5101:3-34-01.2 Physical therapy, occupational therapy and speech-language pathology/audiology services: coverage and limitations.

(A) Medicaid covered skilled therapies are:

(1) Physical therapy;

(2) Occupational therapy;

(3) Speech language pathology/audiology.

(B) Medicaid providers authorized to be reimbursed by the department for skilled therapy are:

(1) Eligible providers of physician services, defined in accordance with rule 5101:3-4-01 of the Administrative Code, for skilled therapy performed by the physician; a licensed physical therapist, licensed occupational therapist, licensed speech-language pathologist, or licensed audiologist employed by or under contract with the physician; a licensed physical therapist assistant under the direct supervision of a licensed physical therapist employed by or under contract with the physician; a licensed occupational therapy assistant under the direct supervision of a licensed occupational therapist employed by or under contract with the physician; a licensed speech-language pathology aide under the direct supervision of a licensed speech-language pathologist employed by or under contract with the physician; or a licensed audiology aide under the direct supervision of a licensed audiologist employed by or under contract with the physician:

(a) Physicians, in accordance with Chapter 5101:3-4 of the Administrative Code;

(b) Ambulatory health care clinics;

(i) Fee-for-service ambulatory health care clinics, in accordance with Chapter 5101:3-13 of the Administrative Code;

(ii) Cost-based ambulatory health care clinics;

(a) Federally-qualified health centers, as defined in Chapter 5101:3-28 of the Administrative Code;

(b) Outpatient health facilities, as defined in Chapter 5101:3-29 of the Administrative Code; and

(c) Rural health clinics, as defined in Chapter 5101:3-16 of the Administrative Code;

(2) Advanced practice nurses, in accordance with Chapter 5101:3-8 of the Administrative Code;

(3) Practitioners authorized to bill for skilled therapy services, as specified in accordance with Chapter 5101:3-8 of the Administrative Code;

(4) Intermediate care facilities for persons with mental retardation (ICFs/MR), in accordance with Chapter 5101:3-3 of the Administrative Code;

(5) Hospitals, in accordance with Chapter 5101:3-2 of the Administrative Code; and

(6) Nursing facilities, in accordance with Chapter 5101:3-3 of the Administrative Code.

(C) Coverage and limitations of skilled therapy services, unless otherwise indicated under specific program rules such as for institutional providers and the medicaid school program:

(1) Skilled therapy services are allowable for medicaid reimbursement only if all the following criteria are met:

(a) A medicaid authorized prescriber prescribes therapies for a reasonable amount, frequency, and maximum duration of sixty-day period of treatment or less for rehabilitative services or a maximum duration of six-month period of treatment or less for developmental services, with the period of treatment beginning with the evaluation and concluding with a re-evaluation. In accordance with paragraph (C)(1)(e) of this rule, the re-evaluation includes development of either a new/revised plan of care and treatment or a maintenance plan. The prescribed therapy services:

(i) Are medically necessary, in accordance with rule 5101:3-34-01.1 of the Administrative Code;

(ii) Are of such level of complexity and sophistication, or the condition of the patient is such that the service can be safely and effectively performed only by or under the direct supervision of a licensed therapist; and

(b) A physician or licensed therapist conducts and documents a clinical evaluation and assessment that indicates that the patient has a deficit in physical, occupational and/or speech-language/audiology functionality, and:

(i) Potential exists for the patient's condition to improve within a sixty-day period of treatment for rehabilitative services or six-month period of treatment for developmental services and for the patient to attain or make significant progress toward expected milestones (developmental) or restore functionality (rehabilitative) within twelve months of treatment, beginning with the evaluation; or

(ii) Potential does not exist for the patient to attain or make significant progress toward expected milestones or restore the individual's functionality within twelve months, but a safe and effective maintenance program may be established in accordance with paragraph (C)(1)(e) of this rule;

(iii) Documented evaluation and assessment must include, at a minimum:

