PT, OT, and ST Benefits to Change for Acute Services for Texas Medicaid

Transcription

1 PT, OT, and ST Benefits t Change fr Acute Services fr Texas Medicaid Infrmatin psted Nvember 15, 2013 Effective fr dates f services n r after January 1, 2014, benefit criteria fr physical (PT), ccupatinal (OT), and speech therapy (ST) will change fr acute services fr Texas Medicaid. PT, OT, and ST services, including c-therapy, will be benefits f Texas Medicaid fr clients with an acute medical cnditin r an acute exacerbatin f a chrnic medical cnditin when all f the fllwing criteria are met: Prir authrizatin is btained Therapy is prescribed by a licensed physician A prescriptin is cnsidered current when it is signed and dated within 30 days befre the start f therapy. Dcumentatin f medical necessity indicates a cnditin that requires nging therapy r rehabilitatin in the usual curse, treatment, and management f the client s cnditin. Dcumentatin frm the prescribing prvider and the treating therapist shws there is r will be prgress made twards gals. Therapy is cnsidered acute fr 180 rlling days frm the first date (nset) f therapy fr a specific cnditin. If the client s cnditin persists fr mre than 180 rlling days frm the start f therapy services, the cnditin is cnsidered chrnic and will nt be cvered. Nte: Fr clients wh are 20 years f age and yunger and d nt meet criteria thrugh acute services, therapies may be cnsidered thrugh the Cmprehensive Care Prgram (CCP). PT and OT services that are prvided in the hme setting may be cnsidered as a hme health services benefit. Therapy gals fr an acute cnditin r acute exacerbatin f a chrnic medical cnditin include, but are nt limited t, imprving functin and restring functin. PT, OT, and ST evaluatins and treatment must be rdered r prescribed by the client s physician and based n medical necessity. When services are furnished based n verbal physician rders, the rders must be taken by smene wh is authrized t receive them under state and federal laws and regulatins, (a registered nurse (RN), physical therapist, ccupatinal therapist, r speech language pathlgist), as well as under a therapy prvider's internal plicies. Verbal rders must be reduced t writing, include the date f receipt, and be signed and dated by the RN, r qualified physical, ccupatinal, r speech therapist respnsible fr furnishing r supervising the rdered services. The rders must be transcribed t the plan f care (POC), and must be maintained in the client's medical recrd and made available upn request. When a revisin r extensin f PT, OT, r ST services is based n verbal physician rders, the verbal rder may be taken and dcumented by either the RN r qualified

2 physical, ccupatinal, r speech therapist respnsible fr furnishing r supervising the rdered services. Verbal physician rders must be cuntersigned by the client's physician within the time frame required by the therapy prvider's internal plicies. Therapy and swallwing functin evaluatins are a benefit nce per 180 rlling days, any prvider. Therapy and swallwing functin re-evaluatins are a benefit when dcumentatin supprts a change in the client s status r with a request fr extensin f services. Additinal therapy evaluatins r re-evaluatins and swallwing functin evaluatins r re-evaluatins that exceed these limits may be cnsidered fr reimbursement with dcumentatin f ne f the fllwing: A change in the client s medical cnditin A change-f-prvider letter that is signed and dated by the client r respnsible adult and dcuments all f the fllwing: The date that the client ended therapy (effective date f change) with the previus prvider The names f the previus and new prviders An explanatin f why prviders were changed Nte: Prviders wh terminate services must give reasnable ntice t the client and must maintain dcumentatin f the reasn in the client s medical recrd. An evaluatin r re-evaluatin perfrmed n the same date f service as an evaluatin r re-evaluatin frm a different therapy discipline must be perfrmed at distinctly separate times t be cnsidered fr reimbursement. Cncurrent evaluatins r reevaluatins perfrmed by tw disciplines will nt be reimbursed. All dcumentatin that is related t the therapy services that are prir authrized and prvided, including the cmprehensive treatment plan, must be maintained in the client s medical recrd and made available upn request. Fr each therapy discipline that is prvided, the dcumentatin that is maintained in the client's medical recrd must identify the therapy prvider's name and include all f the fllwing: Date f service Start time f therapy Stp time f therapy Ttal minutes f therapy Specific therapy perfrmed Client s respnse t therapy Texas Medicaid reimburses physicians and licensed therapists wh are authrized by the state licensing bards (i.e., licensed physical therapists, licensed ccupatinal therapists, and licensed speech language pathlgists) t prvide therapy services. Therapy services may als be prvided by licensed physical therapy assistants, licensed ccupatinal therapy assistants, and licensed speech-language pathlgy assistants under the supervisin f a licensed physical therapist, licensed ccupatinal therapist, r licensed speech-language pathlgist. Claims fr services that are prvided by a licensed assistant are submitted by the licensed therapist.

