Current through Register Vol. 50, No. 9, March 1, 2024
RELATES TO:
KRS
205.520
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
Family Services, Department for Medicaid Services, has a responsibility to
administer the Medicaid Program.
KRS
205.520(3) authorizes the
cabinet, by administrative regulation, to comply with any requirement that may
be imposed or opportunity presented by federal law to qualify for federal
Medicaid funds. This administrative regulation establishes the Medicaid Program
coverage provisions and requirements regarding physical therapy services
provided by an independent physical therapist or physical therapy assistant
working under the direct supervision of an independent physical
therapist.
Section 1. Provider
Participation.
(1)
(a) To be eligible to provide and be
reimbursed for physical therapy as an independent provider, a provider shall
be:
1. Currently enrolled in the Kentucky
Medicaid Program in accordance with
907
KAR 1:672;
2. Except as established in paragraph (b) of
this subsection, currently participating in the Kentucky Medicaid Program in
accordance with
907
KAR 1:671; and
3. Except as provided in subsection (2) of
this section, a physical therapist.
(b) In accordance with
907
KAR 17:015, Section 3(3), a provider of a service to
an enrollee shall not be required to be currently participating in the
fee-for-service Medicaid Program.
(2) Physical therapy provided in accordance
with Section 2 of this administrative regulation by a physical therapist
assistant who works under the direct supervision of a physical therapist who
meets the requirements in subsection (1) of this section shall be reimbursable
if the physical therapist is the biller for the therapy.
Section 2. Coverage and Limit.
(1) The department shall reimburse for
physical therapy if:
(a) The therapy:
1. Is provided:
a. By a:
(i)
Physical therapist who meets the requirements in Section 1(1) of this
administrative regulation; or
(ii)
Physical therapist assistant who works under the direct supervision of a
physical therapist who meets the requirements in Section 1(1) of this
administrative regulation; and
b. To a recipient;
2. Is ordered for the recipient by a
physician, physician assistant, or advanced practice registered nurse for:
a. Maximum reduction of a physical or
intellectual disability; or
b.
Restoration of a recipient to the recipient's best possible functioning
level;
3. Is prior
authorized; and
4. Is medically
necessary; and
(b) A
specific amount of visits is requested for the recipient by a physical
therapist, physician, physician assistant, or an advanced practice registered
nurse.
(2)
(a) There shall be an annual limit of twenty
(20) physical therapy visits per recipient per calendar year except as
established in paragraph (b) of this subsection.
(b) The limit established in paragraph (a) of
this subsection may be exceeded if services in excess of the limits are
determined to be medically necessary by the:
1. Department, if the recipient is not
enrolled with a managed care organization; or
2. Managed care organization in which the
enrollee is enrolled, if the recipient is an enrollee.
(c) Prior authorization by the department
shall be required for each therapy visit that exceeds the limit established in
paragraph (a) of this subsection for a recipient who is not enrolled with a
managed care organization.
Section 3. No Duplication of Service.
(1) The department shall not reimburse for
physical therapy provided to a recipient by more than one (1) provider of any
program in which physical therapy is covered during the same time
period.
(2) For example, if a
recipient is receiving physical therapy from a physical therapist enrolled with
the Medicaid Program, the department shall not reimburse for physical therapy
provided to the same recipient during the same time period via the home health
program.
Section 4.
Records Maintenance, Protection, and Security.
(1)
(a) A
provider shall maintain a current health record for each recipient;
(b)
1. A
health record shall document each service provided to the recipient including
the date of the service and the signature of the individual who provided the
service; and
2. The individual who
provided the service shall date and sign the health record on the date that the
individual provided the service.
(2)
(a)
Except as established in paragraph (b) of this subsection, a provider shall
maintain a health record regarding a recipient for at least five (5) years from
the date of the service or until any audit dispute or issue is resolved beyond
five (5) years; and
(b) If the
secretary of the United States Department of Health and Human Services requires
a longer document retention period than the period referenced in paragraph (a)
of this subsection, pursuant to
42 C.F.R.
431.17, the period established by the
secretary shall be the required period.
(3) A provider shall comply with 45 C.F.R.
Part 164 .
Section 5.
Medicaid Program Participation Compliance.
(1)
A provider shall comply with:
(a)
907
KAR 1:671;
(b)
907
KAR 1:672; and
(c) All applicable state and federal
laws.
(2)
(a) If a provider receives any duplicate
payment or overpayment from the department, regardless of reason, the provider
shall return the payment to the department.
(b) Failure to return a payment to the
department in accordance with paragraph (a) of this subsection may be:
1. Interpreted to be fraud or abuse;
and
2. Prosecuted in accordance
with applicable federal or state law.
Section 6. Third Party Liability.
A provider shall comply with
KRS
205.622.
Section 7. Use of Electronic Signatures.
(1) The creation, transmission, storage, and
other use of electronic signatures and documents shall comply with the
requirements established in
KRS
369.101 to
369.120.
(2) A provider that chooses to use electronic
signatures shall:
(a) Develop and implement a
written security policy that shall:
1. Be
adhered to by each of the provider's employees, officers, agents, or
contractors;
2. Identify each
electronic signature for which an individual has access; and
3. Ensure that each electronic signature is
created, transmitted, and stored in a secure fashion;
(b) Develop a consent form that shall:
1. Be completed and executed by each
individual using an electronic signature;
2. Attest to the signature's authenticity;
and
3. Include a statement
indicating that the individual has been notified of his or her responsibility
in allowing the use of the electronic signature; and
(c) Provide the department, immediately upon
request, with:
1. A copy of the provider's
electronic signature policy;
2. The
signed consent form; and
3. The
original filed signature.
Section 8. Auditing Authority. The department
shall have the authority to audit any claim, medical record, or documentation
associated with any claim or medical record.
Section 9. Federal Approval and Federal
Financial Participation. The department's coverage of services pursuant to this
administrative regulation shall be contingent upon:
(1) Receipt of federal financial
participation for the coverage; and
(2) Centers for Medicare and Medicaid
Services' approval for the coverage.
Section 10. Appeal Rights.
(1) An appeal of an adverse action by the
department regarding a service and a recipient who is not enrolled with a
managed care organization shall be in accordance with
907
KAR 1:563.
(2) An appeal of an adverse action by a
managed care organization regarding a service and an enrollee shall be in
accordance with
907
KAR 17:010.
STATUTORY AUTHORITY:
KRS
194A.030(2),
194A.050(1),
205.520(3),
42
C.F.R. 440.130,
42
U.S.C. 1396d(a)(13)(C)