Physical, Occupatinal, and Speech Therapy - Children (Acute and Chrnic) Infrmatin psted May 6, 2016 Nte: This article applies t claims submitted t TMHP fr prcessing. Fr claims prcessed by a Medicaid managed care rganizatin (MCO), prviders must refer t the MCO fr infrmatin abut benefits, limitatins, prir authrizatin, and reimbursement. The updates t the Texas Medicaid Physical, Occupatinal, and Speech Therapy plicy benefit fr children wh are 20 years f age and yunger are effective May 1, 2016. The Health and Human Services Cmmissin (HHSC) is releasing the updated benefit plicy t assist prviders with the new Texas Medicaid Physical, Occupatin, and Speech Therapy benefits and authrizatin requirements. This ntificatin is a rerelease f the February 2, 2016 ntificatin, and all subsequent updates made in March and April have been incrprated. The June 15, 2016 release f the Texas Medicaid Prvider Prcedures Manual (TMPPM) will include this benefit plicy, and it will replace all benefit criteria and authrizatin requirements currently stated in the TMPPM. HHSC is als re-releasing clarificatins n hw t reprt standardized test results fr develpmental delay (previusly released March 31, 2016) and the prcedures required fr re-evaluatins and re-certificatins (previusly released April 29, 2016). Refer t: The article titled Changes t CCP Physical, Occupatinal, and Speech Therapy Plicy fr Clients Wh Are Birth thrugh 20 Years f Age, which was psted t this website n March 31, 2016, and the article titled Clarificatin Regarding Hw t Obtain Authrizatin fr Physical, Occupatinal, and Speech Therapy Re-evaluatin Prcedure Cdes, which was psted n this website n April 29, 2016. The benefits are effective May 1, 2015. Reminders and Clarificatins Originally Published March 31, 2016, and April 29, 2016 Develpmental Delay Criteria (Infrmatin Psted March 31, 2016) Plicy states that when reprting test results fr develpmental delay: Eligibility fr therapy will be based upn a scre that falls 1.5 standard deviatins (SD) r mre belw the mean in at least ne subtest area f cmpsite scre n a nrmreferenced, standardized test. HHSC reminds prviders that age equivalents, percent delay, r scaled scres will nt be accepted as a measure f develpmental delay, thugh prviders may include this infrmatin in their evaluatin summaries. Raw scres must be included in the evaluatin summary, but are nt sufficient t cmmunicate the measure f standard deviatin frm the mean n the assessment tl. It is necessary t submit test results t cmmunicate the scre n a nrm-referenced, standardized test in the frm f standard deviatin, z-scres, t-scres, standard scres with the mean (M) and SD f that standard scre specified, r percentile rank. A test r subtest scre with an SD f 1.5 r mre belw the mean may be cmmunicated as: Z- scre f -1.50 r lwer
T-scre (M=50, SD=10) f 35 r lwer Standard scres (M=100, SD=15) f 78 r lwer Percentile rank f 7 r lwer Reevaluatin Authrizatin and Reimbursement (Infrmatin Psted n April 29, 2016) A prvider must state the date the re-evaluatin was perfrmed n the PA frm. The re-evaluatin prcedure cde must be submitted n the PA frm when submitted with a request fr recertificatin. When submitting claims fr re-evaluatins, prviders shuld use the authrizatin number as referenced n the authrizatin letter. Reimbursement fr the re-evaluatin is nt tied t cntinuatin f services. If a therapy prvider perfrms a re-evaluatin f a client, and the therapy prvider determines services are n lnger necessary, a prvider may state that they intend t discharge the client. The intent t discharge shuld be stated n the PA frm in the "prjected tapered-dwn frequency" sectin. T summarize the prcess fr btaining authrizatin fr a re-evaluatin, HHSC expects prviders t: Obtain an rder fr reevaluatin frm the client's prescribing prvider befre perfrming a reevaluatin Perfrm a reevaluatin within 30 days f the signed and dated rder Submit PA frm with recmmended frequency and duratin t cntinue services t prescribing prvider. Or fllw written r verbal rder prcedure as specified in plicy. Submit t TMHP n earlier than 30 days befre the current authrizatin perid expires: The request fr recertificatin with all elements required fr recertificatin, including the plan f care (see requirements fr initial authrizatin and recertificatin utlined belw) The PA frm, r electrnic equivalent, signed and dated by the therapist. The prescribing prvider must sign the PA frm r therapist must fllw written/verbal rder per plicy. Include the apprpriate reevaluatin cde, and date reevaluatin perfrmed, n the PA frm s that the submitted claim assciated with the reevaluatin prcedure can be cnsidered fr reimbursement. The fllwing is the benefit plicy which was released n February 2, 2016, all updates made in March and April have been incrprated. This benefit plicy will replace all benefit criteria and authrizatin requirements currently stated in the TMPPM.