3 Services that are perfrmed by students wh are enrlled in an accredited therapy prgram are nt reimbursed under Texas Medicaid, because the students are nt licensed health-care prviders. Therapy services prvided t a client that are perfrmed by a therapy student in which a licensed therapist is nt directly, hands-n, invlved with the therapy prvided t the client will nt be reimbursed under Texas Medicaid; hwever, a service that is prvided by a licensed health-care prvider while a student is present may be reimbursed. Prviders f therapy services, which include licensed therapists as well as designated assciates, are allwed a maximum f 12 hurs f therapy services perfrmed per day, regardless f whether the prvider f services is emplyed by an agency r individually enrlled in Texas Medicaid. All therapy service dcumentatin, alng with therapy ntes, must include a beginning and ending time and is subject t retrspective review. Physical Therapy (PT) PT prvided under the rders f a client s physician is limited t treatment f acute medical cnditins r acute exacerbatins f a chrnic medical cnditin that invlve the musculskeletal r neurmuscular systems and may include physical agents such as massage, electrical stimulatin, tractin, r exercise as a frm f therapy. PT des nt include diagnsis r psychlgical services that are typically perfrmed by a licensed psychlgist r behaviral health therapist. PT prvided in the ffice r utpatient hspital setting may be a benefit under any f the fllwing situatins: It is perfrmed by a licensed physician. It is rendered in accrdance with the Executive Cuncil f Physical Therapy and Occupatinal Therapy Examiners and perfrmed by ne f the fllwing: A licensed physical therapist A licensed physical therapy assistant under the supervisin f a licensed physical therapist A PT evaluatin (prcedure cde 97001) r re-evaluatin (prcedure cde 97002) will be denied if it is submitted by any prvider n the same date f service as therapy treatment prcedure cdes that are submitted with mdifier GP. A PT evaluatin (prcedure cde 97001) may als be billed with mdifier U1 fr a wheeled mbility system seating assessment that is perfrmed by a licensed physical therapist. The fllwing prcedure cdes will be limited t nce per date f service, per distinct therapy type: Prcedure Cdes Occupatinal Therapy (OT)

