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OREGON HEALTH AUTHORITY, DIVISION OF MEDICAL ASSISTANCE PROGRAMS




 

DIVISION 131
PHYSICAL AND OCCUPATIONAL THERAPY SERVICES

410-131-0040
Foreword for Physical
and Occupation Therapy
(1) The Division of Medical
Assistance Programs (Division) Physical and Occupational Therapy (PT/OT) Services
Program rules are designed to assist licensed physical and occupational therapists
deliver health care services and prepare health claims for clients with medical
assistance program coverage.
(2) Oregon Administrative Rules
(OAR) 410-131-0040 through 410-131-0160:
(a) Apply to services delivered
by home health agencies and by hospital-based therapists in the outpatient setting.
Billing and reimbursement for therapy services delivered by home health agencies
and hospital outpatient departments are to be in accordance with the rules in their
respective provider guides.; and
(b) Do not apply to services
provided to hospital inpatients.
(3) The Division enrolls only
the following types of providers as performing providers under the PT/OT program:
(a) A person licensed by the
relevant State licensing authority to practice physical therapy; and
(b) A person licensed by the
relevant State licensing authority to practice occupational therapy.
(4) The PT/OT program rules
contain information on policy, prior authorization, and service coverage and limitations
for some procedures. All Division rules are intended to be used in conjunction with
the General Rules for Oregon Medical Assistance Programs (OAR 410 division 120)
and the Oregon Health Plan (OHP) Administrative Rules (OAR 410 division 141).
(5) The Oregon Health Services
Commission’s Prioritized List of Health Services is found in OAR 410-141-0520
and defines the services covered under the Division.
(6) The PT/OT provider must
understand and follow all Division rules that are in effect on the date services
are provided.
Stat. Auth.: ORS 413.042, 414.065

Stats. Implemented: ORS 414.065

Hist.: HR 8-1991, f. 1-25-91,
cert. ef. 2-1-91; DMAP 35-2011, f. 12-13-11, cert. ef. 1-1-12
410-131-0080
Therapy Plan of Care
and Record Requirements
(1) A therapy plan of care is required
for prior authorization (PA) for payment.
(2) The therapy plan of care
must include:
(a) Client's name, diagnosis,
and type, amount, frequency and duration of the proposed therapy;
(b) Individualized, measurably
objective functional goals;
(c) Documented need for extended
service, considering 60 minutes as the maximum length of a treatment session;
(d) Plan to address implementation
of a home management program as appropriate from the initiation of therapy forward;
(e) Dated signature of the
therapist or the prescribing practitioner establishing the therapy plan of care;
and
(f) For home health clients,
any additional requirements included in Oregon Administrative Rule (OAR) 410 division
127.
(3) The therapy treatment
plan and regimen will be taught to the client, family, foster parents, or caregiver
during the therapy treatments. No extra treatments will be authorized for teaching.
(4) A therapy plan of care
shall comply with the relevant state licensing authority’s standards.
(5) If a state licensing
authority has not adopted therapy plan of care standards, the therapy plan of care
must include:
(a) The need for continuing
therapy clearly stated;
(b) Changes to the therapy
plan of care, including changes to duration and frequency of intervention, and
(c) Any changes or modifications
to the plan of care shall be documented, signed, and dated by the prescribing practitioner
or therapist who developed the plan.
(6) Therapy records must
include:
(a) A written referral, including:
(A) The client's name;
(B) The ICD-10-CM diagnosis
code; and
(C) Shall specify the type
of services, amount, and duration required.
(b) A copy of the signed
therapy plan of care must be on file in the provider's therapy record prior to billing
for services;
(c) Documents, evaluations,
re-evaluations, and progress notes to support the therapy treatment plan and prescribing
provider's written orders for changes in the therapy treatment plan;
(d) Modalities used on each
date of service;
(e) Procedures performed
and amount of time spent performing the procedures is documented and signed by the
therapist; and
(f) Documentation of splint
fabrication and time spent fabricating the splint.
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 688.135,
414.065
Hist.: HR 8-1991, f. 1-25-91,
cert. ef. 2-1-91; HR 19-1992, f. & cert. ef. 7-1-92; OMAP 18-1999, f. &
cert. ef. 4-1-99; OMAP 32-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 41-2001, f.
9-24-01, cert. ef. 10-1-01; OMAP 39-2006, f. 12-15-06, cert. ef. 1-1-07; DMAP 35-2011,
f. 12-13-11, cert. ef. 1-1-12; DMAP 65-2014, f. 10-30-14, cert. ef. 11-4-14; DMAP
51-2015, f. 9-22-15, cert. ef. 10-1-15
410-131-0100
Maintenance
(1) Determination of when maintenance
therapy is reached is made through comparison of written documentation of evaluation
of the last several functional evaluations related to initial baseline measurements.
(2) Therapy becomes maintenance
when any one of the following occur:
(a) The therapy plan of care
goals and objectives are reached; or
(b) There is no progress toward
the therapy plan of care goals and objectives; or
(c) The therapy plan of care
does not require the skills of a therapist; or
(d) The client, family, foster
parents, and/or caregiver have been taught and can carry out the therapy regimen
and are responsible for the maintenance therapy.
(3) Maintenance therapy is not
a reimbursable service.
(4) Re-evaluation to change
the therapy plan of care and up to two treatments for brief retraining of the client,
family, foster parents or caregiver are not considered maintenance therapy and are
reimbursable.
(5) Providers must maintain
adequate documentation as outlined in OAR 410-120-1360, Requirements for Financial,
Clinical and Other Records.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065
& 688.135

