1 Department of Medical Assistance Services

2 OUTPATIENT REHABILITATION SERVICES Presented by: Amy Burkett, Health Care Compliance Specialist II Department of Medical Assistance Services March 19, 2007

3 AGENDA w Rehabilitation Criteria w Rehabilitation Services w Documentation Requirements w Quality Management Utilization Review w Appeals Process

4 COMMONLY USED ACRONYMS DMAS - Department of Medical Assistance Services CMS – Centers for Medicare and Medicaid Services PA - Preauthorization POC - Plan of Care IFSP – Individualized Family Service Plan PCP - Primary Care Physician KePro - Va. Medicaid Preauthorization Contract Agency VAC - Virginia Administrative Code

5 PROGRAM PROVISIONS w PHYSICAL THERAPY w OCCUPATIONAL THERAPY w SPEECH-LANGUAGE PATHOLOGY

6 COVERED SERVICES Medically necessary rehab services are a covered service for Medicaid recipients. Medical necessity is: w Services ordered by a physician w Recipient treatment plan of care w Accepted medical standards of practice (not experimental or investigational) w Safe and cost-effective level of care

7 PROVIDERS OF SERVICE Outpatient rehab services may be provided by: w Acute Care and Rehab Hospitals w Nursing Facilities w Rehabilitation Agencies w School Divisions w Early Infant Intervention Agencies

8 Prior Authorization KePro prior authorization information: Toll Free Phone: Richmond Phone:

9 REGULATIONS Outpatient Rehab program criteria and policy guidelines may be found in: w 42 CFR (Code of Federal Regulations) w VAC (Virginia Administrative Code) w Virginia Medicaid Rehabilitation Manual NOTE: These regulations are accessible through the DMAS Agency Website

10 DEFINITION OF A VISIT w A visit is defined as the tx session that a rehab therapist is with a recipient to provide covered services as prescribed by a physician. w A visit is not defined in measurements or increments of time. w Reimbursement is made on a per visit basis per discipline.

11 DEFINITION OF A VISIT (continued) Examples of therapy visits: w PT/OT co-treatment visit = 1 visit (same therapy treatment goals) w PT in the AM/ PT in the PM = 2 visits w PT and OT in the PM = 1 visit per discipline

12 REHABILITATION THERAPISTS’ QUALIFICATIONS

13 PHYSICAL THERAPY Services may be provided by: w Physical therapist (LPT) licensed by the Virginia Board of Physical Therapy w Physical therapy assistant (LPTA) licensed by the Virginia Board of Physical Therapy and supervised by the LPT

14 OCCUPATIONAL THERAPY Services may be provided by: w Occupational Therapist (OTR) registered by the Nat’l Board for Certification in O.T. and licensed by the Virginia Board of Medicine w Certified Occupational Therapy Assistant (COTA) certified by Nat’l Board for Certification in O.T. and supervised by an OTR

15 SPEECH-LANGUAGE PATHOLOGY Services may be provided by: w Licensed SLP who has (a) CCC’s from ASHA; or (b) has completed the equivalent educ. requirements & work experience; or (c) has completed the academic program & acquiring work experience; OR w SLP licensed by the Board of Audiology & Speech-Language Pathology (BOA & SLP)

16 SPEECH -LANGUAGE PATHOLOGY (cont’d) Since Jan. 1, 2001, DMAS has reimbursed for provision of SLP services by speech-language assistants with supervision by a licensed SLP or CCC/SLP. Speech-language assistants may be: w Bachelor’s level w Master’s level without licensure

17 DOCUMENTATION REQUIREMENTS

18 MEDICAID REQUIRED DOCUMENTATION w Physician w Physical therapist w Occupational therapist w Speech-language pathologist

19 DOCUMENTATION REQUIREMENTS Physician: w Order for therapy evaluation w Order for plan of care (IFSP) for therapy services w Review and Re-certification for continued therapy annually w Discharge order

20 PHYSICIAN ORDER/POC MD order required prior to the provision of any therapy services. The MD order for initial therapy evaluation and treatment may be in the form of: w Prescription for the evaluation w Plan of Care (IFSP) with MD review and MD signature/date of approval

21 PHYSICIAN ORDER/POC (continued) w Discharge Order: When services are no longer required, the therapist must obtain a physician discharge order when discontinuing therapy services to the recipient.

22 DOCUMENTATION REQUIREMENTS Therapist: w Evaluation w Annual Plan of Care (IFSP) prepared, signed and dated by a licensed therapist w Progress Notes w Discharge Summary

23 THERAPY EVALUATION COMPONENTS w Medical History w Medical Diagnosis w Previous Treatments w Functional limitations/deficits w Medical findings w Clinical signs and symptoms w Therapist Recommendations

24 RE-EVALUATIONS Re-evaluations will be reimbursed by DMAS when there is : w Interruption in services, or w Change in recipient’s condition NOTE: “Program generated” evaluations are not reimbursed by DMAS

25 THERAPY PLAN OF CARE COMPONENTS w Frequency/duration w Modalities/interventions w Anticipated functional improvement w Measurable goals with time frames for achievement (LTG/STG) w Discharge plan and estimated date of discharge

26 THERAPY PLAN OF CARE COMPONENTS (continued) Long and Short Term Goals must be: w Patient-oriented w Measurable w Realistic w Include time frames for goal achievement (month/day/year) NOTE: Long-term goals must be in place to cover the annual time frame requested

27 THERAPY PLAN OF CARE COMPONENTS (continued) w Goals must be specific to the recipient’s needs identified in the initial evaluation w Identify discipline (PT/OT/SLP), frequency (1x/wk, 2x/wk, 1-2x/wk), individual and/or group therapy, and treatment modalities/interventions

28 THERAPY PLAN OF CARE w The plan must be reviewed/revised annually w Renewal or modification/revision of the plan must be signed and dated by a qualified therapist w Physician must review, sign and date the plan of care within 21 days of the implementation date

29 PLAN OF CARE SIGNATURE REQUIREMENTS w Therapist’s name, title, and full date w Physician name, title, and full date w Dated signatures are required on the POC/IFSP and any addendum orders NOTE: All signatures must be dated by the author. For example, a therapist cannot date a physician’s signature.

30 THERAPY PLAN OF CARE ADDENDUM ORDER POC Addendum Order must be signed by the physician when: w All LTG’s are achieved or one or more LTG’s are revised/added/deleted, or; w Recipient has a significant change in his/her condition, or; w Change in frequency or duration of tx

31 THERAPIST PROGRESS NOTES Progress notes must be written for each visit and must include: w Recipient’s response to treatment w Treatment rendered w Progress toward recipient goals w Change in recipient’s condition w Therapist, title, signature and date NOTE: Not documented, not reimbursed!

32 THERAPIST PROGRESS NOTES (continued) w Supervisory 30 day on-site review when an LPTA, COTA, or a speech-language assistant are providing treatment w Licensed therapist is not required to co- sign the progress notes written by an assistant w Licensed therapist must document the 30 day supervisory review (including signature, title, and date)

33 TERMINATION OF SERVICES Therapy services must be terminated when further progress toward the established goals is unlikely or therapy treatments can be maintained by the recipient or a caregiver.

34 CONDITIONS OF DISCHARGE Discharge from outpatient rehab must be considered when one of the following conditions exist: w No further potential for improvement is demonstrated w The skills of a qualified therapist are no longer required w The recipient has reached their maximum level of progress

35 DISCHARGE SUMMARY The discharge summary must describe: w Functional outcome w Recipient LTG’s achieved w Follow-up plans w Discharge disposition NOTE: Must complete within 30 days of recipient’s discharge from services. Must be signed, titled, and dated by the licensed therapist.

36 Quality Management Utilization Review

37 DMAS QUALITY MANAGEMENT UTILIZATION REVIEW The purpose of UR is to ensure: w Services are medically necessary w Appropriate provision of services w High quality of services w Criteria for services are met w Documentation requirements are met

38 DMAS UR RESPONSIBILITY DMAS is responsible for validation of: w Appropriateness of care provided w Adequacy of services w Necessity of continued participation w Verification of documentation requirements, including physician orders

39 PROVIDER UR RESPONSIBILITY w Justify provision of services w Identify the treatment provided w Must meet all DMAS documentation requirements w Appropriate discontinuation of services

40 RETENTION OF MEDICAL RECORDS w Medical records must be retained for not less than 5 years after recipient discharge date w Medical records must be readily available, organized, and legible w Applicable to both open and closed medical records

41 APPEALS PROCESS

42 APPEAL PROCESS w RECIPIENT w PROVIDER

43 APPEAL PROCESS Recipient Appeal If the denied rehab service has not been provided to the recipient, the denial may be appealed only by the recipient or his/her legally appointed representative. Recipient appeals must be submitted within 30 days to DMAS Appeals Division.

44 APPEAL PROCESS Provider Appeal The rehab provider has the right to request reconsideration of DMAS utilization review retractions. The request for reconsideration and all supporting documentation, must be submitted to DMAS within 30 days of the denial notification.

45 APPEAL PROCESS Provider Appeal (continued) w First Level Appeal - to the DMAS Supervisor of the Facility and Home Based Services Unit w Second Level Appeal - to the DMAS Appeals Division (IFFC Hearing) w Third Level Appeal - to the DMAS Appeals Division (Formal Hearing)

46 GENERAL INFORMATION Please feel free to visit our web site at: For clinical questions you may call the DMAS Facility and Home Based Services Unit at , option 1 The Unit fax number is For billing questions call the DMAS Provider Helpline at