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December 2016 Texas Medicaid Provider Procedures Manual

Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook : 4 * Therapy Services Overview

4
Physical, occupational and speech therapy services must be medically necessary to the treatment of the individual’s chronic or acute need. A diagnosis alone is not sufficient documentation to support the medical necessity of therapy. To be considered medically necessary, all of the following conditions must be met:
The services requested must be of a level of complexity or the patient’s condition must be such that the services required can only be effectively performed by or under the supervision of a licensed occupational therapist, physical therapist, or speech-language pathologist, and requires the skills and judgment of the licensed therapist to perform education and training.
Functional goals refer to a series of behaviors or skills that allow the client to achieve an outcome relevant to his/her safety and independence within context of everyday environments. Functional goals must be specific to the client, objectively measurable within a specified time frame, attainable in relation to the client’s prognosis or developmental delay, relevant to client and family, and based on a medical need.
The goals of the requested services to be provided are directed at improving, adapting, restoring, or maintaining functions which have been lost or impaired due to a recent illness, injury, loss of body part or congenital abnormality or as a result of developmental delay or the presence of a chronic medical condition.
Evidence of care coordination with the prescribed pediatric extended care center (PPECC) provider, when the client receives therapy services in a PPECC setting.
The goals of the requested services to be provided are directed at improving, adapting or restoring functions which have been lost or impaired due to a recent illness, injury, loss of body part and restore client’s function to within normal activities of daily living (ADL).
There must be reasonable expectation that therapy will result in a meaningful or practical improvement in the client’s ability to function within a reasonable and predictable time period.
Medical necessity criteria for therapy services provided in the home must be based on the supporting documentation of the medical need and the appropriateness of the equipment, service, or supply prescribed by the prescribing provider for the treatment of the individual.
The therapy service must be related to the client’s medical condition, rather than primarily for the convenience of the client or provider.
Frequency must always be commensurate with the client’s medical and skilled therapy needs, level of disability (for clients who are 20 years of age and younger), and standards of practice; it is not for the convenience of the client or the responsible caregivers.
The following apply:
Treatment plans and plans of care developed must include not only the initial frequency (high, moderate or low) but the expected changes of frequency throughout the duration period requested based on the client’s anticipated therapy treatment needs.
An example of a tapered down frequency request initiated with a high frequency is: 3 times a week for 2 weeks, 2 times a week for 2 weeks, 1 time a week for 2 weeks, 1 time every other week).
Refer to:
Subsection 4.5, “Frequency and Duration Criteria for PT, OT, and ST Services” in this handbook for the frequency prior authorization criteria.
Therapy services are limited to one evaluation, reevaluation or treatment up to the limits outlined in this handbook for each therapy discipline per date of service.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.