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December 2016 Texas Medicaid Provider Procedures Manual

Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook

Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook
Table of Contents
1 General Information 4
2 Enrollment 4
3 Managed Care Organization (MCO) Clients Who Transition to Medicaid Fee-For-Service (FFS) 4
3.1 Submission Guidelines 4
3.2 Documentation Requirements 5
3.3 New Services and Extension of Services 5
3.4 Loss of Eligibility 5
4 * Therapy Services Overview 6
4.1 Physical Therapy 7
4.2 Occupational Therapy 7
4.3 Speech Therapy 8
4.3.1 Types of Communication Disorders 8
4.4 Co-Treatment 8
4.4.1 Group Therapy 9
4.4.1.1 Group Therapy Documentation Requirements 9
4.5 Frequency and Duration Criteria for PT, OT, and ST Services 10
4.5.1 High Frequency 10
4.5.2 Moderate Frequency 11
4.5.3 Low Frequency 11
4.5.4 Maintenance Level/Prevent Deterioration 11
4.5.5 Requesting Therapy Services 11
4.6 Criteria for Discontinuation of Therapy 12
4.7 Exclusions (Non-covered Services) 12
5 Children’s Therapy Services Clients birth through 20 years of age 13
5.1 * Services, Benefits, and Limitations 13
5.1.1 Acute PT, OT, and ST Services 14
5.1.2 Chronic Services 15
5.2 Authorization Requirements for PT, OT, and ST Services 15
5.2.1 Initial Evaluation and Considerations for Prior Authorization for Treatment 16
5.2.1.1 Initial Evaluation for Acute and Chronic Therapy Services 16
5.2.2 Additional Evaluation and Documentation Requirements for Speech Therapy 17
5.2.2.1 Bilingual Testing Requirements 18
5.2.3 Written and Verbal Orders 18
5.2.4 Requests for Recertification—Acute Therapy Services 18
5.2.5 Requests for Recertification - Chronic Therapy Services 20
5.2.5.1 Reevaluation (every 180 days) 20
5.2.6 Requests for Revisions to Existing Prior Authorizations or Recertification for Acute and Chronic Therapy Services 21
5.2.7 Change of Therapy Provider 22
5.2.8 Treatment Note 22
5.3 Developmental Delay Criteria 22
5.4 Age Adjustment for Children Born Prematurely 23
5.5 * PT, OT, and ST Procedure Codes 23
5.5.1 Therapy Co-Treatment 25
6 Adult Services 25
6.1 Services, Benefits, and Limitations 25
6.1.1 Acute Therapy Place of Service 26
6.2 Authorization Requirements for Outpatient and Home Health —PT, OT, and ST Services 27
6.2.1 Initial Evaluation and Considerations for Prior Authorization for Treatment 27
6.2.1.1 * Documentation 27
6.2.2 Written and Verbal Orders 28
6.2.3 Requests for Recertification -Up to an Additional 60 days for Acute Services 29
6.2.4 Requests for Revisions to Existing Prior Authorization or Recertification 30
6.2.5 Change of Therapy Provider 31
6.2.6 Treatment Note 31
6.3 PT, OT, and ST Procedure Codes 32
7 Claims Filing and Reimbursement 33
7.1 Claims Information 33
7.2 Reimbursement/Billing Guidelines 34
7.2.1 Method for Counting Minutes for Timed Procedure Codes in 15-Minute Units 34
7.3 Claims Resources 35
7.4 Contact TMHP 35
8 Forms 35
9 Claims Forms Examples 36
 

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