Hist.: HR 8-1991, f. 1-25-91,
cert. ef. 2-1-91; HR 19-1992, f. & cert. ef. 7-1-92; OMAP 18-1999, f. &
cert. ef. 4-1-99; OMAP 32-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 41-2001, f.
9-24-01, cert. ef. 10-1-01; DMAP 35-2011, f. 12-13-11, cert. ef. 1-1-12
410-131-0120
Limitations of Coverage
and Payment
(1) Oregon Health Plan (OHP) Plus clients
shall be responsible for paying a co-payment for some services. This co-payment
shall be paid directly to the provider. See OAR 410-120-1230, Client Co-payment,
and Table 120-1230-1 for specific details. [Table not included. See ED. NOTE.]
(2) The provision of PT/OT
evaluations and therapy services require a prescribing practitioner referral, and
services must be supported by a therapy plan of care signed and dated by the prescribing
practitioner (see OAR 410-131-0080).
(3) PT/OT initial evaluations
and re-evaluations do not require Prior Authorization (PA), but are limited to:
(a) Up to two initial evaluations
in any 12-month period; and
(b) Up to four re-evaluation
services in any 12-month period;
(4) Reimbursement is limited
to the initial evaluation when both the initial evaluation and a re-evaluation are
provided on the same day.
(5) All other occupational
and physical therapy treatments require PA. See also OAR 410-131-0160 and Table
131-0160-1. [Table not included. See ED. NOTE.]
(6) A licensed occupational
or physical therapist, or a licensed occupational or physical therapy assistant
under the supervision of a therapist, must be in constant attendance while therapy
treatments are performed:
(a) Duration — Therapy
treatments may not exceed one hour per day each for occupational and physical therapy;
(b) Modalities:
(A) Require PA;
(B) Up to two modalities
may be authorized per day of treatment;
(C) Need to be billed in
conjunction with a therapeutic procedure code; and
(D) Each individual supervised
modality code may be reported only once for each client encounter. See Table 131-0160-1.
[Table not included. See ED. NOTE.]
(c) Massage therapy is limited
to two units per day of treatment and shall only be authorized in conjunction with
another therapeutic procedure or modality.
(7) Supplies and materials
for the fabrication of splints must be billed at the acquisition cost, and reimbursement
may not exceed the Division’s maximum allowable in accordance with the physician
fee schedule. Acquisition cost is purchase price plus shipping. Off-the-shelf splints,
even when modified, are not included in this service.
(8) The following services
are not covered:
(a) Services not medically
appropriate;
(b) Services that are not
paired with a funded diagnosis on the Health Evidence Review Commission's (HERC)
Prioritized List of Health Services pursuant to OAR 410-141-0520;
(c) Work hardening;
(d) Back school/back education
classes;
(e) Hippotherapy (e.g. horse
or equine-assisted therapy);
(f) Services included in
OAR 410-120-1200 Excluded Services Limitations;
(g) Durable medical equipment
and medical supplies other than those splint supplies listed in Table 131-0120-1,
OAR 410-131-0280 [Table not included. See ED. NOTE.]; and
(h) Maintenance therapy (see
OAR 410-131-0100).
(9) Physical capacity examinations
are not a part of the PT/OT program but may be reimbursed as administrative examinations
when ordered by the local branch office. See the Division’s OARs 410, division
150 for information on administrative examinations and report billing.
(10) Table 131-0120-1. [Table
not included. See ED. NOTE.]
[ED. NOTE: Tables referenced are available
from the agency.]
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 688.135,
414.065
Hist.: HR 8-1991, f. 1-25-91,
cert. ef. 2-1-91; HR 19-1992, f. & cert. ef. 7-1-92; HR 28-1993, f. & cert.
ef. 10-1-93; HR 43-1994, f. 12-30-94, cert. ef. 1-1-95; HR 2-1997, f. 1-31-97, cert.
ef. 2-1-97; OMAP 8-1998, f. & cert. ef. 3-2-98; OMAP 18-1999, f. & cert.
ef. 4-1-99; OMAP 32-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 53-2002, f. &
cert. ef. 10-1-02; OMAP 64-2003, f. 9-8-03, cert. ef. 10-1-03; OMAP 59-2004, f.
9-10-04, cert. ef. 10-1-04; OMAP 15-2005, f. 3-11-05, cert. ef. 4-1-05; DMAP 35-2011,
f. 12-13-11, cert. ef. 1-1-12; DMAP 75-2013(Temp), f. 12-31-13, cert. ef. 1-1-14
thru 6-30-14; DMAP 23-2014, f. & cert. ef. 4-4-14
410-131-0160
Prior Authorization for
Payment
(1) Most Oregon Health Plan
(OHP) clients have prepaid health services, contracted for by the Oregon Health
Authority (Authority) through enrollment in a Prepaid Health Plan (PHP). Client’s
who are not enrolled in a PHP receive services on an "open card" or "fee-for-service”
(FFS) basis.
(2) The provider must verify
whether a PHP or the Division of Medical Assistance Programs (Division) is responsible
for reimbursement. Refer to OAR 410-120-1140 Verification of Eligibility.
(3) If a client is enrolled
in a PHP there may be prior authorization (PA) requirements for some services that
are provided through the PHP. Providers must comply with the PHP’s PA requirements
or other policies necessary for reimbursement from the PHP before providing services
to any OHP client enrolled in a PHP. The physical or occupational therapy (PT/OT)
provider needs to contact the client’s PHP for specific instructions.
(4) If a client receives services
on a FFS basis, the Division or their contractor may require a PA for certain covered
services or items before the service can be provided or before payment will be made.
A PT/OT provider assumes full financial risk in providing services to a FFS client
prior to receiving authorization, or in providing services that are not in compliance
with Oregon Administrative Rules (OARs). See OAR 410-120-1320 Authorization of Payment,
this rule and Table 131-0160-1 Services Require Payment Authorization:
(a) PT/OT initial evaluations
and re-evaluations do not require a prior authorization (see OAR 410-131-0120);
(b) To ensure reimbursement
for continuation of PT/OT services and procedures beyond the initial evaluation,
the PT/OT provider must request a PA within five working days following initiation
of services:
(A) PA requests dated within
five working days of initiation of services may be approved retroactively to include
services provided within five days prior to the date of the PA request;
(B) PA requests dated beyond
five working days of initiating services will not be authorized retroactive, and
if authorized will be effective the date of the PA request. The division recognizes
the facsimile or postmark as the PA date of request;
(c) All PA requests require
a therapy plan of care (see OAR 410-131-0080); and
(d) A PA is not required for
Medicare-covered PT/OT services provided to dual-eligible clients, Medicare clients
who are also Medicaid-eligible.
(5) If the service or item is
subject to prior authorization, the PT/OT provider must follow and comply with PA
requirements in these rules, and the General Rules, including but not limited to:
(a) The service is adequately
documented (see OAR 410-120-1360 Requirements for Financial, Clinical and Other
Records). Providers must maintain documentation in the provider's files to adequately
determine the type, medical appropriateness, or quantity of services provided;
(b) The services provided are
consistent with the information submitted when authorization was requested;
(c) The services billed are
consistent with those services provided;
(d) The services are provided
within the timeframe specified on the authorization of payment document; and
(e) Includes the PA number on
all claims for occupational and physical therapy services that require PA, or the
claim will be denied.
(6) Table 131-0160-1
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025
& 414.065

