DAR File No. 30653

Health, Health Care Financing, Coverage and Reimbursement Policy

R414-21

Physical and Occupational Therapy

NOTICE OF PROPOSED RULE

DAR File No.: 30653
Filed: 11/05/2007, 08:49
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

Based on internal agency review, this change is to update and clarify the provision of physical and occupational therapy services. It also clarifies definitions, program access requirements, coverage, limitations, and reimbursement for physical and occupational therapy.

Summary of the rule or change:

The new rule clarifies and specifies program access requirements for physical and occupational therapy. It removes from the old rule prior authorization and reauthorization procedures as these are contained in the provider manuals. The new rule increases the number of physical or occupational therapy visits allowed without prior authorization from 10 to 20 and amends the limitations for treatment. It expands the deadline for recipients to seek treatment to 90 days following a cerebral vascular accident (CVA). The new rule clarifies reimbursement for physical and occupational therapy, and clarifies criteria for services provided through home health agencies.

State statutory or constitutional authorization for this rule:

Sections 26-18-3 and 26-1-5; and 42 CFR 440.110(a)(1)(2) and 42 CFR 440.110(b)(1)(2)

Anticipated cost or savings to:

the state budget:

There is no budget impact expected because the majority of physical and occupational therapy recipients currently complete 20 visits per calendar year, when authorization is requested after the first ten. The administrative efficiencies achieved because of this rulemaking will allow the department to use staff to review other services provided to Medicaid recipients.

local governments:

There is no budget impact because local governments do not fund physical therapy or occupational therapy services and there is no expected change in the number of physical and occupation therapy visits covered.

small businesses and persons other than businesses:

It is expected that there will be no actual impact to small business or any persons because the majority of physical and occupational therapy recipients currently complete 20 visits per calendar year, when prior authorization is requested after ten visits.

Compliance costs for affected persons:

There is no compliance cost to a single Medicaid recipient or to a provider because coverage without prior authorization is expanded.

Comments by the department head on the fiscal impact the rule may have on businesses:

This rule change expands coverage without prior authorization. Most patients complete their care in 20 or less visits, so there should not be an impact on the majority of Medicaid recipients. Business impact should be minimal. David N. Sundwall, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY UT 84116-3231

Direct questions regarding this rule to:

Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

12/31/2007

This rule may become effective on:

01/07/2008

Authorized by:

David N. Sundwall, Executive Director

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-21. Physical and Occupational Therapy.

[R414-21-1. Policy Statement.

(1) "Qualified" physical therapists and occupational therapists may provide services for Medicaid eligible individuals upon the order of a doctor of medicine, osteopathy, dentistry or podiatry.

(2) Non-licensed therapists, although they may have received the required academic training, may not provide services for Medicaid eligible recipients with the expectation of reimbursement from Medicaid.

 

R414-21-2. Authority and Purpose.

(1) Authority

(a) The provision of physical therapy and occupational therapy evaluation and treatment is authorized under the authority of the 42 CFR in the following Sections:

(i) 405.1718a Medicare Standard, Nursing Home patients;

(ii) 405.1718b Medicare Standard, Nursing Home equipment;

(iii) 405.1718c Medicare Standard, Nursing Home personnel;

(iv) 440.70(b)(4) Home health provisions of service;

(v) 440.110(a)(1)(2) Physical Therapy and 440.110(b)(1)(2)Occupational Therapy definitions and qualifications;

(vi) 442.486 Physical Therapy services, ICF/MR;

(vii) 442.487 ICF/MR records and evaluation.

(2) Purpose

(a) The purpose of the physical therapy and occupational therapy program is to increase the functioning ability of each handicapped Medicaid recipient whether the handicap is temporary or permanent.

(b) The rehabilitation goals must include evaluation of the potential of each individual patient, the factual statement of the level of functions present, the identification of the goal that may reasonably be achieved, and the predetermined space of time and concentration of services that would achieve the goal.