(a) The diagnosis, including current physical status, type and severity of the disorder;

(b) Review of auditory, visual, motor, and cognitive status;

(c) Case history information including parental/family perspectives on the patient's development and capacity to participate in therapy services;

(d) Standardized and/or non-standardized methods such as instruments that examine age-appropriate developmental criteria;

(e) Test results and interpretation;

(f) Prognosis (developmental or rehabilitative potential)

(g) Recommendations including the need for further appraisal, follow-up, or referral; and

(c) A physician or licensed therapist develops, documents, and forwards to the medicaid authorized prescriber a written, goal oriented plan of care and treatment for the patient that must:

(i) Be based on the clinical evaluation and assessment of the patient's condition;

(ii) As appropriate, be coordinated with services provided by non-medicaid providers or programs (e.g., child welfare, child care, prevocational and vocational services);

(iii) Provide a process to involve the patient and other responsible persons in the provision of services;

(iv) Be included as part of the patient's medical record;

(v) Be signed by the physician or licensed therapist who develops the plan of care and treatment;

(vi) Includes, at a minimum:

(a) Specific services, procedures, and methods to be used, and the amount, duration and frequency of each service;

(b) Specific functional goals to be achieved, including the level or degree of improvement expected within sixty days for rehabilitative services or within six months for developmental services;

(c) The prescription for services, as established by the medicaid authorized prescriber, in accordance with paragraph (C)(1)(a) of this rule;

(d) Documentation of patient participation or other responsible person; and

(e) Specific timelines for re-evaluation of the plan and updates to the plan of treatment.

(vii) Within thirty days of the first date of therapy service, have documented approval by the medicaid authorized prescriber; and

(d) A physician, licensed therapist, licensed therapy aide or licensed therapist assistant working within his or her scope of practice as defined by state law, furnishes the prescribed therapy services in accordance with this rule and in accordance with the individual's written plan of care and treatment that has been approved by the medicaid-authorized prescriber; and

(e) The licensed therapist conducts, documents, and forwards to the medicaid authorized prescriber a therapy patient progress summary at the conclusion of the period of treatment, or less than the prescribed period of treatment, if the patient achieves the goals set in the plan of care and treatment, if the physician or licensed therapist determines that the patient has reached the maximum level of function, or the licensed therapist determines that the patient is not participating in services. This patient progress summary:

(i) Addresses the degree of consumer progress made toward the expected potential/functionality;

(ii) Includes:

(a) Development of new/revised plan of care and treatment; or

(b) Development of a maintenance plan.

(iii) Communicates the patient progress summary with the medicaid-authorized prescriber, thus promoting continuity of care.

(a) If the therapy patient progress summary indicates a new or revised plan of care and treatment, the new or revised plan must be approved by the medicaid authorized prescriber within thirty days; or

(b) If the therapy patient progress summary indicates development of a maintenance program and instruction of the consumer (and the consumer's family/caregivers, if applicable) regarding the maintenance program, the development of the maintenance plan and instruction is covered as part of therapy, but services furnished under a maintenance plan are not covered; and

(f) The licensed therapist furnishing the prescribed therapy services must document, in the patient 's record:

(i) The evaluation and assessment that supports the use of therapy intervention as described in paragraph (C)(1)(b) of this rule;

(ii) The plan of care and treatment as described in paragraph (C)(1)(c) of this rule;

(iii) The number, frequency, and type of treatment services furnished as described in paragraph (C)(1)(d) of this rule;

(iv) The patient progress summary as described in paragraph (C)(1)(e) of this rule;

(v) The patient's history;

(vi) Type of treatment used, including body areas treated;

(vii) The date therapy was initiated and the date of each treatment;

(viii) The prescription, including the name of the medicaid authorized prescriber who prescribed the services, in accordance with paragraph (C)(1)(a) of this rule; and

(g) The prescribed services are billed by a medicaid provider authorized to bill the department for skilled therapy services, in accordance with paragraph (B) of this rule.

