapy treatment might be the future of PT!

One thing is for sure: the pandemic has thrust us all into the position of looking much more closely at how online physical therapy will play a role in the future of PT. Whether it’s our main delivery model or an ancillary option to our current models, there is no doubt that online PT treatments are here to stay. I am eager to hear from you if you have received this type of treatment and/or if you have delivered telehealth. Please comment and let us all know about your experiences!