CHAPTER 13 THERAPY SERVICES

CHAPTER 13 THERAPY SERVICES 13.1. Introduction Therapy services can be a crucial component in assisting DMRS service recipients to develop or maintain the skills and abilities needed to achieve outcomes identified in the Individual Support Plan (ISP). This chapter provides information about therapy services that are provided and funded through Medicaid HCBS waivers or state-funded DMRS programs. Therapy services provided through a Medicaid waiver and other DMRSfunded programs are not intended to replace the services that are covered by a service recipient s TennCare managed care organization (MCO) or by Medicare or private health insurance. The TennCare MCO is required to cover therapy services as medically necessary in accordance with the TennCare MCO contract. The TennCare MCO contract is available on the TennCare website (see Appendix F). The TennCare MCO generally provides therapy services needed when a service recipient has an acute illness or injury or when therapy services are needed following a significant medical event, such as surgery. If a service recipient is enrolled in a Medicaid waiver or other DMRS-funded programs and experiences an acute issue requiring therapy services, funding for such services that is available through Medicare, the TennCare MCO or private insurance must be accessed and utilized before Medicaid waiver or other DMRS-funded therapy services will be provided or resumed. 13.2. Waiver Definition for Physical Therapy The waiver definition shall apply to all physical therapy services provided in a Medicaid waiver. The waiver definition shall also be used to define physical therapy services provided in other DMRS-funded programs. The waiver definition for physical therapy services approved by the Centers for Medicaid and Medicare Services (CMS) is: Physical Therapy: Physical therapy shall mean diagnostic, therapeutic and corrective services which are within the scope of state licensure. Physical Therapy services provided to improve or maintain current functional abilities as well as prevent or minimize deterioration of chronic conditions leading to a further loss of function are also included within this definition. Services must be provided by a licensed physical Provider Manual, Chapter 13 Therapy Services 13-1

therapist or by a licensed physical therapist assistant working under the supervision of a licensed physical therapist. Physical Therapy must be ordered by a physician, physician assistant or nurse practitioner and must be provided face-to-face with the enrollee. Physical Therapy therapeutic and corrective services shall not be ordered concurrently with Physical Therapy assessments (i.e., assess and treat orders are not accepted). Physical Therapy shall be provided in accordance with a treatment plan developed by a licensed physical therapist based on a comprehensive assessment of the enrollee s needs and shall include specific functional and measurable therapeutic goals and objectives. The goals and objectives shall be related to provision of Physical Therapy to prevent or minimize deterioration involving a chronic condition which would result in further loss of function. Continuing approval of Physical Therapy services shall require documentation of reassessment of the enrollee s condition and continuing progress of the enrollee toward meeting the goals and objectives. Physical Therapy shall not be billed when provided during the same time period as Occupational Therapy; Speech, Language and Hearing Services; Nutrition Services, Orientation and Mobility Training; or Behavior Services, unless there is documentation in the enrollee s record of medical justification for the two services to be provided concurrently. Physical Therapy shall not be billed with Day Services if the Day Services are reimbursed on a per hour basis. Physical Therapy is not intended to replace services that would normally be provided by direct care staff. Physical Therapy services are not intended to replace services available through the Medicaid State Plan/TennCare program or services available under the Rehabilitation Act of 1973 or Individuals with Disabilities Education Act. To the extent that such services are covered in the Medicaid State Plan/TennCare Program, all applicable Medicaid State Plan/TennCare Program services shall be exhausted prior to using the waiver service. Physical Therapy assessments shall be limited to a maximum of 3.0 hours per enrollee per day, and other Physical Therapy services shall be limited to a maximum of 1.5 hours per enrollee per day. Physical Therapy assessments shall not be billed on the same day with other Physical Therapy services. 13.3. Waiver Definition for Occupational Therapy The waiver definition shall apply to all occupational therapy services provided in a Medicaid waiver. The waiver definition shall also be used to define occupational therapy services provided in other DMRS-funded programs. The waiver definition for occupational therapy services approved by the CMS is: Provider Manual, Chapter 13 Therapy Services 13-2

Occupational Therapy: Occupational Therapy shall mean diagnostic, therapeutic and corrective services which are within the scope of state licensure. Occupational Therapy services provided to improve or maintain current functional abilities as well as prevent or minimize deterioration of chronic conditions leading to a further loss of function are also included within this definition. Services must be provided by a licensed occupational therapist or by a licensed occupational therapist assistant working under the supervision of a licensed occupational therapist. Occupational Therapy must be ordered by a physician, physician assistant or nurse practitioner and must be provided face-to-face with the enrollee. Occupational Therapy therapeutic and corrective services shall not be ordered concurrently with Occupational Therapy assessments (i.e., assess and treat orders are not accepted). Occupational Therapy shall be provided in accordance with a treatment plan developed by a licensed occupational therapist based on a comprehensive assessment of the enrollee s needs and shall include specific functional and measurable therapeutic goals and objectives. The goals and objectives shall be related to provision of Occupational Therapy to prevent or minimize deterioration involving a chronic condition which would result in further loss of function. Continuing approval of Occupational Therapy services shall require documentation of reassessment of the enrollee s condition and continuing progress of the enrollee toward meeting the goals and objectives. Occupational Therapy shall not be billed when provided during the same time period as Physical Therapy; Speech, Hearing and Language Services; Nutrition Services, Orientation and Mobility Training, or Behavior Services, unless there is documentation in the enrollee s record of medical justification for the two services to be provided concurrently. Occupational Therapy shall not be billed with Day Services if the Day Services are reimbursed on a per hour basis. Occupational Therapy is not intended to replace services that would normally be provided by direct care staff. Occupational Therapy services are not intended to replace services available through the Medicaid State Plan/TennCare program or services available under the Rehabilitation Act of 1973 or Individuals with Disabilities Education Act. To the extent that such services are covered in the Medicaid State Plan/TennCare Program, all applicable Medicaid State Plan/TennCare Program services shall be exhausted prior to using the waiver service. Occupational Therapy assessments shall be limited to a maximum of 3.0 hours per enrollee per day, and other Occupational Therapy services shall be limited to a maximum of 1.5 hours per enrollee per day. Occupational Therapy assessments shall not be billed on the same day with other Occupational Therapy services. Provider Manual, Chapter 13 Therapy Services 13-3

