Chapter. CPT only copyright 2008 American Medical Association. All rights reserved. 28Physical Medicine and Rehabilitation

Transcription

1 Chapter 28Physical Medicine and Rehabilitation Enrollment Benefits, Limitations, and Authorization Requirements Osteopathic Manipulative Treatment (OMT) Physical Medicine, Physical Therapy (PT), and Occupational Therapy (OT) Authorization Requirements Coordination with the Public School System Claims Information Reimbursement TMHP-CSHCN Services Program Contact Center CPT only copyright 2008 American Medical Association. All rights reserved.

2 Chapter Enrollment To enroll in the CSHCN Services Program, physical medicine and rehabilitation providers must be actively enrolled in Texas Medicaid, have a valid Provider Agreement with the CSHCN Services Program, have completed the CSHCN Services Program enrollment process, and comply with all applicable state laws and requirements. Out-of-state physical medicine and rehabilitation providers must meet all these conditions, and be located in the United States, within 50 miles of the Texas state border, and be approved by the Department of State Health Services (DSHS). Important: CSHCN Services Program providers are responsible for knowing, understanding, and complying with the laws, administrative rules, and policies of the CSHCN Services Program and Texas Medicaid. By enrolling in the CSHCN Services Program, providers are charged not only with knowledge of the adopted CSHCN Services Program agency rules published in Title 25 Texas Administrative Code (TAC), but also with knowledge of the adopted Medicaid agency rules published in 1 TAC, Part 15, and specifically including the fraud and abuse provisions contained in Chapter 371. CSHCN Services Program providers also are required to comply with all applicable laws, administrative rules, and policies that apply to their professions. Specifically, it is a violation of program rules when a provider fails to provide health-care services or items to recipients in accordance with accepted medical community standards and standards that govern occupations, as explained in 1 TAC (a)(6)(A) for Medicaid providers, which also applies to CSHCN Services Program providers as set forth in 25 TAC 38.6(b)(1). Accordingly, CSHCN Services Program providers can be subject to sanctions for failure to, at all times, deliver health-care items and services to recipients in full accordance with all applicable licensure and certification requirements. These include, without limitation, requirements related to documentation and record maintenance, such that a CSHCN Services Program provider can be subject to sanctions for failure to create and maintain all records required by his or her profession, as well as those required by the CSHCN Services Program and Texas Medicaid. Refer to: Section 2.1, Provider Enrollment, on page 2-2 for more detailed information about CSHCN Services Program provider enrollment procedures Benefits, Limitations, and Authorization Requirements The CSHCN Services Program may reimburse medically necessary and appropriate outpatient PT and OT for CSHCN Services Program clients. A physician or podiatrist (for conditions below the ankle) must prescribe PT and OT services that are provided through or in a rehabilitation center, a licensed hospital, a physician s office, or the office of an enrolled PT or OT provider. The CSHCN Services Program may reimburse therapists for travel to the client s community, based on standard CSHCN Services Program travel reimbursement policy, when no local therapist is available or when services are provided in the client s home. Use the CSHCN Services Program local procedure code 100PT, Transportation therapist, per mile. Only licensed therapists may provide PT and OT services. The CSHCN Services Program reimburses therapists and outpatient facilities based on the procedure codes listed in this chapter. Therapy sessions include the time span the therapist is with the client, time spent preparing the client for the session, and the time spent completing documentation Osteopathic Manipulative Treatment (OMT) OMT is a form of manual treatment to eliminate or alleviate somatic dysfunction and related disorders. This treatment may be accomplished by a variety of techniques. OMT may be considered for reimbursement by the CSHCN Services Program in the following situations: Acute musculoskeletal condition Acute exacerbation of a chronic condition Acute treatment pre- or postsurgery when directly related to the surgical treatment The acute phase is defined as the period of time up to 180 days from the start date of therapy. The acute modifier AT must be submitted with the claim in order for payment to be made. The AT modifier is described as representing treatment provided for an acute condition CPT only copyright 2008 American Medical Association. All rights reserved.