Physical, Occupatinal, and Speech Therapy - Children (Acute and Chrnic) Statement f Benefits This medical plicy addresses acute and chrnic physical therapy (PT), ccupatinal therapy (OT), and speech therapy (ST) services fr clients wh are birth thrugh 20 years f age. This plicy des nt address freestanding inpatient rehabilitatin services. Unless therwise specified, "days" refers t calendar days. PT, OT, and ST are benefits f Texas Medicaid in Cmprehensive Outpatient Rehabilitatin Facilities (CORFs) and Outpatient Rehabilitatin Facilities (ORFs) nly fr clients aged birth thrugh 20 years. Services prvided t a client n schl premises are nly permitted when delivered befre r after schl hurs. The nly PT, OT, and ST services that can be delivered during schl hurs are therapy services prvided by schl districts as Schl Health and Related Services (SHARS). Clients wh are eligible fr PT, OT, and ST thrugh the public schl system (SHARS), may nly receive additinal therapy thrugh Medicaid if medical necessity criteria is met as utlined in this plicy. Fr specific guidelines related t therapy services prvided thrugh Early Childhd Interventin, refer t the Early Childhd Interventin (ECI) Services - CCP plicy. Therapy services must be perfrmed by ne f the fllwing: a licensed physical therapist, licensed ccupatinal therapist, licensed speech-language pathlgist, a physician within their scpe f practice, r ne f the fllwing under the supervisin f a licensed therapist f the specific discipline: Licensed therapy assistant Licensed speech-language pathlgy intern (Clinical Fellw) Nte: An advanced practice registered nurse (APRN) r a physician assistant (PA) may sign all dcumentatin related t the prvisin f therapy services n behalf f the client's physician when the physician delegates this authrity t the APRN r PA. PT/OT/ST services are prvided in ne f the fllwing places f service by setting and prvider: Outpatient Office Hme Cmprehensive utpatient rehabilitatin facility (CORF)/ Outpatient rehabilitatin facility (ORF) Independently enrlled therapists Physical Therapy Grup Hspitals Physician Physical Therapy Grup Independently enrlled therapists
Other Hme Health Agency Independently enrlled therapists Physical Therapy Grup ECI SHARS In determining whether a service requires the skill f a licensed physical and ccupatinal therapist r speech language pathlgist, cnsideratin must be given t the inherent cmplexity f the service, the cnditin f the client, and the accepted standards f medical and therapy practice guidelines. If the service culd be perfrmed by the average nnmedical persn, the absence f a cmpetent persn (such as a family member r medical assistant) t perfrm it des nt cause it t be a skilled therapy service. If the nature f a service is such that it can safely and effectively be perfrmed by the average nnmedical persn withut direct supervisin f a licensed therapist, the services cannt be regarded as skilled therapy. Acute Services Acute PT, OT, and ST services are benefits f Texas Medicaid fr the medically necessary shrt term treatment f an acute medical cnditin r an acute exacerbatin f a chrnic medical cnditin. Treatments are expected t significantly imprve, restre r develp physical functins diminished r lst as a result f a recent trauma, illness, injury, disease, surgery, r change in medical cnditin, in a reasnable and generally predictable perid f time (60 days), based n the prescribing prvider's and therapist's assessment f the client s restrative ptential. Nte: Recent is defined as ccurring within the past 90 days f the prescribing prvider's evaluatin f cnditin. Treatments are directed tward restratin f r cmpensatin fr lst functin. Services d nt duplicate thse prvided cncurrently by any ther therapy. Services must meet acceptable standards f medical practice and be specific and effective treatment fr the client's cnditin. Services are prvided within the prvider's scpe f practice, as defined by state law. Acute is defined as an illness r trauma with a rapid nset and shrt duratin. A medical cnditin is cnsidered chrnic when 120 days have passed frm the start f therapy r the cnditin is n lnger expected t reslve r may be slwly prgressive ver an indefinite perid f time. With dcumentatin f medical need, PT, OT and ST may cntinue fr a maximum f 120 days fr an acute medical cnditin r an acute exacerbatin f a chrnic medical cnditin.
Once the client s cnditin is n lnger cnsidered acute, cntinued therapy fr a chrnic cnditin will nly be cnsidered fr clients wh are birth thrugh 20 years f age. Chrnic Services Chrnic physical, ccupatinal, and speech therapy services are benefits f Texas Medicaid fr the medically necessary treatment f chrnic medical cnditins and develpmental delay when a medical need is established fr the develpmental delay as indicated in this plicy. All eligible clients wh are birth thrugh 20 years f age may cntinue t receive all medically necessary therapy services, with dcumentatin prving medical necessity. The gals f the services prvided are directed at maintaining, imprving, adapting, r restring functins which have been lst r impaired due t a recent illness, injury, lss f bdy part, cngenital abnrmality, degenerative disease, r develpmental delay. Services d nt duplicate thse prvided cncurrently by any ther therapy. Services must meet acceptable standards f medical practice and be specific and effective treatment fr the client's cnditin. Services are prvided within the prvider s scpe f practice, as defined by state law. Treatment fr chrnic medical cnditins and develpmental delay will nly be cnsidered fr clients wh are birth thrugh 20 years f age. Plicy Overview/Scpe Physical, ccupatinal and speech therapy services must be medically necessary t the treatment f the individual's chrnic r acute need. A diagnsis alne is nt sufficient dcumentatin t supprt the medical necessity f therapy. T be cnsidered medically necessary, all f the fllwing cnditins must be met: The services requested must be cnsidered under the accepted standards f practice t be a specific and effective treatment fr the patient's cnditin, The services requested must be f such a level f cmplexity r the patient's cnditin must be such that the services required can nly be effectively perfrmed by r under the supervisin f a licensed ccupatinal therapist, physical therapist, r speech-language pathlgist, and requires the skills and judgment f the licensed therapist t perfrm educatin and training, The gals f the requested services t be prvided are directed at imprving, adapting, restring, r maintaining functins which have been lst r impaired due t a recent illness, injury, lss f bdy part r cngenital abnrmality r as a result f develpmental delay r the presence f a chrnic medical cnditin. Functinal gals refer t a series f behavirs r skills that allw the client t achieve an utcme relevant t his/her safety and independence within cntext f everyday envirnments. Functinal gals must be specific t the client, bjectively measurable within a specified time frame, attainable in relatin t the client's prgnsis r develpmental delay, relevant t client and family, and based n a medical need.