4 OT prvided under the rders f the client s physician is limited t the evaluatin and treatment f a client whse ability t functin in life rles is impaired due t an acute medical cnditin r an acute exacerbatin f a chrnic medical cnditin. OT uses therapeutic gal-directed activities t treat clients. OT des nt include diagnsis r psychlgical services that are typically perfrmed by a licensed psychlgist r behaviral health therapist. OT prvided in the ffice r utpatient hspital setting may be a benefit under any f the fllwing situatins: It is perfrmed by a licensed physician. It is rendered in accrdance with the Executive Cuncil f Physical Therapy and Occupatinal Therapy Examiners and perfrmed by ne f the fllwing: A licensed ccupatinal therapist A licensed ccupatinal therapy assistant r a certified ccupatinal therapy assistant under the supervisin f a licensed ccupatinal therapist An OT evaluatin (prcedure cde 97003) r re-evaluatin (prcedure cde 97004) will be denied if it is submitted by any prvider n the same date f service as therapy treatment prcedure cdes that are submitted with mdifier GO. An OT evaluatin (prcedure cde 97003) may als be submitted with mdifier U1 fr a wheeled mbility system seating assessment that is perfrmed by a licensed ccupatinal therapist. The fllwing prcedure cdes will be limited t nce per date f service, per distinct therapy type: Prcedure Cdes Speech Therapy (ST) ST prvided under the rders f a client s physician is limited t treatment f an acute medical cnditin r an acute exacerbatin f a chrnic medical cnditin that invlves the head r neck and affects speech prductin r swallwing functin. ST des nt include diagnsis r psychlgical services that are typically perfrmed by a licensed psychlgist r behaviral health therapist. ST prvided in the ffice r utpatient hspital setting may be a benefit under any f the fllwing situatins: It is perfrmed by a physician. It is rendered in accrdance with the State Bard f Examiners fr Speech-Language Pathlgy and Audilgy and perfrmed by ne f the fllwing: A licensed speech-language pathlgist A licensed speech-language pathlgy assistant under the supervisin f a licensed speech-language pathlgist

5 A licensed speech-language pathlgy intern under the supervisin f a licensed speech-language pathlgist ST evaluatins r re-evaluatins and swallwing functin evaluatins r re-evaluatins may be cnsidered fr reimbursement n the same date f service. When prvided by a licensed speech-language pathlgist, prcedure cde may be used nly fr additinal augmentative cmmunicatin device training. Prcedure cde must be prir authrized and be specifically requested n the prir authrizatin request frm. The prvider must submit dcumentatin supprting the service as medically necessary and beneficial t the client. Prcedure cde will be denied when submitted with the same date f service as prcedure cde 92506, 92610, r S9152. Prcedure cdes and S9152 will be denied when submitted with the same date f service as prcedure cde C-therapy C-therapy is defined as tw different therapy disciplines that are perfrmed n the same client at the same time by a licensed therapist fr each therapy discipline and rendered in accrdance with the Executive Cuncil f Physical Therapy and Occupatinal Therapy Examiners r the State Bard f Examiners fr Speech-Language Pathlgy and Audilgy. C-therapy may be cnsidered a benefit when it is medically necessary fr the client t receive therapy frm tw different therapy disciplines at the same time. The therapy perfrmed must require the expertise f tw different disciplines (i.e., licensed physical therapist, licensed ccupatinal therapist, r licensed speech-language pathlgist), t perfrm the therapy safely and effectively t reach the client s gals as determined by the apprved POC, which must be signed and dated by the client s physician. When perfrming c-therapy, a primary therapist must be designated by the tw perfrming therapists. Only the primary perfrming therapist may bill fr the therapy services rendered. The secndary therapist will nt be reimbursed by Texas Medicaid fr assisting a designated primary perfrming therapist with c-therapy services. C-therapy dcumentatin requirements are as fllws: Medical necessity fr the individual therapy services must be justified befre perfrming c-therapy. Dcumentatin supprts c-therapy gals and hw c-therapy will help achieve the therapist s gals fr the client, fr each therapy discipline. A physician rder r prescriptin is received fr c-therapy. An explanatin f why the client requires, and will receive, multidisciplinary team care, defined as at least tw therapy disciplines (PT, OT, r ST) Retrspective review may be perfrmed t ensure dcumentatin supprts the medical necessity f the c-therapy perfrmed and that the billing was apprpriate fr the services prvided by the designated primary perfrming therapist. Claims fr c-therapy services must be submitted with mdifier U3.

