Therapy guidelines. Diagnosis. Revised October Therapy guidelines asuris.com. Asuris Administrative Manual

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1 Therapy guidelines The guidelines in this sectin are subject t individual plan benefits and may nt apply t every member. Please access the Availity Web Prtal at availity.cm t verify patient cverage, benefit types and eligibility effective dates. The fllwing treatment plan infrmatin applies t all therapy prviders: Treatment plans and prgress ntes may be requested fr selected members. We reserve the right t review past recrds and claims submissins t determine whether member cntract criteria are met fr cverage f physical therapy under the member s utpatient rehabilitatin benefit. We require fully dcumented treatment plans include the fllwing: I. Apprpriate and legible chart nte dcumentatin II. III. IV. Physician prescriptin r referral Dcumentatin f functinal limitatins and therapy gals Prgress reprts and/r ntes which supprt the fllwing: Patients prgress tward meeting therapy gals. Diagnsis r diagnses must supprt the level f care prvided. Medical necessity f the care prvided must be demnstrated and may be subject t review. Prcedures perfrmed must be within the scpe f license as defined by either the Revised Cde f Washingtn, Washingtn Administrative Cde, r the gverning Quality Assurance Cmmissin. Prescriptins and referrals When a prvider prescribes physical therapy, they must include the accident infrmatin n the prescriptin and, if applicable, the referral. The prescribing prvider must als include a plan f treatment and the length f treatment. A new prescriptin must be n file when extending treatment beynd the dates n the riginal prescriptin. When the treating physical therapist submits a claim, whether paper r electrnic, it is nt necessary t submit the patient s prescriptin. We d require the prescriptin t be n file in yur ffice. Maintenance therapy Maintenance Therapy means a treatment plan that seeks t prevent disease, prmte health, and prlng and enhance the quality f life r therapy that is perfrmed t maintain r prevent deteriratin f a chrnic cnditin. Once the maximum therapeutic benefit has been achieved fr a given cnditin, any additinal therapy prvided is cnsidered maintenance therapy. Nte: Mst f ur plans exclude cverage fr maintenance therapy. Infrmatin needed n a claim When submitting claims, speech therapists must include the fllwing infrmatin n the claim frm: Diagnsis Revised Octber Therapy guidelines

2 Date f nset Name f the prescribing r referring prvider Licensed massage therapy is lcated in the Alternative care sectin f this manual. Physical therapy Cverage fr physical therapy is limited t rehabilitatin, when medically necessary t restre r imprve functin that was previusly nrmal but was lst due t dcumented injury r illness. Sme cntracts als cver physical therapy fr rehabilitatin, when medically necessary t restre and imprve functin lst as a result f cngenital anmalies. All prviders wh perfrm r refer members fr physical therapy shuld use the fllwing guidelines. Chirpractic manipulatin cdes are nly payable t chirpractrs. CPT cdes fr casting and strapping are payable t physical therapists. Ostepathic manipulatin cdes are nly payable t MD s, DO s, ARNPs and ND s. CPT cdes, such as evaluatin and management cdes, are nt payable t physical therapists. We d nt recgnize wrk hardening/cnditining services fr physical therapy. All licensed prviders must bill fr any and all services they perfrm under their wn name. Miscellaneus CPT cdes used fr unlisted mdalities shuld include narrative descriptins fr the therapeutic prcedures and physical medicine/rehabilitatin services and shuld nly be used when a mre apprpriate cde is nt available. Physical therapy evaluatins and re-evaluatins: An evaluatin is allwed nce, per member, per cnditin and per tax id. A re-evaluatin is allwed nce, every tw weeks, per member, per cnditin and per tax ID. Physical therapy assistants We reimburse physical therapists fr the use f physical therapy assistants and aides as lng as it is in accrdance with Washingtn state regulatins. The actual name f the physical therapy assistant and supervising physical therapist must be clearly dcumented in the patient s file. Services fr physical therapy assistants and aides are allwed as lng as the supervising physical r ccupatinal therapist bills the services under his/her wn name. Exceptins: Physical therapy services cvered by the Federal Emplyee Prgram (FEP) are paid nly when perfrmed by LPTs and RPTs. The physical therapy assistant r aide cannt be anther licensed prvider. All licensed prviders must bill fr any and all services they perfrm under their wn name. Revised Octber Therapy guidelines

3 Supplies Supplies and materials are nt separately reimbursed. Supplies prvided by the physical therapist and used during the therapy sessin are nt cvered. These are cnsidered part f yur peratinal verhead. Supplies sent hme that are prvided but used utside the therapy sessin may be paid accrding t member plan benefits. Use a valid CPT/HCPCS cde fr supplies. Dcument the type f supply, the quantity yu purchased and cst f the supply. CPT is nt accepted by us and will be denied as included in the primary prcedure. If there is n HCPCS cde that adequately describes the supply yu are billing, please use the apprpriate unlisted HCPCS cde(s) with a specific descriptin f the supply included n the claim. Services nt cvered Clean-up Recrd-keeping Reprt-writing csts Treatment preparatin Member transprtatin Patient care cnferences Unattended gym r swim therapy Accidental injury Injury claims must include the fllwing: Date f injury Cause r surce f injury Where the injury tk place Whether the injury is related t an aut accident r emplyment Occupatinal therapy Cverage fr ccupatinal therapy is limited t rehabilitatin, when medically necessary t restre and imprve functin that was previusly nrmal but was lst fllwing a dcumented injury r illness. Sme cntracts als cver ccupatinal therapy fr rehabilitatin, when medically necessary t restre and imprve functin lst as a result f cngenital anmalies. Chirpractic manipulatin cdes are nly payable t chirpractrs. CPT cdes fr casting and strapping are payable t ccupatinal therapists. Revised Octber Therapy guidelines

4 Ostepathic manipulatin cdes are nly payable t MD s, DO s, ARNP s and ND s. CPT cdes, such as evaluatin and management cdes, are nt payable t ccupatinal therapists. We d nt recgnize wrk hardening/cnditining services fr ccupatinal therapy. All licensed prviders must bill fr any and all services they perfrm under their wn name. Miscellaneus CPT cdes used fr unlisted mdalities shuld include narrative descriptins fr the therapeutic prcedures and physical medicine/rehabilitatin services and shuld nly be used when a mre apprpriate cde is nt available. Occupatinal therapy evaluatins and re-evaluatins: An evaluatin is allwed nce, per member, per cnditin, and per tax ID. A re-evaluatin is allwed nce, every 2 weeks, per member, per cnditin, and per tax ID. Nt all plans prvide benefits fr ccupatinal therapy. Sme plans exclude cverage fr ccupatinal therapy services fr all cnditins. Sme plans exclude services fr ccupatinal injury r disease, including thse arising ut f self-emplyment. Occupatinal therapy assistants We reimburse ccupatinal therapists fr the use f ccupatinal therapy assistants and aides as lng as it is in accrdance with Washingtn state regulatins. The actual name f the ccupatinal therapy assistant and supervising ccupatinal therapist must be clearly dcumented in the member s file. This means we allw the services f ccupatinal therapy assistants and aides as lng as the supervising ccupatinal therapist bills the services under their wn name. Exceptins: Occupatinal therapy services cvered by the FEP are paid nly when perfrmed by an OTR, LPTs and RPTs. The ccupatinal therapy assistant r aide cannt be anther licensed prvider. All licensed prviders must bill fr any and all services they perfrm under their wn name. Supplies Supplies and materials are nt separately reimbursed. Supplies prvided by the ccupatinal therapist and used during the therapy sessin are nt cvered. These are cnsidered part f yur peratinal verhead. Supplies sent hme that are prvided but used utside the therapy sessin may be paid accrding t member plan benefits. Use a valid CPT/HCPCS cde fr supplies. Dcument the type f supply, the quantity yu purchased and cst f the supply. Revised Octber Therapy guidelines

5 CPT is nt accepted by us and will be denied as included in the primary prcedure. If there is n HCPCS cde that adequately describes the supply yu are billing, please use the apprpriate unlisted HCPCS cde(s) with a specific descriptin f the supply included n the claim. Accidental injury Injury claims must include the fllwing: Date f injury Cause r surce f injury Where the injury tk place Whether the injury is related t an aut accident r emplyment When the treating ccupatinal therapist submits a claim, whether paper r electrnic, it is nt necessary t submit the patient s prescriptin. We d require the prescriptin t be n file in yur ffice. Speech therapy Cverage fr speech therapy is limited t rehabilitatin when medically necessary t restre and imprve functin that was previusly nrmal but was lst fllwing a dcumented injury r illness. Sme cntracts als cver speech therapy fr rehabilitatin, when medically necessary t restre and imprve functin lst as a result f cngenital anmalies. All prviders wh perfrm r refer members fr speech therapy shuld use the fllwing guidelines. Grup speech therapy is als a cvered service. Submit claims using the apprpriate CPT prcedure cde. Individual speech therapy is allwed up t tw units f service, per date f service. CPT cdes, such as evaluatin and management are nt payable t speech practitiners. Medical evaluatins fr speech, language, and hearing prblems are allwed tw units f service, per date f service. All licensed prviders must bill fr any and all services they perfrm under their wn name. Services nt cvered Medical cnditins that are rutinely excluded fr speech therapy are: Harseness Speech delay Tngue thrust Stammering and stuttering Develpmental articulatin errrs Revised Octber Therapy guidelines

6 Hysterical aphnia (lss f speech) Psychneurtic r psychtic cnditins Functinal dysphnia (difficulty f speech) Neurdevelpmental therapy Mst grup prducts include benefits fr medically necessary neurdevelpment therapy treatment t restre and/r imprve functin fr children age six and under. Benefits include the services f a participating physician, physical therapist, speech pathlgist, (r recgnized ccupatinal therapist, depending n the member s health plan) prvided in the ffice, hme r hspital utpatient department. All prviders wh perfrm r refer patients fr neurdevelpmental therapy shuld use the fllwing guidelines. Submit claims using the apprpriate CPT prcedure cde. Member des nt need t have an underlying illness r injury t qualify fr the neurdevelpmental benefit. Maintenance therapy is cvered under the neurdevelpmental benefit fr preventing significant deteriratin in the member s cnditin. As determined by us, the member is nt eligible fr the neurdevelpmental benefit and the rehabilitatin benefit fr the same cnditin. All licensed prviders must bill fr any and all services they perfrm under their wn name. Services nt cvered Custdial care Nn-medical help Mental disrder care Rehabilitative treatment Patient care cnferences Unattended gym r swim therapy Chemical dependency treatment Maintenance (except as specified abve) Recreatinal, educatinal r vcatinal therapy Revised Octber Therapy guidelines