Testing must establish a client with develpmental delays meets the medical necessity criteria as defined in this plicy, see Develpmental Delay Criteria sectin in this plicy. Medical necessity criteria fr therapy services prvided in the hme must be based n the supprting dcumentatin f the medical need and the apprpriateness f the equipment, service, r supply prescribed by the prescribing prvider fr the treatment f the individual. The therapy service must be related t the client's medical cnditin, rather than primarily fr the cnvenience f the client r prvider. Frequency must always be cmmensurate with the client's medical and skilled therapy needs, level f disability, and standards f practice; it is nt fr the cnvenience f the client r the respnsible caregivers. Treatment plans and plans f care develped must include nt nly the initial frequency (high, mderate r lw) but the expected changes f frequency thrughut the duratin perid requested based n the client's anticipated therapy treatment needs. An example f a tapered dwn frequency request initiated with a high frequency is: 3 times a week fr 2 weeks, 2 times a week fr 2 weeks, 1 time a week fr 2 weeks, 1 time every ther week). Fr prir authrizatin criteria fr frequency, see the Frequency and Duratin Criteria fr PT/OT/ST sectin under the Authrizatin sectin in this plicy. Physical Therapy The practice f physical therapy includes: (1) measurement r testing f the functin f the musculskeletal, r neurlgical, system; (2) rehabilitative treatment cncerned with restring functin r preventing disability caused by illness, injury, r birth defect; (3) treatment, cnsultative, educatinal, r advisry services t reduce the incidence r severity f disability r pain t enable, train, r retrain a persn t perfrm the independent skills and activities f daily living. Texas Medicaid limits physical therapy t the skilled treatment f clients wh have acute r acute exacerbatin f chrnic disrders r chrnic medical cnditin f the musculskeletal and neurmuscular systems. Physical therapy may be prvided by a physician r physical therapist within their licensed scpe f practice. Occupatinal Therapy The practice f ccupatinal therapy includes: (1) evaluatin and treatment f a persn whse ability t perfrm the tasks f living is threatened r impaired by develpmental deficits, sensry impairment, physical injury r illness, (2) using therapeutic gal-directed activities t: (A) evaluate, prevent, r crrect physical dysfunctin; r (B) maximize functin in a persn's life; r (3) applying therapeutic gal-directed activities in treating patients n an individual basis, in grups, r thrugh scial systems, by means f direct r mnitred treatment r cnsultatin.
Texas Medicaid limits ccupatinal therapy t the skilled treatment f clients whse ability t functin in life rles is impaired. Occupatinal therapy may be prvided by a physician r ccupatinal therapist within their licensed scpe f practice. Occupatinal therapy uses purpseful activities t btain r regain skills needed fr activities f daily living (ADL) and/r functinal skills needed fr daily life lst thrugh acute medical cnditin, acute exacerbatin f a medical cnditin r chrnic medical cnditin related t injury, disease r ther medical causes. ADLs are basic self-care tasks such as feeding, bathing, dressing, tileting, grming and mbility. Speech Therapy Speech therapy is a benefit f Texas Medicaid fr the treatment f chrnic, acute r acute exacerbatins f pathlgical r traumatic cnditins f the head r neck, which affect speech prductin, speech cmmunicatin and ral mtr, feeding and swallwing disrders. Speech therapy may be prvided by a physician r speech language pathlgist within their licensed scpe f practice. Speech-language pathlgists treat speech sund and mtr speech disrders, stuttering, vice disrders, aphasia and ther language impairments, cgnitive disrders, scial cmmunicatin disrders, and swallwing (dysphagia) deficits. Speech therapy is designed t amelirate, restre speech/language cmmunicatin and swallwing disrders that have been lst r damaged as a result f a chrnic, acute r acute exacerbatin f a medical cnditin due t a recent injury, disease r ther medical cnditins, r cngenital anmalies r injuries. Types f Cmmunicatin Disrders Language Disrders - Impaired cmprehensin and/r use f spken, written and/r ther symbl systems. This disrder may invlve the fllwing cmpnents: frms f language (phnlgy, mrphlgy, syntax), cntent and meaning f language (pragmatics) and/r the perceptin/prcessing f language. Language disrders may invlve ne, all r a cmbinatin f the abve cmpnents. Speech Prductin Disrders - Impairment f the articulatin f speech sunds, vice and/r fluency. Speech Prductin Disrders may invlve ne, all r a cmbinatin f these cmpnents f the speech prductin system. An articulatin disrder may manifest as an individual sund deficiency, i.e., traditinal articulatin disrder, incmplete r deviant use f the phnlgical system, i.e., phnlgical disrder, r pr crdinatin f the ral-mtr mechanism fr purpses f speech prductin, i.e., verbal and/r apraxia, dysarthria. Oral Mtr/Swallwing/Feeding Disrders - Impairment f the muscles, structures and/r functins f the muth (physilgical r sensry-based) invlved with the entire act f
deglutitin frm placement and manipulatin f fd in the muth thrugh the ral and pharyngeal phases f the swallw. These disrders may r may nt result in deficits t speech prductin. C-Treatment C-treatment is defined as tw different therapy disciplines perfrming therapy n the same client at the same time by a licensed therapist as defined in this plicy fr each therapy discipline, and rendered in accrdance with the Executive Cuncil f Physical Therapy and Occupatinal Therapy Examiners, and State Bard f Examiners fr Speech-Language Pathlgy and Audilgy. C-treatment may be 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 requires the expertise f tw different disciplines (i.e., licensed physical therapist, licensed ccupatinal therapist, r licensed speech-language pathlgist), t perfrm the therapy safely and effectively t reach the client's gals as determined by the apprved plan f care, signed and dated by the client's prescribing prvider. When perfrming c-treatment, a primary therapist must be designated by the tw perfrming therapists. Only the primary perfrming therapist may bill fr the therapy services rendered. The secndary therapist will nt be reimbursed fr assisting a designated primary perfrming therapist. The fllwing c-treatment dcumentatin requirements must be maintained in the client's medical recrds: Medical necessity fr the individual therapy services must be justified befre perfrming c-treatment. Dcumentatin supprts c-treatment gals and hw c-treatment will help the therapist achieve the therapist's gals fr the client, fr each