3 Physical Medicine and Rehabilitation Procedure codes 98925, 98926, 98927, 98928, and must be used when billing for OMT. The modifier AT must be submitted with the claim for OMT. If more than one of these procedure codes is submitted with the same date of service by any provider, the most inclusive code is considered for reimbursement and the others are denied. If a physician submits an initial or subsequent care inpatient visit with the same date of service as an OMT procedure code, both are considered for reimbursement Physical Medicine, Physical Therapy (PT), and Occupational Therapy (OT) Physical medicine is the use of one or more modalities applied to produce therapeutic changes to biologic tissue. It includes, but is not limited to thermal, acoustic, light, mechanical, or electric energy. Physical medicine is not to supplement or replace related services provided through the public school system. Physical medicine may be provided by physicians, podiatrists (for services below the ankle), or physical therapists or occupational therapists under the direction of a physician. The CSHCN Services Program may reimburse for physical medicine under the following conditions: The services do not duplicate those provided by the school district, if the child is receiving therapies through an individualized education plan (IEP). The client has a disability requiring therapy to improve or maintain function, range of motion, strength, or to prevent or decrease the risk of deformity or osteoporosis. The client has an exacerbation of chronic illness or condition (e.g., juvenile rheumatoid arthritis [JRA], hemophilia, or sickle cell crisis). The client has sustained a traumatic injury or is experiencing late effects of a traumatic injury requiring therapy to restore or maintain function, range of motion, strength, or to prevent or decrease the risk of deformity or osteoporosis. The client requires short-term therapy related to surgery or casting. The client or family requires training on the use of equipment or orthotics or prosthetics. The client or family requires instruction in activities for daily living specific to their home environment, or the client requires an assessment for appropriate equipment, seating, braces, orthotics, or prosthetics. Clients may receive therapy services from both the CSHCN Services Program and school districts only when the therapy provided by the CSHCN Services Program addresses different client needs. Therapy provided through the CSHCN Services Program is not intended to duplicate, replace, or supplement services that are the legal responsibility of other entities or institutions. The CSHCN Services Program encourages the private therapist to coordinate with other therapy providers to avoid treatment plans that might compromise the client s ability to progress. Evaluation, reevaluation, and therapy services may not be billed on the same date of service. Reimbursement of an evaluation is limited to once every 6 months. Reimbursement for re-evaluation is limited to once per month. For authorization or claim submission, physical therapists must use procedure code for evaluation and procedure code for reevaluation. Occupational therapists must use procedure code for evaluation and procedure code for reevaluation. Providers must use the following procedure codes for authorization and for claim submission when billing for physical medicine services: 28 Procedure Codes CPT only copyright 2008 American Medical Association. All rights reserved. 28 3

4 Chapter 28 Procedure Codes S8990 The following procedure codes may be paid in multiple quantities of each code, if the claim states that multiple procedures were performed on different body areas, or the claim states that physical medicine treatment was performed more than once per day: Procedure Codes All providers must submit requests for authorization of physical therapy (PT) or occupational therapy (OT) services with the appropriate modifier for the services requested. Requests for PT services should be submitted with modifier GP, and requests for OT services should be submitted with modifier GO. Procedure codes and are comprehensive codes and include an office visit. Providers are not reimbursed for an office visit with the same date of service as procedure codes and because the office visit is denied as part of another procedure submitted with the same date of service. Procedure codes 97001, 97002, 97003, or are comprehensive codes, and other therapy procedure codes are denied if submitted with the same date of service. Procedure codes and are not benefits of the CSHCN Services Program Authorization Requirements PT and OT evaluations and reevaluations do not require authorization. PT and OT services require authorization. Request PT using the GP modifier and OT using the GO modifier. Treatment plans require authorization; up to 6 months of treatment may be authorized. Authorization requests for an extension require documentation of medical necessity. If the client is of school age, the requesting provider must include a copy of the IEP or include a statement from the independent school district indicating that the child is not eligible for therapy services from the school district. Treatment plans are authorized using the OT and PT guidelines by age as stated below. PT and OT may be authorized when the child meets one of the following guidelines: The child is younger than 3 years of age, and measurable progress toward individual treatment goals can reasonably be expected (this may not always indicate physical improvement in the client s condition). The child is 3 years of age or older, not presently eligible for or receiving special education or special services during the school year, and has a disabling condition requiring therapy services where measurable progress toward individual treatment goals can reasonably be expected (this may not always indicate physical improvement in the client s condition). In addition, the child also must have at least one of the following conditions: The child has a developmental anomaly including, but not limited to: cerebral palsy, spina bifida, arthrogryposis, reduction deformities of a limb(s), hydrocephalus, Erbs palsy (brachial plexus palsy), or encephalocele. The child has an acute episode of a chronic condition that may include, but is not limited to: JRA, hemophilia, lupus erythematosus, sickle cell crisis (joint pain, swelling, and limited range of motion), or cancer. The child presents a new condition that may include, but is not limited to: Upper extremity trauma, median or radial nerve lesions, late effects of fractures, burns, spinal cord injury, traumatic brain injury, cerebral embolism, brain tumor, or Guillain-Barré Syndrome. The child is seen in a specialty clinic for periodic assessment or re-evaluations. The child needs short-term therapy related to surgery or casting. The child requires training on the use of equipment such as wheelchairs (powered or manual), 28 4 CPT only copyright 2008 American Medical Association. All rights reserved.