(c) The Medicaid program is designed to provide services within financial limitations. A desired level of function must be balanced with an achievable level of function within a defined length of time. The objectives of the program are to provide a scope of service, supplementary information, limitations, and instructions concerning prior authorizations, billing, and utilization which clearly direct the provider to accomplish the goals he has identified for the patient.

(d) The goal of the physical therapist and the occupational therapist is to improve the ability of the patient, through the rehabilitative process, to function at a maximum level.

(e) The objectives of the provider must include:

(i) The evaluation and identification of the existing problem, not an anticipated problem;

(ii) The evaluation of the potential level of function actually achievable;

(iii) The restoration, to the level reasonably possible, of functions which have been lost due to accident or illness;

(iv) The establishment, to the level reasonably possible, of functions which are lacking due to defects of birth.

(v) The eventual termination or transfer of the responsibility for identified procedures to family, guardians, or other care-givers.

 

R414-21-3. Definitions.

(1) Physical Therapy: means the treatment of a human being by the use of exercise, massage, heat or cold, air, light, water, electricity, or sound for the purpose of correcting or alleviating any physical or mental condition or preventing the development of any physical or mental disability, or the performance of tests of neuromuscular function as an aid to the diagnosis or treatment of any human condition, provided, however, that physical therapy shall not include radiology or electrosurgery.

(2) Physical Therapist: means a person who practices physical therapy. "Physical therapist," "physiotherapist" and "physical therapy technician" are equivalent terms and reference to any one of them in this rule shall include the others.

(3) Qualified Physical Therapist: means an individual who is:

(a) a graduate of a program of physical therapy approved by both the Council on Medical Education of the American Medical Association and the American Physical Therapy Association, or its equivalent;

(b) licensed by the State of Utah; and

(c) a provider for Medicaid.

(4) Occupational Therapy means treatment of a human being by the use of therapeutic exercise, ADL activities, patient education, family training, home environment evaluation, equipment measurement and fitting, and fine motor skills.

(5) Occupational therapist means a person who practices occupational therapy.

(6) Qualified Occupational Therapist means an individual who is:

(a) registered by the American Occupational Therapy Association: or

(b) a graduate of a program in occupational therapy approved by the committee on Allied Health Education and Accreditation of the American Medical Association and engaged in the supplemental clinical experience required before registration by the American Occupational Therapy Association. 42 CFR 440.110.

(c) licensed by the State of Utah; and

(d) a provider for Medicaid

(7) Rehabilitation: means the process of treatment that leads the disabled individual to attainment of maximum function.

(8) Rehabilitation Services: means the delivery of rehabilitative medical or remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of his practice under state law, for maximum reduction of physical or mental disability and restoration of a recipient to his best possible functional level. (42 CFR 440.130 (d).)

 

R414-21-4. Eligibility Requirements/Coverage.

Physical and occupational therapy services are available to categorically and medically needy individuals under Medicaid.

 

R414-21-5. Program Access Requirements.

Physical and occupational therapy services are available to categorically and medically needy individuals under Medicaid.

 

R414-21-6. Service Coverage.

(1) Providers of physical therapy shall offer an adequate program that provides services which utilize therapeutic exercise and the modalities of heat, cold, water, air, sound, massage and electricity; recipient evaluations and tests; and measurements of strength, balance, endurance, range of motion, and activities.

(a) Patients in need of physical therapy services are accepted for evaluation with a referral or recommendation by a physician, dentist, podiatrist or osteopath.

(b) Provision of services is with the expectation that the condition under treatment will improve in a reasonable and predictable time. Continuation of treatment beyond the maximum rehabilitative potential within a specified time will not be approved. Length of time and number of treatments will be predicated by Physical Therapy Association guidelines.

(c) All therapy services after the first ten sessions per client per provider per calendar year require prior authorization.

(2) Providers of occupational therapy shall offer an adequate program that provides services which utilize therapeutic modalities approved by the American Occupational Therapy Association.

(a) Patients in need of occupational therapy services are accepted for evaluation with a referral or recommendation by a physician, dentist, podiatrist or osteopath.