therapy discipline. An explanatin f why the client requires and will receive multi-disciplinary team care, defined as at least tw therapy disciplines (physical, ccupatinal, r speech therapy) during the same therapy sessin. Retrspective review may be perfrmed t ensure dcumentatin supprts that the medical necessity f the c-treatment perfrmed and that the billing was apprpriate fr the services prvided by the designated primary- perfrming therapist. Grup Therapy Grup therapy cnsists f simultaneus treatment t tw r mre clients wh may r may nt be ding the same activities. If the therapist is dividing attentin amng the clients, prviding nly brief, intermittent persnal cntact, r giving the same instructins t tw r mre clients at the same time, the treatment is recgnized as grup therapy. The physician r therapist invlved in grup therapy services must be in cnstant attendance, but ne-n-ne client cntact is nt required. The fllwing requirements must be met in rder t meet the Texas Medicaid criteria fr grup therapy: Prescribing prvider's prescriptin fr grup therapy
Perfrmance by r under the general supervisin f a qualified licensed therapist as defined by licensure requirements, The licensed therapist invlved in grup therapy services must be in cnstant attendance (in the same rm) and active in the therapy, Each client participating in the grup must have an individualized treatment plan fr grup treatment, including interventins and shrt-and lng-term gals and measurable utcmes. Texas Medicaid des nt limit the number f clients wh can participate in a grup therapy sessin. Prviders are subject t certificatin and licensure bard standards regarding grup therapy. Grup Therapy Dcumentatin Requirements The fllwing dcumentatin must be maintained in the client s medical recrd: Prescribing prvider's prescriptin fr grup therapy, Individualized treatment plan that includes frequency and duratin f the prescribed grup therapy and individualized treatment gals, Name and signature f licensed therapist prviding supervisin ver the grup therapy sessin, Specific treatment techniques utilized during the grup therapy sessin and hw the techniques will restre functin, Start and stp times fr each sessin, Grup therapy setting r lcatin, and Number f clients in the grup. The client's medical recrd must be made available upn request. Exclusins (Nn-cvered Services) The fllwing services are nt a benefit f Texas Medicaid: Therapy services that are prvided after the client has reached the maximum level f imprvement r is nw functining within nrmal limits Massage therapy that is the sle therapy r is nt part f a therapeutic plan f care t address an acute cnditin Separate reimbursement fr VitalStim therapy fr dysphagia. VitalStim must be a cmpnent f a cmprehensive feeding treatment plan t be cnsidered a benefit. Repetitive therapy services that are designed t maintain functin nce the maximum level f imprvement has been reached, which n lnger require the skills f a therapist t prvide r versee. Therapy services related t activities fr the general gd and welfare f clients wh are nt cnsidered medically necessary because they d nt require the skills f a therapist, such as: (1) General exercises t prmte verall fitness and flexibility r imprve athletic perfrmance, (2) Activities t prvide diversin r general mtivatin and, (3) Supervised exercise fr weight lss.
Treatment slely fr the instructin f ther agency r prfessinal persnnel in the client's physical, ccupatinal r speech therapy prgram. Emtinal supprt, adjustment t extended hspitalizatin and/r disability, and behaviral readjustment. Therapy prescribed primarily as an adjunct t psychtherapy Treatments nt supprted by medically peer reviewed literature including but nt limited t investigatinal treatments such as sensry integratin, vestibular rehabilitatin fr the treatment f attentin deficit hyperactivity disrder, andyne therapy, cranisacral therapy, interactive metrnme therapy, cranial electr stimulatin, lw-energy neur-feedback, and the Wilbarger brushing prtcl. Therapy nt expected t result in practical functinal imprvements in the client's level f functining. Treatments that d nt require the skills f a licensed therapist t perfrm in the absence f cmplicating factrs (i.e., massage, general range f mtin exercises, repetitive gait, activities and exercises that can be practiced by the client n their wn r with a respnsible adult's assistance). Equipment and supplies used during therapy visits are nt reimbursed separately; they are cnsidered part f the therapy services prvided. Therapy services prvided by a licensed therapist wh is the client s respnsible adult (e.g., bilgical, adptive, r fster parents, guardians, curt-appinted managing cnservatrs, ther family members by birth r marriage). Auxiliary persnnel (aide, rderly, student, r technician) may participate in physical therapy, ccupatinal therapy, r speech therapy sessins when they are apprpriately supervised accrding t each therapy discipline's scpe f practice and prvider licensure requirements. Prviders may nt bill Texas Medicaid fr therapy services prvided slely by auxiliary persnnel. Auxiliary persnnel, a licensed therapy assistant, and a licensed speechlanguage pathlgy intern (Clinical Fellw) are nt eligible t enrll as therapist prviders in Texas Medicaid. Authrizatin Requirements PT/OT/ST Prir authrizatin requests may be submitted t the TMHP Prir Authrizatin Department via mail, fax, r the electrnic prtal. Prescribing r rdering prviders, dispensing prviders, clients' respnsible adults, and clients may sign prir authrizatin frms and supprting dcumentatin using electrnic r wet signatures. Fr additinal infrmatin abut electrnic signatures, please refer t the 'Electrnic Signatures in Prir Authrizatins' medical plicy. Therapy services perfrmed in the acute care inpatient setting d nt require prir authrizatin. Initial Evaluatin and Cnsideratins fr Prir Authrizatin fr Treatment