13.4. Waiver Definition for Speech, Language and Hearing Services The waiver definition shall apply to all speech, language and hearing services provided in a Medicaid waiver. The waiver definition shall also be used to define speech, language and hearing services provided in other DMRS-funded programs. The waiver definition for speech, language and hearing services approved by the CMS is: Speech, Language and Hearing Services: Speech, Language and Hearing Services shall mean diagnostic, therapeutic and corrective services which are within the scope of state licensure which enable an enrollee to improve or maintain current functional abilities and to prevent or minimize deterioration of chronic conditions leading to a further loss of function. Services must be provided by a licensed speech language pathologist or by a licensed audiologist. Speech, Language and Hearing Services must be ordered by a physician, physician assistant or nurse practitioner and must be provided face to face with the enrollee. Speech, Language and Hearing therapeutic and corrective services shall not be ordered concurrently with Speech, Language and Hearing assessments (i.e., assess and treat orders are not accepted). Speech, Language and Hearing Services shall be provided in accordance with a treatment plan developed by a licensed speech language pathologist or a licensed audiologist based on a comprehensive assessment of the enrollee s needs and shall include specific functional and measurable therapeutic goals and objectives. The goals and objectives shall be related to provision of Speech, Language and Hearing Services to prevent or minimize deterioration involving a chronic condition which would result in further loss of function. Continuing approval of Speech, Language and Hearing Services shall require documentation of reassessment of the enrollee s condition and continuing progress of the enrollee toward meeting the goals and objectives. Speech, Language and Hearing Services shall not be billed when provided during the same time period as Physical Therapy, Occupational Therapy, Nutrition Services, Orientation and Mobility Training or Behavior Services, unless there is documentation in the enrollee s record of medical justification for the two services to be provided concurrently. Speech, Language and Hearing Services shall not be billed with Day Services if the Day Services are reimbursed on a per hour basis. Speech, Language and Hearing Services are not intended to replace services that would normally be provided by direct care staff or to replace services available through the Medicaid State Plan/TennCare program. To the extent that such services are covered in the Medicaid State Plan/TennCare Program, all applicable Medicaid State Plan/TennCare Program services shall be exhausted prior to using the waiver service. Provider Manual, Chapter 13 Therapy Services 13-4

Speech, Language and Hearing Services assessments shall be limited to a maximum of 3.0 hours per enrollee per day, and other Speech, Language and Hearing Services shall be limited to a maximum of 1.5 hours per enrollee per day. Speech, Language and Hearing Services assessments shall not be billed on the same day with other Speech, Language and Hearing Services. 13.5. Licensure Requirements As indicated in the waiver definitions above, therapy services must be provided by or under the supervision of a licensed physical therapist or occupational therapist, or by a licensed speech language pathologist or audiologist. Therapists with a temporary license are not allowed to provide therapy services in the DMRS system. Licensed professionals providing therapy services must either be employed or contracted by a licensed home care organization (either a traditional home health agency or a professional support services provider) or be an individual practitioner who has obtained licensure to provide professional support services. Licensure is obtained from the Tennessee Department of Health (see contact information in Appendix B). Reimbursement will not be provided for periods during which licensure has lapsed. 13.5.a. Services Provided by Therapy Assistants and Aides: Reimbursement will not be provided for therapy assistants who are not adequately supervised by a licensed therapist in accordance with professional practice acts and professional standards (see Section 13.5.c.). Reimbursement will not be provided for services rendered by physical therapy or occupational therapy aides. 13.5.b. Services Provided by Clinical Fellows or Students: Reimbursement will not be provided for services rendered by individuals completing clinical fellowships in speech language pathology or audiology or for students in the therapy field. 13.5.c. Supervision of Physical and Occupational Therapy Assistants: The waiver will reimburse providers for the services of a physical or occupational therapy assistant when such services are provided under the direction/supervision of a licensed physical or occupational therapist. Time required to supervise a therapy assistant has been addressed when setting the rates for reimbursement of therapy assistant services. Consequently, reimbursement for time spent supervising a therapy assistant will not be provided. When services are provided concurrently by a therapist and a therapy assistant, reimbursement will be provided for the services of only one of the professionals, either the therapist or the therapy assistant. To direct/supervise a therapy assistant, the licensed therapist must document: 1) Instructing and supporting the therapy assistant; Provider Manual, Chapter 13 Therapy Services 13-5

2) Monitoring the therapy assistant s provision of services; 3) On-site observation of the therapy assistant s treatment and evaluating the appropriateness of the treatment a minimum of every sixty (60) calendar days or more frequently as needed; 4) Providing follow-up with the therapy assistant regarding recommendations resulting from the supervisory visit; 5) Complying with any other supervisory requirements specified in the Rules of Tennessee Board of Occupational and Physical Therapy Examiner s Committee of Physical Therapy Division of Health Related Boards, Chapter 1150-1, General Rules Governing the Practice of Physical Therapy and General Rules Governing the Practice of Occupational Therapy; and 13.6. Other Requirements for Therapy Services Therapy services will be approved and/or reimbursed only if licensure requirements (see Section 13.5.) are met and services are provided in accordance with the waiver service definitions provided in previous sections. This section provides additional information regarding requirements for therapy services. 13.6.a. Physician Order Requirement: Therapy services will not be approved without a physician s order and reimbursement will not be provided for therapy services rendered without an order from a physician, physician s assistant or nurse practitioner. Physician s orders must include the amount, frequency and duration of the service to be provided. Assess and treat orders will not be accepted. An order must be obtained for the therapy assessment. When recommendations based upon the therapy assessment are available, an order must be obtained for therapy services to be provided based upon the medical practitioner s review and determination of whether the recommendations are appropriate and medically necessary. 13.6.b. Face-to-Face Requirement: Approval will be granted for units of time spent providing direct services to an individual. Documenting provision of such services is considered a part of the service. Rates for therapy services are inclusive of the time required for documentation and other administrative activities. Consequently, additional reimbursement is not provided for units of time spent in documentation, whether the documentation is done at the service delivery site or in the therapist s office or home. 13.6.c. Plan of Care Requirements: The therapy plan described in the waiver service definition must be aligned with the action steps and outcomes specified in an approved ISP. The therapy plan must be developed in accordance with the planning process described in Chapter 3. Provider Manual, Chapter 13 Therapy Services 13-6

13.6.d. Provision of Concurrent Services (Co-treatment): Reimbursement will not be made for certain services provided during the same time period unless there is adequate justification documented in the therapy record to support the need for co-treatment. Cotreatment may involve different therapy services, such as occupational therapy, physical therapy and/or speech/language and hearing services. Co-treatment may also apply to the provision of therapy services during the same time as other clinical services, such as behavioral services, nutrition services, orientation and mobility training or nursing services. There must be documentation of the medical necessity to justify the provision of the services concurrently. For example, a physical therapist may be needed to position an individual properly in a side-lyer while a speech language pathologist provides trials of food in this position and assesses the individual s tolerance to the feeding based on physical signs and oxygen saturation levels during the trials. While orders must be obtained for each of the clinical services to be concurrently provided, a specific order to co-treat or provide the services at the same time is not required. Co-treatment does not specifically have to be specified in the ISP; however, each of the services to be provided concurrently must be included. Co-treatment is a intervention or mechanism for addressing or achieving an outcome and is not a goal or outcome in and of itself. 13.6.e. Utilization of Therapy Services: Therapy services are to be utilized to perform functions which contribute to the action steps and outcomes specified in the ISP that cannot be provided by persons other than licensed therapy professionals. Therapy services will not be approved or reimbursed if the activities that need to be completed with the service recipient could be safely performed by direct support staff. Therapy services may be utilized to: 1) Assess service recipient functional abilities and limitations in light of the achievement of action steps and outcomes in the ISP and make recommendations as to how the implementation of a therapy plan could expedite meeting action steps and outcomes or help in overcoming functional barriers; 2) Assess the need for adaptive equipment/assistive technology in light of the action steps and outcomes in the ISP; 3) Develop a therapy plan of care with input from the Circle of Support, including the service recipient s legal representative; 4) Seek input in developing the therapy plan of care from direct support staff and other service providers as appropriate; 5) Assist in converting therapy recommendations to staff instructions that are integrated with the service recipient s daily activities; 6) Provide competency-based training to facilitate direct support staff implementation of any staff instructions provided; Provider Manual, Chapter 13 Therapy Services 13-7

7) Provide training to ensure proper use of adaptive equipment/assistive technology when training is needed beyond that which is provided by the manufacturer or supplier of the equipment; 8) Provide direct hands-on therapy services to develop, improve or maintain skills related to ISP action steps that cannot be accomplished/implemented by direct support staff. 13.6.f. Non-Reimbursable Activities: Reimbursement will not be provided for: 1) Time spent in the community with a service recipient when no skilled services are provided and/or no therapeutic goals are identified (e.g., watching a service recipient participate in activities such as bowling, watching a sporting event with a service recipient, going shopping with a service recipient or riding in a van with the service recipient). 2) Time spent waiting for a service recipient to arrive at the location where therapy services are to be provided; 3) Time spent performing administrative functions such as documentation, staff supervision, telephone conversations, etc.; 4) Time spent traveling to and from sites to locate a service recipient who is scheduled to receive therapy services; 5) Ongoing range of motion provided by a therapist that does not result in measurable functional change in an activity of daily living within a reasonable time period (i.e. two to four months); 6) Endurance activities that are not related to improvement of a functional skill or identified ISP outcome; 7) Range of motion activities or endurance-related activities that could be provided by direct support staff; 8) Ambulation of a service recipient who has an established functional gait pattern; 9) Time spent determining an appropriate communication system without specific documentation showing measurement/evaluation of the outcome of trials and practice sessions; 10) Sensory-based or other activities that are not linked to ISP action steps; 11) Activities related to implementation of an exercise or weight loss program that could be supervised by direct support staff; 12) Ongoing services to facilitate participation in fitness-related leisure activities such as gym work-outs, martial arts, bowling, playing games, walking in the park, shopping mall, library, museum, etc. that could be supervised by direct support staff; 13) Unjustified or excessive time spent monitoring implementation of staff instructions without analyzing measurable data; Provider Manual, Chapter 13 Therapy Services 13-8