(b) Provision of services is with the expectation that the condition under treatment will improve in a reasonable and predictable time. Continuation of treatment beyond the maximum rehabilitative potential within a specified time will not be approved. Length of time and number of treatments will be predicated by Physical Therapy Association guidelines.

 

R414-21-7. Standards of Care.

(1) The services must be considered under accepted standards of medical practice to be a specific and effective treatment for the recipient's conditions.

(2) The services must be of a level of complexity and sophistication, or the condition of the recipient must be such, that services required can be safely and effectively performed only by a qualified physical therapist. To constitute physical therapy, a service must, among other things, be reasonable and necessary to the treatment of the individual's illness. If an individual's expected rehabilitative potential would be insignificant in relation to the extent and duration of the physical therapy, it would not be considered reasonable and necessary. There must be an expectation that the recipient's condition will improve significantly in a reasonable (and generally predictable) period of time. If, at any point in the treatment of an illness, it is determined that the expectation will not materialize, the services will no longer be considered reasonable and necessary.

(3) The amount, frequency, and duration of the services must be reasonable. Requests will be reviewed and a determination made by Health Care Financing, Utilization Management Staff using guidelines provided by the American Physical Therapy Association and the American Occupational Therapy Association.

 

R414-21-8. Programs.

(1) Independent Physical Therapist licensed by Utah and practicing according to the provisions of this rule.

(2) Independent Occupational Therapist licensed by Utah and practicing according to the provisions of this rule.

(3) Physical Therapists and Occupational Therapists associated with a professional group in a hospital or clinic or rehabilitation center. This clinic situation will allow the physical therapy and occupational therapy programs to overlap. The clinic or rehabilitation center under the direction a physician will determine which therapy, P.T. or O.T., will be given. The total treatments for any diagnosis will be determined by the provisions of this rule.

 

R414-21-9. Limitations.

(1) General Limitations

(a) More than ten physical therapy services per calendar year per client per provider are not reimbursable without prior approval following the evaluation. All other services by the same billing provider require prior authorization.

(b) Physical therapy or occupational therapy treatments are limited to one per day.

(c) Independent Occupational Therapist: all services after the initial evaluation require prior authorization.

(d) Clinic or Rehabilitation Center Occupational Therapists: the first ten visits (combination of P.T./O.T. visits) do not require prior authorization. All other services beyond the initial ten visits require prior approval.

(e) The following services are not covered:

(i) Treatment for social or educational needs;

(ii) Treatment for patients who have stable chronic conditions which cannot benefit from physical therapy services;

(iii) Treatment for recipients where there is no documented potential for improvement;

(iv) Treatment for recipients who have reached maximum potential for improvement;

(v) Treatment for recipients who have achieved stated goals;

(vi) Treatment for non-diagnostic, non-therapeutic, routine, repetitive or reinforced procedures;

(vii) Treatment for CVA which begins more than 60 days after onset of the CVA;

(viii) Treatment for residents of ICF/MR;

(ix) Treatment in excess of one session or service per day.

(2) Specifications. Various physical therapy and occupational therapy modalities are included in the therapy procedure code. There are no specific procedure codes in the Medicaid program for such procedures as heat, cold, whirlpool, massage, air and sound therapy. Any modality the therapist chooses is acceptable under the one procedure code.

(a) Hot Pack, Hydrocollator, Infra-Red Treatments, Parafin Baths and Whirlpool Baths. Heat treatments of this type, including whirlpool baths, do not ordinarily require the skills of a qualified physical therapist. However, in a particular case, the skills, knowledge, and judgment of a qualified physical therapist might be required for such treatments as baths where the recipient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, or other complications. Also, if such treatments are given prior to, but as an integral part of, a skilled physical therapy procedure, they would be considered part of the physical therapy service.