Initial evaluatins d nt require prir authrizatin (Prcedure cdes 97001, 97003, 92521, 92522, 92523, 92524, and 92610); hwever, dcumentatin kept in the client's recrd must include a signed and dated prescribing prvider's rder fr the evaluatin, supprt a medical need fr the therapy evaluatin and be available when requested. A therapy evaluatin is cnsidered current when it is perfrmed within 60 days befre the prir authrizatin request is received. T cmplete the prir authrizatin prcess by paper, the prvider must cmplete and submit the prir authrizatin requirements dcumentatin thrugh fax r mail, and must maintain 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 cmplete and submit the prir authrizatin requirements dcumentatin thrugh any apprved electrnic methd, and must maintain 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 prescribing prvider must prvide crrect and cmplete infrmatin, including dcumentatin f medical necessity fr the service(s) requested. The prescribing prvider must maintain dcumentatin f medical necessity in the client's medical recrd. The requesting therapy prvider may be asked fr additinal infrmatin t clarify r cmplete a request. Therapy services, regardless f place r prvider, ccurring after the initial evaluatin, require prir authrizatin. PT, OT, r ST services may be prir authrized t be prvided in the fllwing lcatins: hme f the client, hme f the caregiver r guardian, client's daycare facility r the client's schl. Fr acute therapy services, i.e. acute services billed with an AT mdifier, prir authrizatin requests may nt exceed a 60 day perid per each request. After tw 60 day authrized perids, any cntinued requests fr therapy services must be cnsidered under the chrnic sectins f this plicy. Fr chrnic therapy services, prir authrizatin may be granted fr up t 180 days with dcumentatin f medical necessity and additinal prir authrizatins. Initial prir authrizatin (PA) requests must be received n later than five business days frm the date therapy treatments are initiated. Requests received after the five-businessday perid will be denied fr dates f service that ccurred befre the date that the PA request was received. All f the fllwing dcumentatin is required when submitting an initial request fr therapy services initiated after the cmpletin f the evaluatin fr acute r chrnic services: A cmpleted Texas Medicaid Physical, Occupatinal, r Speech Therapy (PT, OT, ST) Prir Authrizatin Frm signed and dated by bth the therapist and by the prescribing prvider is required. When the request frm is unsigned by the prescribing prvider, it must be accmpanied by a signed and dated written rder r prescriptin r a dcumented verbal rder delineating the prescribed therapy services. The prescribing prvider must certify that the Texas Health Steps checkup is current r that a develpmental screening has been perfrmed within the last 60 days.
Signature f prescribing prvider n PA frm will attest that this service has been prvided. If prescribing prvider prvides verbal rder r written rder separate frm PA frm, staff member wh cnveys the verbal r written rder must cmmunicate that prescribing prvider attests that Texas Health Steps checkup is current r that a develpmental screening has been perfrmed within the last 60 days. Fr acute services: Dcumentatin frm the prescribing prvider that a visit fr the acute r acute exacerbatin f the medical cnditin requiring therapy has ccurred within the last 90 days. Evaluatin and Treatment Plan r Plan f Care (POC) with all f the fllwing required elements: Client's medical histry and backgrund All medical diagnses related t the client's cnditin Date f nset f the client's cnditin requiring therapy r exacerbatin date as applicable Date f evaluatin Time in and time ut Baseline bjective measurements based n standardized testing perfrmed r ther standard assessment tls. Fr chrnic services, see sectin n Develpmental Delay Criteria. Safety risks Client-specific, measurable shrt and lng-term functinal gals within the length f time the service is requested Interpretatin f the results f the evaluatin, including recmmendatins fr therapy amunt, frequency per week and duratin f services Therapy treatment plan/poc t include specific mdalities and treatments planned Dcumentatin f client's primary language Dcumentatin f client's age and date f birth Prgnsis fr imprvement Time in and time ut n the evaluatin nte Requested dates f service fr planned treatments after the cmpletin f the evaluatin Respnsible adult's expected invlvement in client's treatment Histry f prir therapy and referrals as applicable Signature and date f treating therapist Additinal Evaluatin and Dcumentatin Requirements fr Speech Therapy Additinal evaluatin and dcumentatin requirements fr speech therapy includes ne r mre f the fllwing:
Language evaluatins - ral-peripheral speech mechanism examinatin and frmal r infrmal assessment f hearing, articulatin, vice and fluency skills; Speech prductin (vice) - frmal screening f language skills, and frmal r infrmal assessment f hearing, vice and fluency skills; Speech prductin (fluency and articulatin) - frmal screening f language skills, frmal r infrmal assessment f hearing, vice and fluency skills; Oral Mtr/Swallwing/Feeding - In additin t frmal screening f language skills, frmal r infrmal assessment f hearing, vice and fluency skills, if swallwing prblems and/r signs f aspiratin are nted, then a statement indicating that a referral has been made t the client's prescribing prvider t cnsider a vide flurscpic swallw study must be included. Bilingual Testing Requirements Bilingual and multilingual speakers are frequently misclassified as develpmentally delayed. Equivalent prficiency in bth languages shuld nt be expected. Criterin-referenced assessment tls can be used t identify and evaluate a client's strengths and weaknesses, as ppsed t nrm-referenced testing, which assesses an individual relative t a grup. When pssible, use culturally and linguistically adapted test equivalents in bth languages t cmpare ptential deficits and included in the dcumentatin. The therapist will shw the highest scre f the tw languages t determine whether the child qualifies and which language will be used fr the child's therapy. Testing fr all subsequent re-evaluatins shuld nly be cnducted in the language used in therapy. Written and Verbal Orders Fr all therapies, when the request frm submitted is nt signed and dated by the prescribing prvider befre the initiatin f services, the request must be accmpanied by ne f the fllwing: A signed and dated written rder r prescriptin r dcumented verbal rder fr the therapy services (dcumenting the frequency rdered). The rder must be dated within the 30 day perid befre the initiatin f services and include the frequency rdered by the client's prescribing prvider based n the evaluatin and services requested by the therapist (the rder fr the evaluatin may be btained separately), and a prescribing prvider's rder t evaluate and treat is acceptable fr the evaluatin, but nt acceptable fr the therapy treatment. Written rders must cntain the prescribing prvider rdered frequency and duratin and affirmatin that client's Texas Health Steps checkup is current r that a develpmental screening has been perfrmed within the last 60 days. Dcumentatin f a verbal rder t include all f the fllwing: Signed and dated by the licensed prfessinal wh by state and federal law may take a verbal rder Name and credentials f the licensed prfessinal taking the rder wh is respnsible fr furnishing r supervising the rdered services Verbal rder includes the date the verbal rder was taken.
