1. Medicaid Billing Module Physical Therapy Billing Form

2. Changes Services must be documented on the current IEP for meetings held prior to August 1, 2015. Services must be documented on Service Care Plan for IEP meetings held after August 1, 2015. As of August 1, 2015 OT specific ICD 10 Diagnosis codes are required.

3. Physician Authorization Physician Authorization is still required annually to bill for physical therapy. Authorization can now be from a Physician's Assistant or an Advanced Practice Registered Nurse (APRN). Authorization is good for one calendar year from the date signed.

4. Student Demographics Complete this section taking note of the following issues The diagnosis code is to be an ICD 10 code that matches the need for physical therapy. For provider name print the name of the person providing the service.

5. Procedure Codes Complete beginning and end dates for each procedure. List the total number of units for the month for each procedure. The form is to be used for only one month.

6. Student Demographics and Procedures Sample Medicaid NumberLast NameFirst Name 0000000000DoeJane WVEIS #Diagnosis CodeDate of Birth 999999999 01-01-1900 County1 Beginning Date1 Ending Date1 Procedure CodeUnits 05909/01/201509/30/2015 97110 GP 10 School2 Beginning Date2 Ending Date2 Procedure CodeUnits 20309/01/201509/30/201597116 GP5 Provider Name3 Beginning Date3 Ending Date3 Procedure CodeUnits 09/01/201509/30/2015 97002 GP 1

7. Explanation of Procedures and Caps Part 1 97001 GPPhysical Therapy Evaluation1 event per calendar year 97002 GPPhysical Therapy Re-evaluation2 events per calendar year 97032 GPApplication of a modality to one or more areas; electrical stimulation (manual), each 15 minutes 20 units per month 97110 GPTherapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility 20 units per month 97112 GPNeuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception for sitting and/or standing activities, each 15 minutes 20 units per month 97113 GPAquatic therapy with therapeutic exercises, each 15 minutes20 units per month

8. Explanation of Procedures and Caps Part 2 97116 GPGait training (includes stair climbing) each 15 minutes20 units per month 97140 GPManual therapy techniques (Mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes 20 units per month 97150 GPTherapeutic procedure(s), group (2 or more individuals), each 15 minutes.20 units per month 97530 GPTherapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance) each 15 minutes 20 units per month 97532 GPDevelopment of cognitive skills to improve attention, memory, problem solving, (includes compensatory training), direct (one-on-one) patient contact by the provider, each 15 minutes 20 units per month 97533 GPSensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes 20 units per month

9. Start and Stop Times Enter the start and stop times for each service on the corresponding date at the bottom of the form. These will be used to easily identify dates billable services were conducted for students with transportation services.

10. Start and Stop Times Date123456789101112131415 Start Time End Time Date16171819202122232425262728293031 Start Time End Time

11. Physical Therapy Assistants (PTA) PTAs can only bill for therapy when a Physical Therapist (PT) certified by the WV Board of Examiners is directly supervising. Directly supervising requires the Board Certified PT to be on site when the therapy is being provided. PTAs cannot bill for evaluations.

12. Additional Documentation Progress/therapy logs will also be required. Original copies of progress/therapy logs must be on file in the special education central office. PTA progress/therapy logs are to be co- signed by the supervising PT for therapy dates that are billed for Medicaid There is not a required form for documentation of progress/therapy logs.

13. Signature and Credentials Staff who provided the service will sign the form and list credentials. For PTAs, the supervising PT must co-sign the billing form.

14. Terry Riley – Coordinator Office of Special Education tjriley@k12.wv.us 304-957-9833 ext 53223 WVDE Medicaid Website: http://wvde.state.wv.us/osp/medicaid.html tjriley@k12.wv.us http://wvde.state.wv.us/osp/medicaid.html