DAR File No. 38132

Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-21

Physical and Occupational Therapy

Notice of Proposed Rule

(Amendment)

DAR File No.: 38132
Filed: 11/13/2013 10:34:07 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to streamline and consolidate the scope of physical therapy and occupational therapy services for Medicaid recipients.

Summary of the rule or change:

This amendment consolidates the scope of physical therapy and occupational therapy services by removing sections in the rule text that specify reimbursement, eligibility, and service coverage, and deferring to the scope of services found in the Physical Therapy and Occupational Therapy Services Provider Manual and in the Medicaid State Plan.

State statutory or constitutional authorization for this rule:

• 42 CFR 440.110
• Section 26-18-3
• Section 26-1-5

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because this change only consolidates the scope of physical therapy and occupational therapy services for Medicaid recipients.

local governments:

There is no impact to local governments because they do not fund or provide physical therapy and occupational therapy services to Medicaid recipients.

small businesses:

There is no impact to small businesses because this change only consolidates the scope of physical therapy and occupational therapy services for Medicaid recipients.

persons other than small businesses, businesses, or local governmental entities:

There is no impact to Medicaid providers and to Medicaid recipients because this change only consolidates the scope of physical therapy and occupational therapy services for Medicaid recipients.

Compliance costs for affected persons:

There are no compliance costs to a single Medicaid provider or to a Medicaid recipient because this change only consolidates the scope of physical therapy and occupational therapy services for Medicaid recipients.

Comments by the department head on the fiscal impact the rule may have on businesses:

This makes no change in eligibility or benefits so it has no impact on business.

David Patton, PhD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at [email protected]
• Nina Baker at the above address, by phone at 801-538-9127, by FAX at 801-538-6412, or by Internet E-mail at [email protected]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

12/31/2013

This rule may become effective on:

01/07/2014

Authorized by:

David Patton, Executive Director

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-21. Physical Therapy and Occupational Therapy.

R414-21-1. Introduction.

The Physical Therapy and Occupational Therapy programs provide a scope of services for Medicaid recipients in accordance with the Physical Therapy and Occupational Therapy Services Utah Medicaid Provider Manual and Attachment 4.19-B of the Medicaid State Plan, as incorporated into Section R414-1-5.

[R414-21-1. Introduction and Authority.

(1) This rule governs physical and occupational therapy services provided to Medicaid clients. It implements the provision of physical therapy and occupational therapy evaluation and treatment as authorized by 42 CFR 440.110(a)(1)(2), 440.110(b)(1)(2), and 440.70(b)(4).

(2) Physical and occupational therapy are optional services for adults.

 

R414-21-2. Eligibility Requirements.

Physical therapy and occupational therapy services are available to categorically and medically needy individuals under Medicaid when received from an independent occupational therapist or an independent physical therapist including group practices, rehabilitation centers, and hospitals.

 

R414-21-3. Program Access Requirements.

(1) Physical therapy may be provided only by a licensed physical therapist. The physical therapist may have a physical therapy assistant or aide under the physical therapist's immediate supervision provide the direct service so long as the physical therapist is present in the area where the person supervised is performing services and immediately available to assist the person being supervised in the services being performed.

(2) Occupational therapy may be provided only by a licensed occupational therapist. The occupational therapist may have a occupational therapy assistant under the occupational therapist's immediate supervision provide the direct service so long as the occupational therapist is present in the area where the person supervised is performing services and immediately available to assist the person being supervised in the services being performed.

 

R414-21-4. Service Coverage.

(1) Medicaid covers the following physical therapy services:

(a) therapeutic exercise;

(b) the application of heat, cold, water, air, sound, massage, and electricity;

(c) recipient evaluations and tests;

(d) measurements of strength, balance, endurance, range of motion and activities.

(2) Medicaid covers occupational therapy services to treat the following:

(a) traumatic brain injury;

(b) traumatic spinal cord injury;

(c) traumatic hand injury;

(d) congenital anomalies or developmental disabilities resulting in neurodevelopmental deficits; or

(e) cerebral vascular accident (CVA), but only if treatment begins within 90 days after the onset of the CVA.

(3) In exercising its best professional judgement to determine the amount, duration, and scope of optional services sufficient to reasonably achieve the purpose of the physical therapy or occupational therapy service, the Department uses the guidelines provided by the American Physical Therapy Association and the American Occupational Therapy Association to determine the number of visits allowed for the diagnosis.

(4) Medicaid does not cover:

(a) services for social or educational needs only;

(b) services to a recipient with a stable chronic condition whose function cannot be improved by the application physical therapy services;

(c) service to a recipient with no documented potential for improvement or who has reached maximum potential for improvement;

(d) non-diagnostic, non-therapeutic, repetitive or reinforcing procedures or other maintenance services, except for services that are both:

(i) to children under the age of 20 years; and

(ii) are limited to one therapy visit per month to train the caregiver to provide routine care, and repetitive or reinforced procedures in the residence.

(5) Medicaid pays for only one physical therapy session per day. Medicaid pays for only one occupational therapy session per day.

(6) Services to a resident of an Intermediate Care Facility for the Mentally Retarded are paid as part of the per diem payment for the recipient. Medicaid does not pay separately for those services.

(7) Physical therapy is limited to 20 visits annually without obtaining prior authorization to assure that the sessions are within the amount, duration, and scope limits established by the Department.

(8) Occupational therapy is limited to 20 visits annually without prior authorization to assure that the visits are within the amount, duration, and scope limits established by the Department.

 

R414-21-5. Services Provided Through Home Health Agencies.

(1) If a physical therapy service is provided outside of the physical therapists treatment facility, the provider must obtain prior authorization from the Department for each physical therapy session, including the evaluation. to assure that the sessions are within the amount, duration, and scope limits established by the Department and that the recipient could not obtain the service at the physical therapist's treatment facility.

(2) The Department does not cover occupational therapy services that are not provided at the occupational therapist's treatment facility.

 

R414-21-6. Reimbursement.

(1) Physical and occupational therapy is reimbursed using the fee schedule established in the Utah Medicaid State Plan and incorporated by reference in Section R414-1-5.

(2) Services provided by a physical therapy assistant or aide or by an occupational therapy assistant must be billed as part of the services provided by the supervising physical or occupational therapist.

]

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [July 1, 2009]2014

Notice of Continuation: March 2, 2012

Authorizing, and Implemented or Interpreted Law: 26-1-4.1; 26-1-5; 26-18-3