Verbal rder includes the services, frequency and duratin prescribed by the rdering prvider. Verbal rder includes attestatin frm prescribing prvider that client's Texas Health Steps checkup is current r that a develpmental screening has been perfrmed within the last 60 days. Requests fr Recertificatin - Acute Therapy Services A recertificatin fr prir authrizatin f acute therapy services may be cnsidered up t a maximum f 60 day increments, when services cntinue t meet authrizatin criteria. Re-evaluatin cdes (Prcedure cdes 97002, 97004, and S9152) require authrizatin fr acute therapy services and must be submitted with the recertificatin request. Therapy fr clients wh are birth thrugh 20 years f age wh d nt meet the acute therapy services criteria may be cnsidered fr chrnic therapy services. Recertificatin fr an acute r acute exacerbatin f medical cnditins includes a Prgress Summary and a Texas Medicaid Physical, Occupatinal r Speech Therapy (PT, OT, ST) Prir Authrizatin Frm. A cmplete request must be received n earlier than 30 days befre the current authrizatin perid expires. Requests fr recertificatin services received after the current authrizatin expires will be denied fr dates f service that ccurred befre the date the submitted request was received. Prir authrizatin fr recertificatin requests may be cnsidered fr increments up t 60 days fr each therapy service request, with dcumentatin supprting the medical necessity including all f the fllwing: Texas Medicaid Physical, Occupatinal r Speech Therapy (PT/OT/ST) Prir Authrizatin Frm r electrnic equivalent signed and dated by the therapist and signed and dated by the prescribing prvider. When the request frm is unsigned by the prescribing prvider, it must be accmpanied by a written rder r prescriptin r a verbal rder fr the prescribed therapy services. A prgress summary (see prgress summary dcumentatin requirements), and a revised treatment plan r plan f care fr the recertificatin dates f service requested, including all f the fllwing: Date therapy services started Changes in the treatment plan, the ratinale and the requested change in frequency f visits fr changing the plan Dcumentatin f reasns cntinued therapy services are medically needed Dcumentatin f client's participatin in treatment, as well as client/respnsible adult's participatin r adherence with a hme treatment prgram New treatment plan r plan f care fr the recertificatin dates f service requested Updated r new functinal and measurable shrt and lng-term treatment gals with new time frames, as applicable. Prgnsis with clearly established discharge criteria.
Dcumentatin f cnsults with ther prfessinals and services r referrals made and crdinatin f service when applicable (e.g., fr schl aged clients, dcumentatin f the crdinatin f care and referrals made fr schl therapies) The updated treatment plan r POC must be signed and dated by the therapist respnsible fr the therapy services. A prgress summary, which may be cntained in the last treatment nte, must be included with the recertificatin request and cntains all f the fllwing: Date therapy started Date the summary cmpleted Time perid (dates f service) cvered by the summary Client's medical and treatment diagnses A summary f client's respnse t therapy/current treatment plan, t include Dcumentatin f any issues limiting the client's prgress Dcumentatin f bjective measures f functinal prgress related t each treatment gal established n the initial evaluatin An assessment f the client's therapy prgnsis and verall functinal prgress Dcumentatin f client's participatin in treatment as well as client/respnsible adult's participatin r adherence with a hme treatment prgram Updated r new functinal and measurable shrt and lng-term treatment gals with time frames, as applicable Dcumentatin f client's cntinued need fr therapy Clearly established discharge criteria Dcumentatin f cnsults with ther prfessinals and services r crdinatin f service when applicable. The prgress summary must be signed and dated by the therapist respnsible fr the therapy services. Requests fr Recertificatin - Chrnic Therapy Services Re-evaluatin (every 180 days) A re-evaluatin is a cmprehensive evaluatin and must take place every 180 days and cntains all the elements f an initial evaluatin. It may be used t make a determinatin whether r nt skilled therapy is medically necessary, r when determining the effectiveness f the current plan, r when the current plan requires significant mdificatin and revisin f the interventins and gals due t changes in the client's medical status r lack f prgress with the current treatment. A re-evaluatin requires authrizatin and must be submitted with the recertificatin request (Prcedure cdes 97002, 97004, and S9152).