(b) Gait Training. Gait evaluation and training furnished a recipient whose ability to walk has been impaired by neurological, muscular, or skeletal abnormality, require the skills of a qualified physical therapist. However, if gait evaluation and training cannot reasonably be expected to improve significantly the patient's ability to walk, such services would not be considered reasonable or medically necessary. Repetitious exercises to improve gait or maintain strength and endurance and assist in walking are appropriately provided by supportive personnel such as aides or nursing personnel and do not require the skills of a qualified physical therapist.

(c) Ultrasound, shortwave, and microwave treatments. These modalities must always be performed by a qualified physical therapist.

(d) Range of Motion Tests. Therapeutic exercises which must be performed by or under the supervision of a qualified physical therapist, due either to the type of exercise employed or condition of the recipient, would constitute physical therapy. Range of motion exercises require the skills of a qualified physical therapist only when they are part of active treatment of a specific disease which has resulted in the loss or restriction of mobility (as evidenced by physical therapy notes showing the degree of motion lost and the degree to be restored). Such exercises, either because of their nature or condition of the recipient, may be performed safely and effectively by a qualified physical therapist briefly. Generally, range of motion exercises related to the maintenance of function do not require the skills of a qualified physical therapist and are not reimbursable.

(3) Home Health Limitations

(a) In a home health agency where the physical therapist is an employee of the agency or where there is a contractual arrangement with the therapist, the home health agency must follow the Medicaid guidelines.

(b) All therapy services, including the evaluation, require prior authorization.

(c) Occupational therapy is not a benefit in the home health program.

 

R414-21-10. Prior Authorization.

(1) Ten services per calendar year per client are reimbursable without prior approval following the evaluation.

(a) All other services by the same provider require prior authorization.

(b) All physical therapy treatment, therapies, or sessions require a prior approval beginning after the first ten services per client per calendar year per billing provider.

(2) Process. The evaluation does not require prior approval. The first ten services per patient per billing provider per calendar year do not require prior approval. Prior approval for therapy services after the first ten services per provider per calendar year require prior approval before the services begin. The request for prior approval for treatment should include a copy of the plan of treatment for the patient or a document which includes:

(a) the diagnosis, and the severity of the condition;

(b) the prognosis for progress;

(c) the expected goals and objectives for the recipient to attain;

(d) the detail of the method(s) of treatment;

(e) the frequency of treatment sessions, length of each session, and duration of the program.

(3) Prior Approval Procedure

(a) Prior approval requests will be evaluated for the number, frequency, and duration of treatments.

(i) The number of services approved will be based on the documented diagnosis, history and goals.

(ii) The frequency of services will be determined by the provider not to exceed one treatment per day.

(b) Reauthorization will require review by the patient's primary physician and will be dependent upon the medical necessity of the patient. Medicaid physician consultants will review and evaluate requests for continued service.

(4) Prior Approval Criteria

(a) Prior approval requests for treatment will be reviewed and approved or denied based on the following criteria:

(i) Services are for treatment of medically oriented disorders and disabilities.

(ii) Services are professionally appropriate under standards in the field, utilizing professionally appropriate methods and materials, in a professionally appropriate environment.

(iii) Services are provided with the expectation that the condition under treatment will improve in a reasonable and predictable time to the identified level.

(iv) Services are provided with a plan that explicitly states the methods to be used and the termination conditions.

(v) Services are requested for a patient suffering from CVA within 60 days of the CVA.

(5) Reauthorization

(a) When a reauthorization is necessary after the initial prior-approved sessions, a medical evaluation and documentation from the physician, as well as the therapist, must be attached to the prior authorization request. A new treatment plan is necessary defining the new goals. A new medical summary from the physician must also be attached. Additional requests should also include any supplemental data such as past treatment, progress made, family problems that may hinder progress, and a definite termination date. Medicaid physician consultants will review and evaluate requests for continued service in accordance with the process and criteria set forth in R414-21.

 

R414-21-11. Reimbursement for Services.

Physical therapy reimbursement procedure codes and instructions are found in the Physical Therapy Provider Manual.

]

R414-21-1. Introduction and Authority.

