Updated PT, OT, and ST Benefit Changes for Acute Services for Texas Medicaid Effective January 1, 2014

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1 Updated PT, OT, and ST Benefit Changes fr Acute Services fr Texas Medicaid Effective January 1, 2014 Infrmatin psted December 31, 2013 Nte: This article applies t claims submitted t TMHP fr prcessing. Fr claims prcessed by a Medicaid managed care rganizatin (MCO), prviders must refer t the MCO fr infrmatin abut benefits, limitatins, and reimbursement. This is an update t an article titled PT, OT, and ST Benefits t Change fr Acute Services fr Texas Medicaid, which was published n this website n Nvember 15, The benefit changes that will implement n January 1, 2014, have changed. The fllwing is the cmplete updated article, which identifies the benefit changes that will be implemented n January 1, This updated article replaces the riginal article that was published n Nvember 15, Therapy is cnsidered acute fr 180 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. Therapy evaluatins are a benefit nce per 180 rlling days, any prvider. Therapy reevaluatins are a benefit when dcumentatin supprts ne f the fllwing: A change in the client s status A request fr extensin f services A change f prvider Additinal therapy 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 the client ended therapy (effective date f change) with the previus prvider The names f the previus and new prviders An explanatin why prviders were changed All dcumentatin that is related t the therapy services that are prir authrized and prvided, including medical necessity and 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

2 Prir Authrizatin PT, OT, and ST evaluatins r re-evaluatins, when prvided with the limits utlined in this article, will nt require prir authrizatin. PT, OT, and ST prvided in the ffice r utpatient setting will require prir authrizatin. Prir authrizatin fr individual therapy services will be cnsidered when all f the fllwing criteria are met: The client has an acute cnditin r an acute exacerbatin f a chrnic medical cnditin resulting in a significant decrease in functinal ability that will benefit frm therapy services in an ffice r utpatient setting. Dcumentatin supprts treatment gals and utcmes fr the specific therapy disciplines requested. Services d nt duplicate thse that are prvided cncurrently by any ther therapy. Services are within the prvider s scpe f practice, as defined by state law. 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). Cverage perids d nt necessarily cincide with calendar weeks r mnths, but instead cver a number f services t be scheduled between a start date 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 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) Special Medical 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. 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 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

3 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. Prvider must attest that all therapy services prvided fr the week in questin have been billed. 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 mre than three business days frm the date therapy treatments are initiated. Requests that are 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) Special Medical 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 mre than 60 days befre the start f therapy. A written rder r prescriptin is cnsidered current when it is signed and dated n r n mre than 60 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. Nte: Prir authrizatin requests that were submitted t the TMHP Prir Authrizatin Department using the previusly published Request fr Outpatient Physical, Occupatinal, r Speech Therapy (PT, OT, ST) Prir Authrizatin frm will be cnsidered n a case-bycase basis. 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.

4 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 Subsequent Prir Authrizatin Requests A prir authrizatin request fr subsequent services must be received within 30 days befre the current authrizatin expires. Requests fr subsequent services that are received after the current prir authrizatin expires will be denied fr dates f service that ccurred befre the date the submitted request was received. Prir authrizatin requests fr subsequent services may be cnsidered fr increments up t 90 days fr each request with dcumentatin that supprts medical necessity and includes all f the fllwing: A new cmpleted Request fr Outpatient Physical, Occupatinal, r Speech Therapy (PT, OT, ST) Special Medical Prir Authrizatin Frm that has been 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 mre than 60 days befre the start f therapy. A written rder r prescriptin is cnsidered current when it is signed and dated n r n mre than 60 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. A current therapy evaluatin r re-evaluatin fr each therapy discipline that dcuments the client s age at the time f the evaluatin r re-evaluatin. A therapy evaluatin r re-evaluatin is current when it is perfrmed within 30 days befre the request fr subsequent services An updated, client-specific cmprehensive treatment plan that was established by the rdering physician r therapist t be fllwed during treatment in the ffice r utpatient setting must include all f the fllwing: Date and signature f the licensed therapist Diagnsis(es)

5 Updated treatment gals that are related t the client s individual needs fr the therapy discipline and assciated disciplines requested A descriptin f the specific therapy disciplines that are being prescribed Duratin and frequency f therapy Date f nset f the illness, injury, r exacerbatin that requires the ffice r utpatient hspital services A brief summary f the utcmes f the previus treatment as it relates t the client s debilitating cnditin 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 mre than three business days frm the date that the revised therapy treatments are initiated. Requests that are 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) Special Medical 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 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 a 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.

6 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. Mderate Frequency: Therapy prvided tw times a week may be cnsidered when dcumentatin supprts 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 may be cnsidered when the dcumentatin supprts ne r mre 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. Fr mre infrmatin, call TMHP Cntact Center at