Rutine reassessments that ccur during each treatment sessin r visit r fr a prgress reprt required fr an extensin f services r discharge summary are nt cnsidered a cmprehensive re-evaluatin. Tests used must be nrm-referenced, standardized and specific t the therapy prvided. See sectin n Develpmental Delay Criteria. A recertificatin request may be cnsidered, when services will be medically needed after the previusly apprved authrizatin perid ends. A cmplete request must be received n earlier than 30 days befre the current authrizatin perid expires. Requests fr recertificatin services received after the current authrizatin expires will be denied fr dates f service that ccurred befre the date the request is received. A re-evaluatin may ccur as early as 60 days prir t the end f the current authrizatin perid. A therapy re-evaluatin is cnsidered current when it is perfrmed within 60 days befre the current authrizatin perid expires. The re-evaluatin must ccur within 30 days f the signed and dated rder frm the referring prvider. Prir authrizatin fr recertificatin requests may be cnsidered fr increments up t 180 days fr each request with dcumentatin supprting the medical necessity including all f the fllwing: Texas Medicaid Physical, Occupatinal, r Speech Therapy (PT, OT, ST) Prir Authrizatin Frm r electrnic equivalent signed and dated by the therapist and by the prescribing prvider. When the request frm is unsigned by the prescribing prvider, it must be accmpanied by a written rder r prescriptin r a verbal rder fr the prescribed therapy services. A re-evaluatin must include a revised treatment plan r plan f care including all f the fllwing: Date therapy services started Changes in the treatment plan, the ratinale, and the requested change in frequency f visits Dcumentatin f reasns cntinued therapy services are medically needed Dcumentatin f develpmental delay. See sectin n Develpmental Delay Criteria. Dcumentatin f client's participatin in treatment, as well as client/respnsible adult's participatin r adherence with a hme treatment prgram New treatment plan r POC fr the recertificatin dates f service requested Updated r new functinal and measurable shrt and lng-term treatment gals with new time frames, as applicable. Previus authrizatin perid's gals and prgress must be included. Prgnsis with clearly established discharge criteria. The discharge plan must reflect realistic expectatins frm the episde f therapy.
Dcumentatin f cnsults with ther prfessinals and services r referrals made and crdinatin f service when applicable (e.g., fr schl aged clients, dcumentatin f the crdinatin f care and referrals made fr schl therapies). The updated treatment plan r POC must be signed and dated by the therapist respnsible fr the therapy services. The Fllwing Sectins Apply t bth Acute and Chrnic Therapy Services Requests fr Revisins t Existing Prir Authrizatin/ Recertificatin- Acute and Chrnic Therapy Services A revisin t an existing authrizatin/recertificatin must be dcumented in the client's recrd when significant changes ccur in the frequency r treatment plan. When frequency is increased, r services requiring separate authrizatin are added, a request fr revisin must be submitted fr prir authrizatin. Requests fr revisins must be received n later than five business days frm the date the revised therapy treatments are initiated. Requests fr revisins received after the five business day perid will be denied fr dates f service that ccurred befre the date the request was received. A prir authrizatin request fr revisins t services may be cnsidered up t the end f the current apprved prir authrizatin. Requests fr revisin must be submitted with the fllwing dcumentatin: Texas Medicaid Physical, Occupatinal, r Speech Therapy (PT, OT, ST) Prir Authrizatin Frm, including the date the revisin was initiated, signed and dated by the therapist and signed and dated by the prescribing prvider. When the request frm is nt signed and dated by the prescribing prvider, it must be accmpanied by a written rder r prescriptin r a verbal rder fr the prescribed services. Prgress summary fr acute r chrnic services indicating the medical ratinale fr the change requested, and Updated treatment plan r POC addressing all the elements f the previus plan and addressing all revisins t the services planned, including updated r new functinal and measurable shrt and lng-term treatment gals with new time frames, as applicable. Previus authrizatin perid's gals and prgress must be included. The updated treatment plan r POC must be signed and dated by the therapist respnsible fr the therapy services. Change f Therapy Prvider If a prvider r client discntinues therapy during an existing prir authrized perid and the client requests services thrugh a new prvider, utside the current grup r agency, they must start a new request fr authrizatin and submit all dcumentatin required fr an initial evaluatin, and als the fllwing:
A change-f- therapy prvider letter, signed by the client r respnsible adult The letter must dcument the date that the client ended therapy (effective date f change) with the previus prvider, r last date f service The name f the new prvider and previus prvider When a prvider r client discntinues therapy during an existing prir authrizatin perid and the client requests services thrugh a new prvider lcated within the same enrlled grup f prviders r within a grup f independently enrlled prviders cllabratively wrking tgether, the new prvider can use the same evaluatin and plan f care. The authrizatin perid will nt change when the prvider changes. Treatment Nte The fllwing dcumentatin must be kept n file by the treating prvider and be available when requested: Client's name Date f service Time in and ut f each therapy sessin Objectives addressed (shuld cincide with plan f care) and prgress nted, if applicable A descriptin f specific therapy services prvided and the activities rendered during each therapy sessin, alng with a frm f measurement. Assessments f client's prgress r lack f prgress Treatment ntes must be legible Therapist must sign each date f entry with full signature and credentials All dcumentatin fr evaluatins, re-evaluatins, prgress summaries, treatment ntes, and discharge summaries must shw client's name, date f service, time in and time ut f each therapy sessin. Frequency and Duratin Criteria fr PT/OT/ST Frequency must always be cmmensurate with the client's medical and skilled therapy needs, level f disability and standards f practice; it is nt fr the cnvenience f the client r the respnsible adult. Exceptins t therapy limitatins may be cvered if medically necessary criteria are met fr the fllwing: a. Presentatin f new acute cnditin, r b. Therapist interventin is critical t the realistic habilitative/restrative gal prvided dcumentatin prving medical necessity is received. When therapy is initiated, the therapist must prvide educatin and training f the client and respnsible caregivers, by develping and instructing them in a hme treatment prgram t prmte effective carryver f the therapy prgram and management f safety issues.