14) Services or intermittent assessments not supported by the original assessment and included in the ISP; and 15) Services provided in a Intermediate Care Facility for the Mentally Retarded (ICF/MR), Skilled Nursing Facility (SNF), local K 12 educational facility or other federally funded program. 13.6.g. Continuation of Therapy Services: Therapy services are generally approved for a time-limited period that may be based upon a physician s order or upon a therapy practitioner s estimation of the time required to achieve the therapeutic outcomes specified in the therapy plan of care and ISP. If additional time is needed beyond the period of approval originally obtained, a new service authorization request must be submitted. Continued approval of and reimbursement for therapy services will require documentation that the service recipient s condition has been reassessed and that progress toward meeting individual outcomes is ongoing. 13.7. Limits on Units of Service A limit has been established on the number of units of each therapy service that may be provided and reimbursed during a day. The limits are based upon utilization history and upon the amount of direct therapy service that a service recipient would typically be able to tolerate in a single session. Additional time is allowed for assessment to ensure that assessments are completed with expediency so that the service recipient s therapy needs may be addressed as soon as possible. 13.7.a. Reimbursement of Direct Face-to-Face Therapy Services: Reimbursement may be authorized for provision of each direct therapy service specified in the ISP, including the training of direct support staff by licensed therapists, for up to one and onehalf (1.5) hours per enrollee per day. 13.7.b. Reimbursement of Therapy Assessments: Reimbursement of face-to-face therapy assessments will be provided for up to three (3) hours per day for the purpose of performing therapy assessments. 13.8. Establishing the Need for a Therapy Assessment The need for a therapy assessment may arise when: 1) Other assessments, such as the uniform assessment, risk assessment or Physical Status Review (PSR) indicate the need for further evaluation; 2) A health/safety issue is identified that requires a particular type of therapy assessment to achieve appropriate resolution; or Provider Manual, Chapter 13 Therapy Services 13-9

3) A service recipient cannot accomplish a particular action step or outcome and therapy assessment and recommendations are warranted to determine recommendations for potential changes to the ISP which could result in achievement of actions steps or outcomes. 13.8.a. Indicators for Occupational Therapy Assessment: An occupational therapy assessment may be justified when a service recipient has issues, limitations or decline in functional abilities related to: 1) Home management and leisure activities; 2) Mealtime difficulties (e.g., difficulty eating, choking, signs of aspiration, poor positioning or the need for adaptive equipment); 3) Difficulty getting on or off the toilet or in and out of the bathtub or shower; 4) Poor oral hygiene; 5) Limited use of the hands; 6) Contractures or decreased range of motion of the shoulders, arms or hands; 7) Sensory processing issues (e.g., self-injurious behavior, self-stimulating behavior, difficulty transitioning from one location to another, touch avoidance or sensitivity to sounds, lights or smells); 8) Accessibility issues in the home, workplace or community; or 9) Vocational needs. 13.8.b. Indicators for Physical Therapy Assessment: A physical therapy assessment may be justified when a service recipient has issues, limitations or decline in functional abilities related to: 1) Difficulty transferring from one surface to another, such as from a wheelchair to the bed; 2) Inability to be mobile without physical assistance; 3) Difficulty moving from a sitting to a standing position; 4) Improperly fitting equipment; 5) Inability to move adequately to alternate positions; 6) Skin breakdown resulting from limited mobility; 7) Unsteady gait or changes in walking pattern; 8) Falls or near falls; 9) Chronic physical impairments, contractures or muscular tightening; or 10) Limited movement due to pain. Physical therapy assessment may also be indicated when an environmental accessibility evaluation is needed or when there is frequent occurrence of staff injuries resulting from providing assistance with transfers or mobility. Provider Manual, Chapter 13 Therapy Services 13-10

13.8.c. Indicators for Speech Language Assessment: A speech language assessment may be justified when a service recipient has issues such as: 1) Difficulty chewing or swallowing, eating too fast, loss of food/fluid from the mouth or pocketing food in the mouth; 2) Signs of aspiration including gagging, wheezing, coughing, choking, persistent drooling, wet vocal quality, changes in breathing during or after meals, refusal of fluid/liquids, frequent upper respiratory infections and/or aspiration pneumonia; 3) Difficulty or frustration with trying to make others understand what is being communicated, including difficulty making wants and needs known, inability to make choices and/or inability to voice opinions; 4) Difficulty communicating with new people or in new environments; 5) Discrepancy between receptive and expressive language skills (i.e., ability to understand exceeds ability to express); or 6) Social skills deficits (e.g., inappropriate use of affection, inappropriate use of words, inability to take turns or inappropriate behaviors related to inability to make self understood). 13.8.d. Indicators for Hearing Assessment: A hearing assessment may be justified when a service recipient has issues such as: 1) Being unresponsive to auditory cues such as speech, slamming doors, car horns, etc.; 2) Turning the head to favor a particular ear when spoken to; 3) Requesting that things be repeated very frequently; 4) Watching for facial cues when spoken to; 5) Being unable to follow verbal directions; 6) Turning the television up too loud; 7) Pulling or rubbing ears when spoken to; 8) Complaining of or showing signs of dizziness; 9) Complaining of ringing in the ears; 10) Complaining of or exhibiting sudden hearing loss or deafness; 11) Hypersensitivity to certain noises or keeping the hands over the ears when certain noises are encountered; 12) Having a hearing aid that is not used, previous use of a hearing aid that is not currently in the service recipient s possession or complaining that an available hearing aid does not help; 13) Having malformed ear lobes or ear canals; 14) Having history of ear infections or fluid behind the eardrum; 15) Having history of cerumen (ear wax) buildup; Provider Manual, Chapter 13 Therapy Services 13-11

16) Having drainage from the ear(s); 17) Having a history of previously identified hearing loss; or 18) Normal aging processes that result in decreased hearing function. 13.9. Assessing Durable Medical Equipment and Assistive Technology Needs Service recipients may require durable medical or assistive technology equipment such as wheelchair seating systems, positioning aids, hearing aids, communication devices, specialized dishes or utensils, etc. to ensure health/safety, improve independence or overcome barriers to outcome achievement (see Chapter 14, Section 14.2 for the waiver definition and requirements related to durable medical equipment and assistive technology equipment). Therapy providers are responsible for identifying the need for such equipment/assistive technology during a therapy assessment. Following the assessment, the therapy provider will have a role in ensuring that recommended equipment is provided within a reasonable time frame. The time frame required to provide such equipment may vary depending upon the complexity of the equipment needed, whether the equipment needed is standard equipment or must be made to order, the funding source requirements for justification of the equipment needed or other factors. Therapy provider responsibilities related to assessing for and obtaining equipment include: 1) Performing and documenting assessments; 2) Submitting the written therapy assessment to the support coordinator /case manager; 3) Identifying appropriate equipment, possibly through use of trial equipment as available; 4) Obtaining physician s orders for the equipment needed; 5) Providing letters of justification, physician s order and additional information/documentation needed to obtain approval or reimbursement authorization for the equipment; 6) Obtaining a signed release from the service recipient when pictures or videos must be provided to justify the equipment request; 7) Assisting the service recipient and support coordinator to identify a durable medical equipment or assistive technology provider; 8) Maintaining contact with the support coordinator regarding the status of the equipment request; and 9) Developing staff instructions and/or providing staff training upon delivery of new equipment, when training/instruction beyond that provided by the manufacturer/equipment provider is required. Provider Manual, Chapter 13 Therapy Services 13-12