6 Prir Authrizatin PT, OT, and ST prvided in the ffice r utpatient setting will require prir authrizatin. PT, OT, and ST evaluatins r re-evaluatins, when prvided with the limits utlined in this article, will nt require prir authrizatin. Prir authrizatin may be granted fr a perid nt t exceed 90 days per event fr acute care services. A prir authrizatin may be extended fr an additinal 90 days when a request is submitted with supprting dcumentatin. Subsequent requests fr services exceeding 180 days will nt be prir authrized. IMPORTANT: Clients with an acute medical cnditin wh currently receive therapy services withut a prir authrizatin in the ffice r utpatient facility setting will als be subject t the prir authrizatin requirement effective January 1, Initial prir authrizatins may be apprved up t 90 days, less any days that have passed since the date f nset. If mre than 90 days have passed, the prir authrizatin may be apprved fr the number f days remaining in the acute care perid (180 days). Nte: Texas Medicaid will nt authrize therapy services that duplicate services that are the legal respnsibility f the schl districts. The schl district, thrugh the Schl Health and Related Services (SHARS) prgram, is required t meet the therapy needs f the client while the client is at schl. Hwever, if thse needs cannt be met by SHARS r the schl district, dcumentatin that supprts medical necessity may be submitted fr cnsideratin f prir authrizatin. Cverage perids d nt necessarily cincide with calendar weeks r mnths, but instead cver a number f services t be scheduled between a start and end date that is assigned during the prir authrizatin perid. A week includes the day f the week n which the prir authrizatin perid begins and cntinues fr seven days. The number f therapy services authrized fr a week must be prvided in that prir authrizatin week. Claims fr services that exceed thse authrized fr the prir authrizatin week are subject t recupment. Prviders must identify the requested PT, OT, r ST prcedure cde with the apprpriate GP, GO, r GN mdifier at the time each request fr PT, OT, r ST is made: Prviders can submit the prir authrizatin request n paper r electrnically. T submit the prir authrizatin request n paper, prviders must cmplete the Request fr Outpatient Physical, Occupatinal, r Speech Therapy (PT, OT, ST) Prir Authrizatin Frm. T cmplete the prir authrizatin prcess by paper, the prvider must submit the prir authrizatin requirements dcumentatin thrugh fax r mail and must retain a cpy f the prir authrizatin request and all submitted dcumentatin in the client s medical recrd at the therapy prvider s place f business. Nte: The Request fr Outpatient Physical, Occupatinal, r Speech Therapy (PT, OT, ST) Prir Authrizatin Frm will be available n this website beginning December 2, T submit the prir authrizatin request electrnically, prviders can use the secure TMHP prvider prtal t cmplete the SMPA, Request fr Outpatient Therapy (PT, OT, r ST). T cmplete the prir authrizatin prcess electrnically, the prvider must submit the prir authrizatin requirements dcumentatin thrugh any

7 apprved electrnic methd and must retain a cpy f the prir authrizatin request and all submitted dcumentatin in the client s medical recrd at the therapy prvider s place f business. T avid unnecessary denials, the physician must submit crrect and cmplete infrmatin including dcumentatin f medical necessity fr the service requested. The physician must maintain dcumentatin f medical necessity, including the treatment plan and therapy evaluatin r re-evaluatin, in the client s medical recrd. The physician's riginal signature cpy must be kept in the physician s medical recrd fr the client. The requesting therapy prvider may be asked fr additinal infrmatin t clarify r cmplete a request fr therapy. PT, OT, and ST prcedure cdes that are authrized in 15-minute units will be limited t a cmbined maximum f 4 units (1 hur) per day, per therapy type. Additinal services may be cnsidered with prir authrizatin. If the claims fr therapy services exceed fur units a day, the claim will be denied, but prviders may appeal with all f the fllwing infrmatin: Prvider must identify the authrizatin week perid that includes the date f service being appealed. Attestatin that all therapy services prvided fr the week in questin have been billed. Prvider must indicate they are appealing fr the units in excess f fur per day, but they have nt exceeded their apprved units fr the week. Initial Prir Authrizatin Requests Therapy services may be initiated upn the receipt f the physician s rder. Therapy services initiated befre the date f the physician rder will nt be apprved. The initial request fr prir authrizatin must be received n later than three business days frm the date therapy treatments are initiated. Requests received after the threebusiness-day perid will be denied fr dates f service that ccurred befre the date that the request was received. The fllwing supprting dcumentatin must be submitted fr an initial prir authrizatin request: A cmpleted Request fr Outpatient Physical, Occupatinal, r Speech Therapy (PT, OT, ST) Prir Authrizatin Frm r electrnic equivalent. The request frm must be signed and dated by the rdering physician. If the prir authrizatin frm is nt signed and dated by the physician, the frm must be accmpanied by a written rder r prescriptin that is signed and dated by the physician, r a dcumented verbal rder frm the physician that includes the date the verbal rder was received. Nte: A verbal rder is cnsidered current when the date received is n r n later than 30 days befre the start f therapy. A written rder r prescriptin is cnsidered current when it is signed and dated n r n later than 30 days befre the start f therapy. A request received withut a physician's signature, dcumented verbal rder, r written prescriptin will nt be prcessed and will be returned t the prvider.