Prviders may request high, mderate, r lw frequencies n the Texas Medicaid Physical, Occupatinal r Speech Therapy (PT, OT, ST) Prir Authrizatin Frm by indicating 3, 2, r 1 time per week respectively. Prviders may request lw r maintenance level by requesting 1, 2, r 3 times per mnth. Additinal dcumentatin is required when requesting a frequency f 3 times a week r mre. High Frequency (3 times per week): Can nly be cnsidered fr a limited duratin (apprximately 4 weeks r less) r as therwise requested by the prescribing prvider with dcumentatin f medical need t achieve an identified new skill r recver functin lst due t surgery, illness, trauma, acute medical cnditin, r acute exacerbatin f a medical cnditin, with well-defined specific, achievable gals within the intensive perid requested. Therapy prvided three times a week may be cnsidered fr 2 r mre f these exceptinal situatins: The client has a medical cnditin that is rapidly changing. The client has a ptential fr rapid prgress (e.g., excellent prgnsis fr skill acquisitin) r rapid decline r lss f functinal skill (e.g., serius illness, recent surgery). The client's therapy plan and hme prgram require frequent mdificatin by the licensed therapist. On a case-by-case basis, a high frequency requested fr a shrt-term perid (4 weeks r less) which des nt meet the abve criteria may be cnsidered with all f the fllwing dcumentatin: Letter f medical need frm the prescribing prvider dcumenting the client's rehabilitatin ptential fr achieving the gals identified, Therapy Summary dcumenting all f the fllwing: Purpse f the high frequency requested (e.g., clse t achieving a milestne) Identificatin f the functinal skill which will be achieved with high frequency therapy Specific measurable gals related t the high frequency requested and the expected date the gal will be achieved. A higher frequency (4 r mre times per week) may be cnsidered n a case-bycase basis with clinical dcumentatin supprting why 3 times a week will nt meet the client's medical needs. Mderate Frequency: Therapy prvided tw times a week may be cnsidered when dcumentatin shws ne r mre f the fllwing: The client is making very gd functinal prgress tward gals. The client is in a critical perid t gain new skills r 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 may be cnsidered when the dcumentatin shws ne r mre f the fllwing: The client is making prgress tward the client's gals, but the prgress has slwed, r dcumentatin shws the client is 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 t every ther week 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. Nte: As the client's medical need fr therapy decreases, it is expected that the therapy frequency will decrease as well. Maintenance Level/Prevent Deteriratin: This frequency level (e.g., every ther week, mnthly, every 3 mnths) is used when the therapy plan changes very slwly, the hme prgram is at a level that may managed by the client r the respnsible adult, r the therapy plan requires infrequent updates by the skilled therapist. A maintenance level r preventive level f therapy services may be cnsidered when a client requires skilled therapy fr nging peridic assessments and cnsultatins and the client meets ne f the fllwing criteria: Prgress has slwed r stpped, but dcumentatin supprts that nging skilled 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. Develpmental Delay Criteria T establish a develpmental delay, all f the fllwing criteria must be met: Tests used must be nrm-referenced, standardized, and specific t the therapy prvided. Re-testing with nrm-referenced standardized test tls fr re-evaluatins must ccur every 180 days. Tests must be age apprpriate fr the child being tested and prviders must use the same testing instrument as used in the initial evaluatin. If reuse f the initial testing instrument is nt apprpriate, i.e. due t change in client status r restricted age range f the testing tl, prvider shuld explain the reasn fr the change. Eligibility fr therapy will be based upn a scre that falls 1.5 standard deviatins (SD) r mre belw the mean in at least ne subtest area f cmpsite scre n a nrm-referenced, standardized test. Raw scres must be reprted alng with scre reflecting SD frm mean.
When the client's test scre is less than 1.5 SD belw the mean, a criterinreferenced test alng with infrmed evidenced-based clinical pinin must be included t supprt the medical necessity f services and may be sent t physician review t determine medical necessity. If a child cannt cmplete nrm-referenced standardized assessments, then a functinal descriptin f the child's abilities and deficits must be included. Measurable functinal shrt and lng term gals will be cnsidered alng with test results. Dcumentatin f the reasn a standardized test culd nt be used must be included in the evaluatin. Specific Develpmental Delay Criteria Requirements fr speech diagnses: Language: at least ne nrm-referenced, standardized test with gd reliability and validity, a scre that falls 1.5 SD r mre belw the mean, and clinical dcumentatin f an infrmal assessment that supprts the delay Articulatin: at least ne nrm-referenced, standardized test with gd reliability and validity, a scre that falls 1.5 SD r mre belw the mean, and clinical dcumentatin f an infrmal assessment that supprts the delay Apraxia: at least ne nrm-referenced, standardized test with gd reliability and validity, a scre that falls 1.5 SD r mre belw the mean, and clinical dcumentatin f an infrmal assessment that supprts the delay Fluency: at least ne nrm-referenced, standardized test with gd reliability, a scre that falls 1.5 SD r mre belw the mean, and clinical dcumentatin f an infrmal assessment that supprts the delay Vice: a medical evaluatin is required fr eligibility and based n medical referral Oral Mtr/Swallwing/Feeding: an in-depth, functinal prfile f ral mtr structures and functin If the client's test scre is less than 1.5 SD belw the mean, additinal dcumentatin supprting the client's medical need fr therapy will be cnsidered and the request will be sent t physician review t determine medical necessity. Additinal speech therapy visits r sessins may be cnsidered fr mderate speech language, articulatin, vice and dysphagia develpmental delays when dcumentatin submitted supprts medical necessity as delineated in the frequency criteria in this plicy. Age Adjustment fr Children Brn Prematurely Age is adjusted fr children brn befre 37 weeks gestatin and is based n a 40-week term. The develpmental age must be measured against the adjusted age rather than chrnlgical age until the child is 24 mnths ld. The age adjustment cannt exceed 16 weeks. Criteria fr Discntinuatin f Therapy Discntinuatin f therapy may be cnsidered in ne r mre f the fllwing situatins: