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December 2016 Texas Medicaid Provider Procedures Manual

Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook : 5 Children’s Therapy Services Clients birth through 20 years of age : 5.1 * Services, Benefits, and Limitations

This section addresses acute and chronic physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services for clients who are 20 years of age or younger. This section does not address freestanding inpatient rehabilitation services.
Unless otherwise specified, “days” refers to calendar days.
PT, OT, and ST are benefits of Texas Medicaid in Comprehensive Outpatient Rehabilitation Facilities (CORFs) and Outpatient Rehabilitation Facilities (ORFs) for clients who are 20 years of age or younger.
CORF and ORF services provided at schools, homes, daycare facilities, or any other non-Medicare approved ORF or CORF facility is not a covered Comprehensive Care Program (CCP) benefit.
Services provided to a client on school premises are only permitted when delivered before or after school hours. The only PT, OT, and ST services that can be delivered during school hours are therapy services provided by school districts as School Health and Related Services (SHARS).
Clients who are eligible for PT, OT, and ST through the public school system (SHARS), may only receive additional therapy through Medicaid if medical necessity criteria is met as outlined in this handbook.
Refer to:
Subsection, “* Therapy” in the Children’s Services Handbook (Vol. 2, Provider Handbooks) for the specific guidelines for therapy services that are provided through Early Childhood Intervention (ECI).
Section 3, “School Health and Related Services (SHARS)” in the Children’s Services Handbook (Vol. 2, Provider Handbooks) for information about therapy services provided through SHARS.
Therapy services must be performed by one of the following: a licensed physical therapist, licensed occupational therapist, licensed speech-language pathologist, a physician within their scope of practice, or one of the following under the supervision of a licensed therapist of the specific discipline:
An advanced practice registered nurse (APRN) or a physician assistant (PA) may sign all documentation related to the provision of therapy services on behalf of the client’s physician when the physician delegates this authority to the APRN or PA.
PT/OT/ST services are provided in one of the following places of service by setting and provider:
Comprehensive outpatient rehabilitation facility (CORF)/Outpatient rehabilitation facility (ORF), independently enrolled therapists, physical therapy group, hospitals, PPECC
Physician, physical therapy group, independently enrolled therapists
Home health agency, independently enrolled therapists, physical therapy group
In determining whether a service requires the skill of a licensed physical and occupational therapist or speech language pathologist, consideration must be given to the inherent complexity of the service, the condition of the client, the accepted standards of medical and therapy practice guidelines, with consideration of the following:
If the service could be performed by the average nonmedical person, the absence of a competent person (such as a family member or medical assistant) to perform it does not cause it to be a skilled therapy service.
If the nature of a service is such that it can be safely and effectively performed by the average nonmedical person without direct supervision of a licensed therapist, the services cannot be regarded as skilled therapy.
Refer to:
Subsection 2.1, “CCP Overview” in the Children’s Services Handbook (Vol. 2, Provider Handbooks) for additional information about CCP.

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