8 A current therapy evaluatin that dcuments the client s age at the time f the evaluatin fr each therapy discipline. Nte: A therapy evaluatin is current when it is perfrmed within 30 days befre the initiatin f therapy services A client-specific, cmprehensive treatment plan that is established by the rdering physician r therapist t be fllwed during treatment in the ffice r utpatient setting and includes all f the fllwing: Date and signature f the licensed therapist Diagnsis Treatment gals fr the therapy discipline and assciated disciplines requested that are related t the client s individual needs A descriptin f the specific therapy disciplines being prescribed Duratin and frequency f therapy Date f nset f the illness, injury, r exacerbatin requiring the ffice r utpatient services Requested dates f service Revisins t Existing Prir Authrizatin Requests A prir authrizatin request fr revisins t services may be cnsidered up t the end f the current apprved prir authrizatin. Requests fr revisins t an existing prir authrizatin must be received n later than three business days frm the date the revised therapy treatments are initiated. Requests received after the three-business-day perid will be denied fr dates f service that ccurred befre the date that the request was received. If a prvider r client discntinues therapy during an existing prir authrized perid and the client requests services thrugh a new prvider, the new prvider must submit all f the fllwing: A new Request fr Outpatient Physical, Occupatinal, r Speech Therapy (PT, OT, ST) Prir Authrizatin Frm r electrnic equivalent A new evaluatin with required dcumentatin A change-f-prvider letter signed and dated by the client r respnsible adult dcumenting the date that the client ended therapy (effective date f change) with the previus prvider, the names f the previus and new prviders, and an explanatin f why prviders were changed. A change f prvider during an existing authrizatin perid will nt extend the riginal authrizatin perid apprved t the previus prvider. Regardless f the number f prvider changes, clients may nt receive therapy services beynd the limitatins utlined in this article. Frequency Levels

9 PT, OT, and ST services may be prvided at ne f the fllwing levels cmmensurate with the client's medical cnditin, life stage, and therapy needs that are identified in the dcumentatin submitted: High Frequency: Therapy prvided three r mre times per week may be cnsidered when dcumentatin supprts all f the fllwing: Client has a medical cnditin that is rapidly changing. Client has a ptential fr rapid prgress r rapid decline r lss f functinal skill. The client's therapy plan and hme prgram require frequent mdificatin by the licensed therapist. The client requires a high frequency f interventin fr a limited duratin (60 days r fewer) t recver functin lst due t surgery, illness, r trauma. Hme exercises as the nly methd f interventin wuld be ineffective. Mderate Frequency: Therapy prvided tw times per week is cnsidered when dcumentatin supprts the client meets ne r mre f the fllwing criteria: The client is making functinal prgress tward gals. The client is in a critical perid t restre functin r is at risk f regressin. The licensed therapist needs t adjust the client's therapy plan and hme prgram weekly r mre ften than weekly based n the client's prgress and medical needs. The client has cmplex needs requiring n-ging educatin f the respnsible adult. Lw Frequency: Therapy prvided ne time per week is cnsidered when the dcumentatin shws all f the fllwing: The client is making prgress tward the client s gals, but the prgress has slwed, r the client may be at risk f deteriratin due t the client s medical cnditin. The licensed therapist is required t adjust the client's therapy plan and hme prgram weekly based n the client's prgress. As a client s cnditin imprves and gals are met, it is anticipated the therapist will decrease t a lesser frequency level. Discharge frm therapy is expected when ne f the fllwing ccurs: The client's gals and utcmes have been achieved. Therapy services n lnger prduce a functinal r measurable utcme. The client r respnsible adult declines t participate. The client is unable t prgress tward anticipated gals r expected utcmes because f medical, psychlgical, r scial factrs. The client is n lnger benefiting frm therapy. Nncvered Services

10 The fllwing services will nt be a benefit f Texas Medicaid: Therapy services that are prvided after the client has reached the maximum level f imprvement. Repetitive therapy services that are designed t maintain functin nce the maximum level f imprvement has been reached. Therapy services prvided in daycare and public recreatinal facilities PT, OT, and ST equipment and supplies used during therapy visits are nt reimbursed separately; they are cnsidered part f the therapy services prvided. Therapy services that are related t activities fr the general gd and welfare f clients but are nt cnsidered medically necessary, such as: General exercises t prmte verall fitness and flexibility Activities t prvide diversin r general mtivatin Supervised exercise fr weight lss Therapy that is prescribed fr treatment f behaviral health diagnses nly (These are cnsidered behaviral health cnditins and nt medical cnditins.) Services that are prvided by any f the fllwing: Unlicensed physical therapy aides, interns, rderlies, students, r technicians Unlicensed ccupatinal therapy aides, interns, rderlies, students, r technicians Unlicensed speech-language pathlgy aides, rderlies, students, r technicians Therapy services that are prvided by the respnsible adult fr the client. Respnsible adults include, but are nt limited t, the fllwing: Bilgical, adptive, r fster parents Guardians Curt-appinted managing cnservatrs Other family members by birth r marriage. Prcedure cde The fllwing services are cnsidered investigatinal and experimental: Prcedure cdes 97533, S8940, and S9476 Andyne therapy Devices (such as Therasuit) used in therapy t imprve and change prpriceptin, reductin f client s pathlgical reflexes, restratin f physilgical muscle synergies fr the purpse f nrmalizatin f afferent vestibul-prpriceptive input Cranisacral therapy The fllwing services are cnsidered investigatinal and are nt supprted by evidence-based studies:

11 Interactive metrnme therapy fr the treatment f attentin deficit hyperactivity disrder (ADHD) Cranial electrtherapy stimulatin (CES) (lw electrical vltages delivered t a client) t influence neurtransmitter activity and prductin f sertnin and dpamine fr ADHD Lw-energy neurfeedback system (LENS) with the gal f teaching a client t prduce brain-wave patterns that reflect fcus and enhance the brain's ability t adapt t a task fr ADHD Wrking memry exercises with the gal f imprving fluid intelligence qutient (IQ) and increasing the ability t slve prblems r adapt t situatins as they ccur Lycra splints and suits used t imprve prximal stability and functin in clients with cerebral palsy PT r OT fr the treatment f ADHD Functinal electrical stimulatin (FES), when used t prmte ambulatin in ther than spinal crd injury (SCI), and threshld electrical stimulatin (TES) as a treatment f mtr disrders, including, but nt limited t, cerebral palsy r sclisis (These are cnsidered investigatinal and nt medically necessary.) Applied behavir analysis (ABA), als called early intensive behaviral interventin (EIBI), when perfrmed by a physical r ccupatinal therapist fr the treatment f attentin deficit disrder (ADD), ADHD, r autism spectrum disrders (ASD). These are nt supprted by evidence-based studies. Fr mre infrmatin, call TMHP Cntact Center at