(2) Non-covered services include:

(a) Services billed by anyone who is not authorized by the department in accordance with Chapter 5101:3-1 of the Administrative Code, to be a provider of therapy services;

(b) Services not furnished by or under the direct supervision of a physician or licensed therapist;

(c) Services rendered by non-licensed persons;

(d) Services furnished under a plan of care and treatment that has not been approved by a medicaid-authorized prescriber in accordance with paragraph (C)(1) of this rule;

(e) Services not furnished in approved places of service;

(f) Therapy services when a patient fails to demonstrate progress within a sixty-day period of treatment for rehabilitative services or six-month period of treatment for developmental services;

(g) Consultations with family members or other non-medical personnel;

(h) Maintenance services;

(i) For non-institutional settings, services listed as not covered in rules 5101:3-4-28 and 5101:3-1-60 of the Administrative Code. Certain modalities are considered part of an associated therapy procedure or medical encounter and are not separately reimbursable.

(j) A universal hearing screening for newborns described in Chapter 3701-40 of the Administrative Code will be covered during the newborn's hospital stay through the hospital program as described in Chapter 5101:3-2 of the Administrative Code. A newborn screen is not a separately reimbursable clinic service.

(3) Limitations/exclusions regarding therapy services:

(a) Habilitation services are covered under medicaid only when:

(i) Provided for residents in an intermediate care facility for persons with mental retardation (ICF/MR); or

(ii) Included under a federally approved home and community-based services (HCBS) waiver for individuals with mental retardation/developmental disability, and are medically necessary services identified in an enrollee's particular HCBS waiver. Special education and related services that otherwise are available to the individual through a local educational agency and vocational rehabilitation services that otherwise are available to the individual through a program funded under 29 U.S.C. 730 (release date: September 29, 2005) are not reimbursable through federally approved HCBS waivers.

(b) Allowable non-institutional "places of service" for skilled therapy services include, but are not limited to:

(i) Licensed child day care centers;

(ii) Adult day care centers; and

(iii) Natural environments.

(c) Limits.

(i) Non-institutional settings, per twelve month period:

(a) Thirty dates of service per twelve month period for any combination of physical and occupational therapy services; and

(b) Thirty dates of service per twelve month period for any combination of speech-language pathology and audiology services; although

(c) Additional therapy services can be requested through prior authorization in accordance with Chapter 5101:3-1 of the Administrative Code.

(ii) Institutional settings, in accordance with Chapters 5101:3-2 and 5101:3-3 of the Administrative Code.

(d) The department does not directly reimburse the following health care providers, even when their services are prescribed by a medicaid authorized prescriber:

(i) A self-employed audiologist or audiologist group practice;

(ii) An audiologist aide under the direct supervision of a self-employed audiologist or audiologist group practice;

(iii) A self-employed speech-language pathologist or speech-language pathology group practice;

(iv) A speech-language pathologist aide under the direct supervision of a self-employed speech language pathologist or speech language pathology group practice.

(e) Services provided by therapy students completing internships must meet all of the following conditions to be reimbursed:

(i) The service must be billed by a medicaid provider:

(a) Who is authorized to bill for the specified services; and

(b) Who has a letter on file from the student's clinical program stating the dates of the student's internship;

(ii) The student must be under the direct supervision of the licensed therapist responsible for the patient's care;

(iii) The licensed therapist responsible for the patient's therapy must have face-to-face contact with the patient during the patient's visit and must confirm that the service provided by the student was appropriate;

(iv) The patient's medical record must contain documentation that the service was provided by a student under the direct supervision of a licensed therapist; and

(v) The patient's medical record must show that the requirements for reimbursement were met and the licensed therapist responsible for the patient's therapy reviewed, countersigned, and dated the notes in the medical records at least once a week so that it is documented that the licensed therapist is responsible for the patient's care.

Effective: 01/01/2008
R.C. 119.032 review dates: 01/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021 , 5111.029