(1) This rule governs physical and occupational therapy services provided to Medicaid clients. It implements the provision of physical therapy and occupational therapy evaluation and treatment as authorized by 42 CFR 440.110(a)(1)(2), 440.110(b)(1)(2), and 440.70(b)(4).

(2) Physical and occupational therapy are optional services for adults.

 

R414-21-2. Eligibility Requirements.

Physical therapy and occupational therapy services are available to categorically and medically needy individuals under Medicaid.

 

R414-21-3. Program Access Requirements.

(1) Physical therapy may be provided only by a licensed physical therapist. The physical therapist may have a physical therapy assistant or aide under the physical therapist's immediate supervision provide the direct service so long as the physical therapist is present in the area where the person supervised is performing services and immediately available to assist the person being supervised in the services being performed.

(2) Occupational therapy may be provided only by a licensed occupational therapist. The occupational therapist may have a occupational therapy assistant under the occupational therapist's immediate supervision provide the direct service so long as the occupational therapist is present in the area where the person supervised is performing services and immediately available to assist the person being supervised in the services being performed.

 

R414-21-4. Service Coverage.

(1) Medicaid covers the following physical therapy services:

(a) therapeutic exercise;

(b) the application of heat, cold, water, air, sound, massage, and electricity;

(c) recipient evaluations and tests;

(d) measurements of strength, balance, endurance, range of motion and activities.

(2) Medicaid covers occupational therapy services to treat the following:

(a) traumatic brain injury;

(b) traumatic spinal cord injury;

(c) traumatic hand injury;

(d) congenital anomalies or developmental disabilities resulting in neurodevelopmental deficits; or

(e) cerebral vascular accident (CVA), but only if treatment begins within 90 days after the onset of the CVA.

(3) In exercising its best professional judgement to determine the amount, duration, and scope of optional services sufficient to reasonably achieve the purpose of the physical therapy or occupational therapy service, the Department uses the guidelines provided by the American Physical Therapy Association and the American Occupational Therapy Association to determine the number of visits allowed for the diagnosis.

(4) Medicaid does not cover:

(a) services for social or educational needs only;

(b) services to a recipient with a stable chronic condition whose function cannot be improved by the application physical therapy services;

(c) service to a recipient with no documented potential for improvement or who has reached maximum potential for improvement;

(d) non-diagnostic, non-therapeutic, repetitive or reinforcing procedures or other maintenance services, except for services that are both:

(i) to children under the age of 20 years; and

(ii) are limited to one therapy visit per month to train the caregiver to provide routine care, and repetitive or reinforced procedures in the residence.

(5) Medicaid pays for only one physical therapy session per day. Medicaid pays for only one occupational therapy session per day.

(6) Services to a resident of an Intermediate Care Facility for the Mentally Retarded are paid as part of the per diem payment for the recipient. Medicaid does not pay separately for those services.

(7) Physical therapy is limited to 20 visits annually without obtaining prior authorization to assure that the sessions are within the amount, duration, and scope limits established by the Department.

(8) Occupational therapy is limited to 20 visits annually without prior authorization to assure that the visits are within the amount, duration, and scope limits established by the Department.

 

R414-21-5. Services Provided Through Home Health Agencies.

(1) If a physical therapy service is provided outside of the physical therapists treatment facility, the provider must obtain prior authorization from the Department for each physical therapy session, including the evaluation. to assure that the sessions are within the amount, duration, and scope limits established by the Department and that the recipient could not obtain the service at the physical therapist's treatment facility.

(2) The Department does not cover occupational therapy services that are not provided at the occupational therapist's treatment facility.

 

R414-21-6. Reimbursement.

(1) Physical and occupational therapy is reimbursed using the fee schedule established in the Utah Medicaid State Plan and incorporated by reference in Section R414-1-5.

(2) Services provided by a physical therapy assistant or aide or by an occupational therapy assistant must be billed as part of the services provided by the supervising physical or occupational therapist.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [July 2, 2003]2008

Notice of Continuation: April 16, 2007

Authorizing, and Implemented or Interpreted Law: 26-1-4.1; 26-1-5; 26-18-3