PT, OT, and ST Benefits t Change fr CCP fr Texas Medicaid Effective January 1, 2014 Infrmatin psted Nvember 15, 2013 Effective fr dates f services n r after January 1, 2014, benefit criteria fr physical therapy (PT), ccupatinal therapy (OT), and speech therapy (ST) will change fr the Cmprehensive Care Prgram (CCP). PT, OT, and ST services, including c-therapy, will be benefits f CCP fr clients wh are 20 years f age and yunger with an acute r chrnic medical cnditin when all f the fllwing criteria are met: 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. Nte: A nurse practitiner (NP), clinical nurse specialist (CNS), r physician assistant (PA) may sign all dcumentatin related t the prvisin f PT, OT, r ST services n behalf f the client s physician when the client s physician delegates this authrity t the NP, CNS, r PA. The NP, CNS, r PA prvider s signature and license number must appear n the frms where the physician signature and license number are required. 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 days frm the start f therapy services, the cnditin is cnsidered chrnic. Prviders must maintain a cmpleted plan f care (POC) that includes dcumentatin that supprts medical necessity fr therapy services and cnfirms that the client meets the criteria fr acute services. The POC must include all f the fllwing: The specific prcedures and disciplines t be used The amunt, duratin, and frequency f therapy The therapist wh participated in develping the POC Rehabilitatin ptential f the client Functinal limitatins f the client Date the client was last seen by the physician Therapy gals fr an acute r chrnic medical cnditin include, but are nt limited t, imprving, maintaining, and slwing the deteriratin f functin. PT, OT, and ST evaluatins and treatment must be prvided accrding t the current written rders f a physician and be based n medical necessity unless the prvider is an Early Childhd Interventin (ECI) therapist.
Nte: PT, OT, and ST evaluatins and re-evaluatins that are perfrmed by ECI therapists must be perfrmed accrding t the therapist s scpe f practice. 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, r ccupatinal therapist), 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 therapist respnsible fr furnishing r supervising the rdered services. The rders must be transcribed t the POC, 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 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 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 reevaluatins 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. PT, OT, and ST prcedure cdes that are billed 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 claims fr all therapy services prvided fr the week in questin have been submitted.
Prvider must indicate the appeal is fr the units in excess f 4 per day, and that the number f units fr the week has nt exceeded the prir authrized number. 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 prvided 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. 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 that is prvided under the rders f a client s physician is limited t treatment f acute r chrnic medical cnditins 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 that is prvided thrugh a physician r utpatient hspital prvider may be a benefit under any f the fllwing situatins: The therapy is perfrmed by a licensed physician.
The therapy 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 Claims fr a PT evaluatin (prcedure cde 97001) may als be submitted 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 97012 97014 97016 97018 97022 97024 97026 97028 97150 Occupatinal Therapy (OT) OT that is 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 develpmental deficits, envirnmental deprivatin, sensry impairment, r psychlgical r scial dysfunctin. OT uses therapeutic, gal-directed activities t treat clients with acute r chrnic medical cnditins. OT des nt include diagnsis r psychlgical services that are typically perfrmed by a licensed psychlgist r behaviral health therapist. OT that is prvided thrugh a physician r utpatient hspital prvider may be a benefit under any f the fllwing situatins: The therapy is perfrmed by a licensed physician. The therapy 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 A claim fr 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 97012 97014 97016 97018 97022 97024 97026 97028 97150
Speech Therapy (ST) ST prvided under the rders f a client s physician is limited t treatment f an acute r 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 thrugh a physician r utpatient hspital prvider may be a benefit under any f the fllwing situatins: The therapy is perfrmed by a physician. The therapy 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 A licensed speech-language pathlgy intern under the supervisin f a licensed speech-language pathlgist Speech therapy may be perfrmed by a speech-language pathlgist wh is either n staff at a hspital r under the persnal supervisin f a physician. Claims fr speech evaluatins and therapy that are submitted directly by an independently practicing speech-language pathlgist will be denied unless the speech-language pathlgist is an ECI prvider. Nte: Speech-language pathlgists wh are als ECI prviders, and perfrm services thrugh the ECI prgram shuld fllw ECI prgram requirements when submitting a claim fr ST services. 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 speech-language pathlgist, prcedure cde 97535 may be used nly fr additinal augmentative cmmunicatin device training. Prcedure cde 97535 must be prir authrized and be specifically requested n the prir authrizatin request frm. The prvider must submit dcumentatin that supprts the service as medically necessary and beneficial t the client. Prcedure cde 97535 will be denied when it is submitted with the same date f service as prcedure cde 92507, 92508, r 92526. 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 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 submit claims fr the therapy services that were 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 claims submissin was apprpriate fr the services prvided by the designated primary perfrming therapist. Claims fr c-therapy services must be submitted with mdifier U3. Prir Authrizatin Prir authrizatin fr individual therapy services will be cnsidered when all f the fllwing criteria are met: The client has an acute r chrnic medical cnditin resulting in a significant decrease in functinal ability that will benefit frm therapy services. 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. 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. Nte: Services prvided by an ECI therapist d nt require prir authrizatin; hwever, the services must cmply with the Individual Family Service Plan (IFSP.) An initial prir authrizatin may be granted fr a perid nt t exceed 90 days, but the prir authrizatin perid may be extended fr an additinal 90 days if a request is submitted with dcumentatin that supprts medical necessity. Subsequent prir authrizatin requests may be granted fr up t 180 days when submitted with dcumentatin f a chrnic cnditin.