Hist.: PWC 706, f. 1-2-75, ef.
2-1-75; PWC 760, f. 9-5-75, ef. 10-1-75; AFS 46-1982, f. 4-30-82 & AFS 52-1982,
f. 5-28-82, ef. 5-1-82 for providers located in the geographical areas covered by
the AFS branch offices located in North Salem, South Salem, Dallas, Woodburn, McMinnville,
Lebanon, Albany and Corvallis, ef. 6-30-82 for remaining AFS branch offices; AFS
98-1982, f. 10-25-82, ef. 11-1-82; AFS 14-1984(Temp), f. & ef. 4-2-84; AFS 22-1984(Temp),
f. & ef. 5-1-84; AFS 40-1984, f. 9-18-84, ef. 10-1-84; AFS 63-1987, f. 12-30-87,
ef. 4-1-88; HR 8-1991, f. 1-25-91, cert. ef. 2-1-91, Renumbered from 461-023-0015;
HR 19-1992, f. & cert. ef. 7-1-92; HR 28-1993, f. & cert. ef. 10-1-93; HR
43-1994, f. 12-30-94, cert. ef. 1-1-95; HR 2-1997, f. 1-31-97, cert. ef. 2-1-97;
OMAP 8-1998, f. & cert. ef. 3-2-98; OMAP 18-1999, f. & cert. ef. 4-1-99;
OMAP 32-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 41-2001, f. 9-24-01, cert. ef.
10-1-01; OMAP 53-2002, f. & cert. ef. 10-1-02; OMAP 92-2003, f. 12-30-03 cert.
ef. 1-1-04; OMAP 59-2004, f. 9-10-04, cert. ef. 10-1-04; DMAP 35-2011, f. 12-13-11,
cert. ef. 1-1-12

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