13.9.a. Customized Equipment Needs: In some cases, a therapy provider many identify the potential need for customized equipment or assistive technology, but may not have the skills required to fully determine what will best meet the service recipient s needs. The need for certain types of customized equipment such as custom hand splints, custom positioning equipment, custom seating equipment, custom communication systems or custom modifications to standard equipment may require referral to a therapist with expertise in assessing needs and fabricating customized equipment. When such situations occur, coordination must be ensured by the support coordinator and therapists involved to avoid duplication of services and to either avoid or justify concurrent billing as appropriate. Special service codes have been developed specific to approval of services and reimbursement of providers approved to assess specialized equipment/assistive technology needs and provide related training. 13.9.b. Addressing Equipment Needs in the ISP: As with other therapy services, the need for equipment assessments and equipment must be considered by the Circle of Support, and addressed in the ISP as determined appropriate. 13.10. Referrals for Therapy Assessments 13.10.a. Information Provided upon Referral: A referral request received by a therapy services provider should include sufficient information to allow the therapist to determine why the referral is being made. Additional information should be requested from the referring entity if the following information is not included: 1) Relevant information pertaining to the therapy service requested from the uniform assessment, the risk assessment, the PSR or other assessments that may have prompted the therapy assessment request; 2) Relevant information pertaining to an identified health/safety risk that may have prompted the need for the particular type of therapy assessment requested; and 3) The ISP action steps and outcomes relevant to the particular type of therapy assessment requested. 13.10.b. Completion of a Referral Form: A referral form must be completed by either the referring entity or therapy provider which includes the information indicated in Section 13.10.a. as well as the date of the referral, the name of the referring entity and identifying and demographic information specific to the service recipient. The referral form may be faxed between the therapy provider and the referring entity to ensure completion. Provider Manual, Chapter 13 Therapy Services 13-13

13.10.c. Acceptance of an Assessment Referral: Upon receipt of a completed referral form, the therapy provider is expected to review the available information and determine if able to complete the requested assessment and provide any therapy services that may be recommended as a result of the assessment. If not, the therapy provider must notify the referring entity of such as soon as possible. If so, the therapy provider will accept the referral by completing the DMRS form titled Request for Provision of Therapeutic Services (see Appendix D) and will obtain physician s orders for the therapy assessment, if not already available. The completed Request for Authorization of Funding for Therapies, Nutrition and Orientation and Mobility Assessment and Services form and physician s orders are to be submitted to the support coordinator/case manager. The support coordinator/case manager will seek approval of therapy services by amending/updating the ISP in accordance with the planning process specified in Chapter 3 and submitting it to the DMRS Regional Office. 13.10.d. Requesting Approval for Therapy Assessments: Obtaining approval of an ISP containing a request for therapy assessment is the responsibility of the support coordinator/case manager. Regional Office staff will review and approve the ISP, including the request for therapy assessment, if forms are properly completed, if required supporting documentation is provided, if the ISP is appropriate to the service recipient s needs and if services are adequately justified and found to be medically necessary. The following information must be submitted with or included in the ISP/service authorization request for therapy assessment services: 1) Documentation of the indicators/reasons for therapy assessment (see Section 13.8. of this chapter); 2) Physician s orders; 3) Estimated number of units of services needed to complete the assessment; and 4) Documentation of how the units of service requested for therapy assessment will be utilized. 13.11. Completing a Therapy Assessment An assessment must be completed prior to the provision of therapy services, as one of the purposes of the assessment is to justify the need for a particular therapy service. Reimbursements will be provided only for assessments completed by licensed therapists. Therapy assistants will not be reimbursed for completing assessments. The assessment should indicate information sought from the service recipient and any other pertinent sources of information, including the family/legal representative as applicable, the support coordinator, direct support professionals and other providers of services, including other clinicians. Upon notification that therapy assessment units have been approved/authorized, the therapy provider is required to complete the assessment within Provider Manual, Chapter 13 Therapy Services 13-14

thirty (30) calendar days of the approval date. Therapy assessments should be inclusive of all service recipient environments (e.g. the home, the worksite, locations where routine outings occur) that are relevant based on the reasons/indicators for the therapy assessment. 13.12. Development of a Therapy Plan of Care 13.12.a. Minimum Requirements for Therapy Plans of Care: When services are recommended following a therapy assessment, a therapy plan of care must be developed by the therapist which includes the following information: 1) Action steps that are person-centered and measurable; 2) The estimated amount (number of units), frequency (number of therapy visits needed within a specific time period) and duration (estimated number of days/weeks/months services will be needed) of therapy services needed to achieve functional outcomes; 3) The number of service units that will be needed to complete the annual reassessment, if it is anticipated that therapy services will be needed beyond the current ISP period; and 4) Any additional plan of care requirements specified in the Department of Health rules, Standards for Home Care Organizations Providing Professional Support Services. 13.12.b. Addressing Therapy Plan of Care in the ISP: The therapy plan of care, including applicable time frames for completion of therapy action steps, must be integrated with other services required by the service recipient. This is accomplished in part by ensuring that the therapy plan is reflective of and consistent with ISP outcomes. Therapy services not indicated in an approved ISP will not be reimbursed. If a therapy assessment results in a recommendation that does not relate to an existing ISP outcome, one of the following actions may occur: 1) Additional outcomes may be included in the ISP in accordance with the planning process specified in Chapter 3; 2) The service recipient or service recipient s legal representative may choose not to accept the recommendation; or 3) The recommendation may be earmarked to be considered for inclusion in the ISP at a later date. Therapy services may be included in an initial ISP, an ISP amendment or an ISP update (see Chapter 3 for detailed information about the planning process). The support coordinator/case manager will distribute the therapy plan of care to the members of the Provider Manual, Chapter 13 Therapy Services 13-15

