Virginia Administrative Code
Title 12 - HEALTH
Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE
Section 12VAC30-60-150 - Quality management review of outpatient rehabilitation therapy services
Universal Citation: 2 VA Admin Code 30-60-150
Current through Register Vol. 41, No. 3, September 23, 2024
A. The following general conditions shall apply to reimbursable outpatient rehabilitation therapy services:
1. The
covered services and medical necessity criteria as set out in
12VAC30-50-200 shall apply to
these outpatient rehabilitation therapy services.
2. Outpatient rehabilitative therapy
services, as defined in 42
CFR 440.130, shall be prescribed by a
licensed physician or a licensed practitioner of the healing arts, specifically
either a nurse practitioner or physician assistant, and be part of a written
plan of care.
3. Quality management
reviews shall be performed by DMAS or its contractor to ensure that all
rehabilitative services provided to Medicaid individuals are medically
necessary and appropriate. Services not specifically documented in the
individual's medical record as having been rendered shall be deemed not to have
been rendered and no reimbursement shall be provided.
B. Covered outpatient rehabilitative therapy services. Rehabilitation services shall be initiated by a physician or licensed practitioner for the evaluation and plan of care. Both require a physician or licensed practitioner signature, title, and full date.
A plan of care for therapy services shall (i) include the specific procedures and modalities to be used, (ii) identify the specific discipline to carry out the plan of care, and (iii) indicate the frequency and duration of services.
C. All practitioners and providers of therapy services shall be required to meet state and federal licensing or certification requirements, or both, as may be applicable.
D. Documentation of physical therapy, occupational therapy, and speech-language pathology services provided in outpatient settings of acute and rehabilitation hospitals, nursing facilities, home health agencies, and rehabilitation agencies shall at a minimum include:
1. An initial evaluation that
describes the clinical signs and symptoms of the individual's condition,
including an accurate and complete chronological picture of the individual's
clinical course and treatments. The initial evaluation or the reevaluation
shall be signed, titled, and dated by the licensed therapist (i) when an
individual is initially admitted to a service, (ii) when there is a significant
change in the individual's condition, or (iii) when an individual is readmitted
to a service.
2. A written plan of
care specifically developed for the individual shall be signed, titled, and
fully dated by a licensed therapist. Within 21 days of the plan of care start
date, the physician or a licensed practitioner shall sign, title, and fully
date the plan of care and it shall:
a.
Describe specifically the anticipated goal-related improvements in functional
level, frequency, and duration of the ordered therapy and the anticipated
timeframes necessary to meet these long-term and short-term individual goals,
including participation by the appropriate rehabilitation therapist or
therapists, the individual, and the family or caregiver, as may be appropriate;
and
b. Include a discharge plan
that contains the anticipated improvements in functional levels and the
anticipated timeframes necessary to meet the individual goals:
(1) For outpatient rehabilitative services
for acute conditions, as defined in
12VAC30-50-200, the plan of care
must be reviewed, updated, and signed and dated at least every 60 days by the
licensed therapist and the physician or other licensed practitioner;
(2) For outpatient services for long-term,
nonacute conditions, as defined in
12VAC30-50-200, the plan of care
must be reviewed, updated, and signed and dated at least every 12 months by the
licensed therapist and the physician or other licensed practitioner.
3. The documentation of
all treatment rendered to the individual in the progress notes, in accordance
with the written plan of care with specific attention to frequency, duration,
modality, and the individual's response to treatment. The licensed therapist
must sign, title, and fully date all progress notes in the medical record. If
therapy assistants provide the treatment under the supervision of a licensed
therapist, the assistant shall also sign, title, and fully date the progress
notes in the medical record.
4. A
description of all changes in the individual's condition, response to the
rehabilitative written plan of care, and appropriate revisions to the written
plan of care.
5. A discharge
summary to be completed by the licensed therapist who is providing the service
at the time that the service is terminated, including a description of the
individual's response to services, level of independence in carrying out
learned skills and abilities, assistive technology necessary to carry out and
maintain activities and skills, and recommendations for continued services
(i.e., referrals to alternate providers, home maintenance programs, and
training to individuals or caregivers).
6. The therapist's signature, title, and full
date (month/day/year) shall appear on all documentation; if therapy assistants
provide the treatment, under the supervision of a licensed therapist, the
supervising licensed therapist must document the findings of the supervisory
onsite visit every 30 days.
E. Restrictions.
1. The intentional altering of medical record
documentation shall be prohibited and is fraudulent. If corrections are
required, the agency's provider-specific guidance documents provide information
on the procedures to be used.
2.
DMAS shall not reimburse for evaluations provided prior to the date of the
physician's or other licensed practitioner's signature. DMAS shall not
reimburse for provider-initiated additional reevaluations that are not specific
to DMAS requirements and that are in excess of DMAS requirements.
Statutory Authority: §§ 32.1-324 and 32.1-325 of the Code of Virginia.
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