5 Physical Medicine and Rehabilitation orthotics or prosthetics, or other equipment such as ambulation aids like walkers or crutches). Short-term assistance is required to instruct the child/family in activities of daily living specific to the home or environment (bathing, toileting, or making equipment assessment for braces, wheelchairs, cushions, and so on). PT or OT services may be authorized as follows: For children from birth to 3 years of age with a developmental anomaly, therapy services may be authorized up to two times a week for 6 months (may be extended up to school eligibility without medical review). Requests for a higher frequency of visits per week require the submission of documentation of medical necessity. Children 3 through 21 years of age with a developmental anomaly should be referred to the public school system for services unless they are ineligible or there is a medically related therapy issue to address. Presurgical therapy related to the reason for surgery may be approved up to three times a week for 1 month. Postsurgical therapy directly related to the reason for surgery or for cast removal may be authorized up to five times a week for 2 months and post rhizotomy for up to three times a week for 1 year. After these specified time periods, extensions require documentation of medical necessity. Therapy addressing an acute episode of a chronic condition (seldom eligible for therapy through the school system) may be authorized up to five times a week for 3 months. After 3 months, the physician s documentation of a continued acute episode is required. After the first 6 months are authorized, documentation of the specific rationale for the need of continued therapy based on the client s chronic diagnosis must be submitted. New conditions such as upper extremity trauma, median or radial nerve lesions, or late effects of fractures, may have therapy authorized up to five times a week for 3 months. Extensions after 6 months require additional documentation of medical necessity. New conditions such as third-degree burns, spinal cord injury, traumatic brain injury, cerebral embolism, brain tumor, or Guillain-Barré Syndrome may have therapy authorized for up to five times a week for 3 months and may be extended up to 1 year. After 1 year, documentation of the specific rationale of the need for continued therapy must be submitted. Home program monitoring for clients from birth to 3 years of age with cerebral palsy, spina bifida, arthrogryposis, reduction deformities of limbs, or hydrocephalus may be authorized for up to two times a month for 6 months. Home program monitoring for clients from birth to 21 years of age with JRA, hemophilia, lupus erythematosus, and sickle cell crisis (joint pain/swelling and limited range of motion) may be approved for up to once a month for 6 months. Extensions may be allowed at up to 6-month intervals with medical justification. Activities of daily living instructions to teach clients, parents, and caregivers for clients 3 years of age through 21 years of age may be authorized up to three times a week for 1 month. Extensions may be allowed at up to 6-month intervals with justification. One equipment assessment before receiving the equipment and one assessment after receiving the equipment may be authorized. Training in the use of manual wheelchairs may be authorized for up to five times a week for 1 month. Training in the use of powered wheelchairs may be authorized for up to five times a week for 1 month and then three times a week for 2 months. Training in the use of orthoses/prostheses (braces/artificial limbs) may be authorized for up to five times a week for 1 month and then three times a week for 2 months. Requests for additional training require documentation of the specific rationale for the medical need. Reciprocating gait orthoses (RGOs) may be provided for children with spina bifida or similar functional disability. The required documentation includes: A statement from the physician indicating the medical necessity. A coordinated PT treatment plan. Documentation that the client/family is expected to comply with the treatment plan. 28 CPT only copyright 2008 American Medical Association. All rights reserved. 28 5

6 Chapter 28 Dynamic splints are provided on a case-by-case basis using the following criteria submitted by the physician: The client s condition to be treated with the dynamic splint. The client s current course of therapy to date for the condition to be treated. The rationale for the use of the dynamic splint at this time. A therapy treatment plan related to the dynamic splint. Training for other equipment (such as walkers or crutches) may be authorized for up to five times a week for 1 month. Refer to: Section 4.2, Authorizations, on page 4-2 for detailed information about authorization requirements. Appendix B, CSHCN Services Program Authorization Request for Initial Outpatient Therapy (TP1), on page B-95 or Appendix B, CSHCN Services Program Authorization Request for Extension of Outpatient Therapy (TP2), on page B-91. Note: Fax transmittal confirmations are not accepted as proof of timely authorization submission Coordination with the Public School System To ensure that there is no duplication of therapy services, any child eligible for special education services must have a copy of their IEP or a statement from the independent school district to verify that the child is not eligible for the same services through the school included with an authorization request in order to submit claims for reimbursement of therapy services Claims Information Outpatient therapy services provided by a physical or occupational therapist or by an outpatient facility must be submitted to TMHP in an approved electronic format or on a CMS-1500 claim form. Providers may purchase CMS-1500 claim forms from the vendor of their choice. TMHP does not supply the forms. When completing a CMS-1500 claim form, all required information must be included on the claim, as TMHP does not key any information from claim attachments. Superbills, or itemized statements, are not accepted as claim supplements. Refer to: Chapter 36, TMHP Electronic Data Interchange (EDI), on page 36-1 for information about electronic claims submissions. Chapter 5, Claims Filing, Third-Party Resources, and Reimbursement, on page 5-1 for general information about claims filing. Section , CMS-1500 Claim Form Instructions, on page 5-21 for instructions on completing paper claims. Blocks that are not referenced are not required for processing by TMHP and may be left blank Reimbursement Outpatient therapy services may be reimbursed according to Texas Medicaid Reimbursement Methodology (TMRM). Physicians, podiatrists, advanced practice nurses (APNs), and occupational and physical therapists may be reimbursed the lower of the billed amount or the amount allowed by Texas Medicaid. Outpatient hospital facilities may be reimbursed at 80 percent of the rate allowed by the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA), which is equivalent to the hospital's Medicaid interim rate TMHP-CSHCN Services Program Contact Center The TMHP-CSHCN Services Program Contact Center at is available Monday through Friday from 7 a.m. to 7 p.m., Central Time, and is the main point of contact for the CSHCN Services Program provider community CPT only copyright 2008 American Medical Association. All rights reserved.