Planning Team for review. Therapists are expected to attend Planning Meetings if the support coordinator/case manager indicates that the service recipient or the service recipient s legal representative has requested their attendance to discuss therapy-related issues. The therapist s role during a Planning Meeting is to: 1) Answer questions about the therapy assessment and/or plan of care; 2) Provide information about alternatives to the recommended course of action: 3) Revise the therapy plan of care as discussed during the meeting: and 4) Document the reason why particular recommendations were not accepted during the planning process. 13.12.c. Annual Therapy Reassessments: For therapy services to continue into a new ISP period, a therapy reassessment will be required within one-hundred-twenty (120) calendar days prior to the ISP effective date. The therapy plan of care must be updated as necessary to reflect recommendations that are consistent with therapy assessment results. For service recipient s who have had an initial assessment completed within six (6) months of the ISP effective date and who have had no significant health or functional changes, an abbreviated assessment can be completed. The abbreviated assessment must include an updated therapy plan of care. Therapy reassessments and updates to the therapy plan of care must be completed by the licensed therapist. Reimbursement will not be provided for therapy assistants to complete reassessments and updates to the therapy plan of care. The written therapy assessment and updated therapy plan of care must be submitted to the service recipient s support coordinator/case manager no later than ninety (90) calendar days prior to the ISP effective date. The therapy assessment and proposed therapy plan of care will be reviewed during the ISP planning process by Planning Team members (see Chapter 3 for detailed information regarding the planning process and annual ISP updates). 13.12.d. Obtaining Physician s Orders for Services: Therapists are responsible for ensuring that physician s orders for therapy services and/or changes in therapy orders are obtained from the physician, physician s assistant or nurse practitioner. Therapy services will not be approved in absence of written physician s orders that include the amount, frequency and duration of therapy services to be provided. 13.12.e. Obtaining Physician s Orders for Dietary Modifications: When a therapist makes recommendations pertaining to dietary modifications requiring a separate physician s order, the primary provider is responsible for obtaining the order. The primary provider is the residential provider if the person receives residential services, the day provider if the person receives day services and does not receive residential services, the personal assistance provider if the person receives personal assistance services and Provider Manual, Chapter 13 Therapy Services 13-16

does not receive day or residential services. If neither residential, day nor personal assistance services are provided, the support coordinator/case manager is responsible for obtaining the physician s diet order. 13.13. Approval of Therapy Services Identified in the ISP 13.13.a. Justification for Therapy Services: As with therapy assessments, other therapy services must be included in the initial or updated ISP or in an ISP amendment and submitted to the DMRS Regional Office for approval. For approval to occur, physicians orders for the therapy service must be provided and the ISP must document: 1) Justification of the need for therapy services requested based upon a therapy assessment, including documentation of the relationship between therapy services and ISP action steps and outcomes and anticipated utilization of the service units requested; 2) Identification of the amount, frequency and duration of therapy services needed, including any hours needed for annual reassessment if anticipated that therapy services will continue into the next ISP period; and 3) Identification of the number of the total units of service requested. 13.13.b. Justification of Maintenance Therapy: Justification for maintenance therapy must include documentation based upon a therapy assessment supporting that proposed interventions will: 1) Sustain current abilities or prevent deterioration in specific functional skills or physical conditions; 2) Allow continued functioning at the present level of independence; and/or 3) Slow deterioration or improve/maintain the comfort of the service recipient during the process of deterioration. 13.14. Provision of Therapy Services The primary purposes for providing therapy assessment and treatment services include facilitating achievement of ISP action steps and outcomes, increasing or maintaining skills to allow independent functioning, preventing deterioration of skills or physical condition and maintaining optimal health and safety. Provision of therapy services includes: 1) Completion of therapy assessments to determine the need for therapy services; 2) Development and revision of the therapy plan of care (see Section 13.12); Provider Manual, Chapter 13 Therapy Services 13-17

3) Participation in planning meetings to ensure that the therapy plan of care is reflective of the ISP and that emerging risk factors related to therapy services are addressed (see Section 13.12.b.); 4) Development of staff instructions, in collaboration with residential, day and personal assistance providers, for therapy-related action steps included in the ISP (see Chapter 3, Section 3.12.g. for requirements for staff instructions); 5) Provision of training to direct support staff regarding staff instructions and/or use of therapy-related equipment; 6) Monitoring on an ongoing basis to ensure that staff instruction and other therapyrelated interventions are appropriately implemented and effective in meeting service recipient needs; 7) Supervision of therapy assistants (see Section 13.5.c.) 8) Provision of direct, hands-on therapy services that may only be provided by a licensed therapy practitioner; 9) Identification of durable medical/adaptive equipment or assistive technology needed, collaboration with the support coordinator/case manager to obtain the assistive technology devices and/or equipment/supplies and provision of training to provider staff and other caregivers to enable proper use of such; 10) Communicating/collaborating with the service recipient and the service recipient s family and/or legal representatives as applicable, managed care organizations or private insurance companies and/or other providers to ensure that therapy-related ISP action steps are achieved and therapy services are integrated; and 11) Documenting the provision of therapy services, including activities and /or data pertaining to the implementation of and progress toward completion/achievement of therapy-related ISP action steps and outcomes. 13.14.a. Locations Where Therapy Services Are Provided: Therapy services are to take place in the site most related to the action step or outcome to be completed or achieved. Reimbursement will not be provided for therapy services provided in locations unrelated to the action step or outcome for which the therapy services were specified. Therapists are required to sign in and out to document the time period during which services were provided. For service recipients receiving therapy services in a residential or day setting, such notations are to be made in the staff notes section of the residential or day record. For individuals living in a family home who do not receive residential or day services, therapy contact notes must be recorded at the service site to document time in and out. Contact notes containing time in and time out must include the signature of the service recipient (if able to sign verifying the correct times) or a caregiver or family member present within the home who is able to verify the time period during which therapy services were provided. A separate entry is required for the time services began and ended. Contact notes must be signed by the licensed therapist Provider Manual, Chapter 13 Therapy Services 13-18