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 ttal f 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. A new prir authrizatin request frm, the Request fr Outpatient Physical, Occupatinal, r Speech Therapy (PT, OT, ST) Prir Authrizatin Frm, will replace the Request fr Initial Outpatient Therapy (Frm TP-1) and the Request fr Extensin f Outpatient Therapy (2 Pages) (Frm TP-2). Prviders must submit the new frm when requesting prir authrizatin n r after January 1, 2014, fr all utpatient physical, ccupatinal, and speech therapy services. Online prir authrizatin thrugh the secure TMHP prvider prtal will be updated t capture all infrmatin required n the new frm. 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, 2013. T cmplete the prir authrizatin prcess by paper, the prvider must submit the required 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 cmplete the prir authrizatin prcess electrnically, the prvider must submit the required 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 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. 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 three business day perid will be denied fr dates f service that ccurred befre the date 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. 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(es) Treatment gals that are related t the client s individual needs fr the requested therapy discipline A descriptin f the specific therapy disciplines being prescribed Duratin and frequency f therapy Date f nset f the illness, injury, r exacerbatin that requires the ffice r utpatient services Requested dates f service The fllwing additinal medical necessity dcumentatin is required fr clients with develpmental disability r delay (DD) r develpmental cgnitive disability (DCD): Diagnsis cde that supprts therapy Onset f the diagnsis Client's current functinal status Standardized testing perfrmed with scring, including standard scres with standard deviatins, r dcumentatin that supprts why testing culd nt be perfrmed r is inapprpriate Client's current deficits Purpse f therapy: attain new skill, maintain current functin, r prevent deteriratin Rehabilitatin ptential Specific and measurable gals Descriptin f hme exercise prgram
Frequency and dates f service requested 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) Prir Authrizatin Frm that has been signed and dated by the rdering physician r electrnic equivalent 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. 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 and includes all f the fllwing: Date and signature f the licensed therapist Diagnsis(es) 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 therapy services A brief summary f the utcmes f the previus treatment as it relates t the client s debilitating cnditin Requested dates f service
The fllwing additinal medical necessity dcumentatin is required fr clients with DD r DCD: Diagnsis cde that supprts therapy Onset f the diagnsis Client's prir and current functinal status Prgress made tward gals with actual number f gals met New testing perfrmed with scring, including standard scres with standard deviatins, r dcumentatin supprting why testing culd nt be dne r is inapprpriate Client's current deficits Purpse f therapy: attain new skill, maintain current functin, r prevent deteriratin Rehabilitatin ptential New gals: specific and measurable (if applicable) Descriptin f hme exercise prgram Client and respnsible adult cmpliance with hme prgram Frequency and dates f service requested 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 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 A new evaluatin with required dcumentatin A change-f-prvider letter that has been signed and dated by the client r respnsible adult and that dcuments 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. Therapy Prvided in the Hme PT, OT, and ST hme services must be prvided in the client's hme. The client's hme can be a client- r family-wned dwelling r apartment, a relative's hme, r ther type f living arrangement. The fllwing settings are nt recgnized as the client's hme:
Hspital Outpatient facility Nursing facility Physician ffice Any ther medical setting Intermediate care facility fr persns with mental retardatin (ICF-MR) Daycare Public recreatinal facility Schl Frequency Levels PT, OT, and ST services may be prvided at ne f the fllwing levels cmmensurate with the client's medical cnditin, develpmental needs, 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 shws 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 achieve an identified new skill r 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 a week is cnsidered when dcumentatin shws the fllwing: 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 r every ther week is cnsidered when the dcumentatin shws 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 develpment r medical cnditin.
The licensed therapist is required t adjust the client's therapy plan and hme prgram weekly based n the client's prgress. Every ther week therapy is supprted fr clients whse medical cnditin is stable, they are making prgress, and it is anticipated the client will nt regress with every ther week therapy. Because the therapy plan changes very slwly, the hme prgram can be managed by the client and the respnsible adult and des nt require frequent changes by the licensed therapist. Maintenance Level/Prevent Deteriratin: every ther week t mnthly r less ften visits/sessins may be cnsidered when the client meets ne f the fllwing criteria: Prgress has slwed r stpped, but dcumentatin supprts that nging therapy is required t maintain the prgress made r prevent deteriratin The dcumentatin submitted shws the client may be making limited prgress tward gals, r gal attainment is extremely slw Factrs are identified that inhibit the client's ability t achieve established gals (e.g., the client cannt participate in therapy sessins due t behavir issues r issues with anxiety) Dcumentatin shws the client and the respnsible adult have a cntinuing need fr educatin, a peridic adjustment f the hme prgram, r regular mdificatin f equipment t meet the client's needs 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 The fllwing services will nt be a benefit f Texas Medicaid: Therapy services prvided by nn-eci prviders in daycare, public recreatinal facilities, r after-schl care prgrams 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, including, but nt limited t, the fllwing: 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 adult that is respnsible 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 97755 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: 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 1-800-925-9126.