providing or supervising services. If time in and out is not appropriately documented, recoupment may occur due to inability to verify service units provided. 13.14.b. Development of Staff Instructions: The licensed therapist is responsible for developing any staff instructions determined necessary to the implementation of therapyrelated ISP action steps. Staff instructions are written strategies for therapy-related tasks or actions that must be implemented by direct support staff employed by the day, residential or personal assistance provider. Staff instructions must be developed in collaboration with the service recipient, the service recipient s family and/or legal representative and the providers who employ direct support staff. Input may be sought from therapy assistants as appropriate; however, reimbursement will not be provided for therapy assistants to participate in development of staff instructions. Staff instructions must be developed and staff training must be provided to allow implementation of the tasks/actions specified within thirty (30) calendar days of the date when therapy services were initiated. Collaboration between two or more therapy disciplines may be necessary to ensure an integrated set of staff instructions for a particular therapy-related action step. When this occurs, one of the therapy clinicians must be identified as having primary responsibility for training staff and monitoring implementation of staff instructions to avoid duplication of services. 13.14.c. Implementation of Staff Instructions: The therapist must provide assistance and consultation to direct support staff to ensure that: 1) Training is provided regarding implementation of therapy related staff instructions; 2) Therapy related Staff instructions are understood sufficiently to ensure implementation; 3) Therapy related staff instructions are integrated into the service recipient s daily routine utilizing a daily schedule, monthly calendar or other appropriate tools as needed; 4) Staff are able to communicate therapy related staff instructions and their basic purpose; 5) Staff are encouraged and provided opportunity to communicate success in implementing therapy related staff instructions or information about implementation barriers to the therapy provider; 6) Staff are able to problem-solve and/or obtain assistance with problem-solving should issues arise pertaining to the implementation of therapy related staff instructions; and 7) Staff are able to seek consultation from the therapy provider as needed. Provider Manual, Chapter 13 Therapy Services 13-19

13.14.d. Training Direct Support Staff to Implement Therapy-related Staff Instructions: Therapists are responsible for providing training regarding staff instructions when new instructions are developed, when existing instructions are changed or amended and when new equipment is delivered and training is needed beyond that routinely provided by the manufacturer or equipment provider. In some cases, the provider and therapist may agree that a supervisor or house manager can provide staff training to new/replacement staff. Designation of a trainer may not be appropriate if the person s health status is unstable, if frequent changes in staff instructions are required or if staff instructions are unusually complex. In such situations, the therapist may be the most appropriate provider to manage ongoing staff training for therapy-related staff instructions. The reason(s) that a therapist must provide ongoing staff training must be thoroughly documented in either therapy contact notes or therapy monthly reviews. The therapist must continue to reassess for changes in the situation that would allow designation of a trainer employed by the provider of the direct support staff. These ongoing reassessments are to be documented in therapy monthly reviews. The following requirements apply to therapy providers involved in staff instruction training whether training is provided by the therapy provider or by trainers who have been instructed by the therapy provider: 1) Training must be competency based staff must be observed implementing staff instructions correctly or using equipment correctly; 2) Training must include information that allows direct support staff to understand the reason why the staff instruction is to be implemented and how it will help the service recipient achieve ISP action steps or outcomes or maintain health and safety; 3) Training must be appropriately documented, including the training content, the names of staff being trained, the dates training sessions occurred and each staff persons performance and competency level; and 4) Monitoring must occur to ensure that training has resulted in staff instructions being carried out correctly and that implementation issues are identified and remedied. 13.14.e. Direct Therapy Services: Direct therapy services are those services which are provided hands-on by the therapist or therapy assistant to the service recipient. Such services are warranted when the nature of the service specified in the ISP is such that it can only be carried by licensed therapy staff in accordance with licensure rules or recognized professional practice standards. Direct therapy services may be required to complete specific actions for a time-limited period, after which direct care staff can be trained to continue implementation. Direct therapy services may include: Provider Manual, Chapter 13 Therapy Services 13-20

1) Completion of equipment trials by an occupational therapy, physical therapy, speech language pathology or audiology provider; 2) Completion of mealtime technique trials by an occupational therapy or speech language pathology provider; 3) Completion of communication system trials by a speech language pathologist or audiologist; 4) Completion of interviews with the service recipient as well as any direct support staff, appropriate family members or legal representatives present with the service recipient for the purpose of completing assessments, developing/revising the therapy plan of care or developing revising staff instructions pertaining to occupational therapy, physical therapy, speech language pathology or audiology services; 5) Provision of direct support staff competency-based training by an occupational therapist, physical therapist, speech language pathologist or audiologist when new staff instructions are developed or new equipment is delivered; 6) Provision of interventions by an occupational therapy provider intended to improve fine or gross motor skills needed to increase independence in completing self-care or home management tasks; 7) Completion of tolerance tests for positioning equipment by an occupational therapist or physical therapist; 8) Provision of interventions by a physical therapy provider intended to improve independence related to transfer or mobility skills; 9) Provision of interventions intended to facilitate communication by a speech language pathologist or audiologist; 10) Attendance with a service recipient at a PCP, orthopedic physician s or specialty physician s appointment if documentation supports the need; and 11) Provision of assistance with positioning or swallowing techniques by a speech language pathologist during a modified barium swallow study or other diagnostic tests. 13.14.f. Monthly Reviews: The therapist is responsible for reassessing therapy services every thirty (30) calendar days or more frequently as necessary for each person receiving therapy services. This is called a monthly review. The monthly review must be completed by the licensed therapist. Reimbursement will not be provided for therapy assistants to complete monthly reviews. Additional information pertaining to monthly review requirements is provided in Chapter 3, Section 3.14. 13.14.g. Discharge from Therapy Services: The therapist should consider whether discharge from therapy services is appropriate during the monthly review process. If discharge is felt to be appropriate, the therapist must advise the person, the family or Provider Manual, Chapter 13 Therapy Services 13-21

legal representative as appropriate and the support coordinator/case manager. The therapist is to provide discharge information as necessary to the Planning Team. Discharge from therapy services is generally appropriate when: 1) Therapy-related ISP action steps have been completed; 2) The service recipient is no longer benefiting from the service; 3) Therapy interventions have been integrated into the service recipient s daily routine and are being carried out independently by the service recipient, by direct support staff and/or through other sources of support; 4) Monitoring by the therapist is no longer necessary; and/or 5) Discontinuation of therapy services is requested by the service recipient or legal representative. 13.15. Documenting the Provision of Therapy Services Therapy providers are required to meet general records requirements pertaining to service recipient records specified in Chapter 8. Monthly review general requirements that therapy providers must meet are provided in Chapter 3, Section 3.18. Therapy providers are required to meet requirements for clinical service assessments (Chapter 8, Section 8.9.d.), clinical service contact notes (Chapter 8, Section 8.9.e.), clinical service monthly reviews (Chapter 8, Section 8.9.f.) and clinical service discharge summaries (Chapter 8, Section 8.9.g.). 13.16. Maintaining and Distributing Therapy Records 13.16.a. Contents of Therapy Records: Therapy providers must maintain clinical service records with contents as specified in Chapter 8, Table 8.6. Original documents (assessments, contact notes, monthly reviews and discharge summaries) created by the therapy provider are to be maintained in the therapy record with copies distributed as indicated in Section 13.16.b. 13.16.b. Distribution of Therapy Records: Copies of therapy assessments, monthly reviews and discharge summaries are to be forwarded to: 1) The support coordinator or case manager for inclusion in the support coordination/case management record; 2) The service recipient s legal representative; and 3) The primary provider, for inclusion in the Comprehensive Individual Record. The therapist is to review assessment findings with the service recipient and provide a copy upon request. Provider Manual, Chapter 13 Therapy Services 13-22

13.17. Service Reimbursement Rates 13.17.a. Travel Differential Rates: Different levels of therapy rates have been established to accommodate travel time. Higher rates are paid for therapy services when necessary to arrange for therapy providers to travel to remote or rural areas where providers are not available or where the numbers of providers are insufficient to meet the demand for therapy services. The support coordinator/case manager must obtain preauthorization for differential rates to be paid through the ISP approval/service authorization process. 13.17.b. Determining the Appropriate Rate Level for Therapy Services: The rate level provided is based upon the average time required to travel within a defined mile radius. Mileage will be determined utilizing the Mapquest website (www.mapquest.com) to determine the mileage between the town where the therapy provider s residence or office (whichever is closest to the service site) is located and the town where therapy services will be provided. If therapy services are provided to a service recipient in different locations, mileage is to be calculated based on the location of the site where therapy services are most frequently provided. Therapy rate levels are based on the following mileage: 1) Level 1: 0-45 mile radius (one way) 2) Level 2: 46-75 mile radius (one way) 3) Level 3: 76+ mile radius (one way) 13.17.c. Requirements Pertaining to Changing Therapy Rate Levels: When a service recipient s usual therapist is unable to provide services due to vacation, medical leave or other reasons, an alternate therapist must be identified to provide services during such absence. In some cases, the alternate therapist may travel from a residence or office that is closer to or further from the service delivery site. When such situations occur, the therapy rate level will remain the same unless the period of absence exceeds fourteen (14) calendar days. When the period of absence exceeds fourteen (14) calendar days, submission of an amended Authorization of Funding for Therapy, Nutrition and Orientation and Mobility Services form (see Appendix D) is required in order to adjust the therapy rate to the appropriate level. The form is to be completed by the therapy provider and submitted to the ISC, who is responsible for requesting service authorization from the DMRS Regional Office. If possible, the authorization request form should be submitted prior to the beginning of the period of absence if the provider is aware that an alternate therapist will need to provide services for an extended period of time. Providers will not receive reimbursement at a higher rate level unless advance authorization is obtained from the DMRS Regional Office. Retroactive requests for authorization of a increase in the rate level will not be approved. If determined that a higher rate was paid Provider Manual, Chapter 13 Therapy Services 13-23

due to the provider s failure to submit the required form in a timely manner to adjust the rate downward, recoupment will be initiated. 13.18. Integration of Therapy Services Into the Service Recipient s Daily Schedule Therapy providers are to work with the service recipient, family caregivers and residential/day provider staff to schedule therapy services. Therapy services should not prevent or delay other services or planned activities. The therapy provider should accommodate to the service recipient s schedule as opposed to the service recipient adjusting his/her schedule to be available at the convenience of the therapist. If for some reason either the service recipient or the therapist needs to reschedule a therapy appointment, notification should be provided to the other party as soon as possible to avoid the frustration caused by missed appointments and the associated costs, such as those generated by travel to the site where services were to be provided. Provider Manual, Chapter 13 Therapy Services 13-24