Current through Register Vol. 24-18, September 15, 2024
(1)
The following health professionals may enroll with the medicaid agency, as
defined in WAC
182-500-0010, to provide
outpatient rehabilitation (which includes occupational therapy, physical
therapy, and speech therapy) within their scope of practice to eligible
clients:
(a) A physiatrist;
(b) A licensed occupational
therapist;
(c) A licensed
occupational therapy assistant (OTA) supervised by a licensed occupational
therapist;
(d) A licensed physical
therapist;
(e) A physical therapist
assistant supervised by a licensed physical therapist;
(f) A licensed speech-language pathologist;
and
(g) A licensed optometrist to
provide vision occupational therapy only.
(2) Clients covered by one of the Washington
apple health programs listed in the table in WAC
182-501-0060 or receiving home
health care services as described in chapter 182-551 WAC (subchapter II) are
eligible to receive outpatient rehabilitation as described in this
chapter.
(3) Clients enrolled in an
agency-contracted managed care organization (MCO) must arrange for outpatient
rehabilitation directly through their agency-contracted MCO.
(4) The agency pays for outpatient
rehabilitation when the services are:
(a)
Covered;
(b) Medically
necessary;
(c) Within the scope of
the eligible person's medical care program;
(d) Ordered by:
(i) A physician, physician assistant (PA), or
an advanced registered nurse practitioner (ARNP); or
(ii) An optometrist, if the ordered services
are for occupational therapy only.
(e) Within currently accepted standards of
evidence-based medical practice;
(f) Authorized, as required within this
chapter, under chapters 182-501 and 182-502 WAC and the agency's published
billing instructions;
(g) Begun
within 30 calendar days of the date ordered;
(h) Provided by one of the health
professionals listed in subsection (1) of this section;
(i) Billed according to this chapter,
chapters 182-501 and 182-502 WAC, and the agency's published billing
instructions; and
(j) Provided as
part of an outpatient treatment program:
(i)
In an office or outpatient hospital setting;
(ii) In the home, by a home health agency as
described in chapter 182-551 WAC;
(iii) In a neurodevelopmental center, as
described in WAC
182-545-900;
(iv) For children with disabilities, age two
or younger, in natural environments including the home and community setting in
which children without disabilities participate, to the maximum extent
appropriate to the needs of the child; or
(v) When provided by licensed and certified
behavioral health agencies as part of a mental health or substance use disorder
treatment program.
(5) For eligible clients age 20 and younger,
the agency covers unlimited outpatient rehabilitation.
(6) For clients age 21 and older, the agency
covers a limited outpatient rehabilitation benefit.
(7) Outpatient rehabilitation services for
clients age 21 and older must:
(a) Restore,
improve, or maintain the person's level of function that has been lost due to a
clinically documented condition; and
(b) Include an ongoing management plan for
the client or the client's caregiver to support timely discharge and continued
progress.
(8) For
eligible clients age 21 and older, the agency limits coverage of outpatient
rehabilitation as follows:
(a) Occupational
therapy, per person, per year:
(i) Without
authorization:
(A) For clients needing
occupational therapy to treat physical conditions:
(I) One occupational therapy
evaluation;
(II) One occupational
therapy reevaluation at time of discharge; and
(III) Twenty-four units of occupational
therapy, which is approximately six hours; and
(B) For clients needing occupational therapy
to treat behavioral health conditions:
(I) One
occupational therapy evaluation;
(II) One occupational therapy reevaluation at
time of discharge; and
(III)
Twenty-four units of occupational therapy, which is approximately six
hours.
(ii)
With expedited prior authorization, up to 24 additional units of occupational
therapy to treat either the client's physical or behavioral health conditions
may be available to continue treatment initiated under the original 24 units
when the criteria below is met:
(A) To
continue treatment of the original qualifying condition; and
(B) The client's diagnosis is any of the
following:
(I) Acute, open, or chronic
nonhealing wounds;
(II) Behavioral
health conditions;
(III) Brain
injury, which occurred within the past 24 months, with residual cognitive or
functional deficits;
(IV) Burns -
Second or third degree only;
(V)
Cerebral vascular accident, which occurred within the past 24 months, with
residual cognitive or functional deficits;
(VI) Lymphedema;
(VII) Major joint surgery - Partial or total
replacement only;
(VIII)
Muscular-skeletal disorders such as complex fractures that required surgical
intervention, or surgery involving the spine or extremities (e.g., arm, hand,
shoulder, leg, foot, knee, or hip);
(IX) Neuromuscular disorders that are
affecting function (e.g., amyotrophic lateral sclerosis (ALS), active infective
polyneuritis (Guillain-Barre));
(X)
Reflex sympathetic dystrophy;
(XI)
Swallowing deficits due to injury or surgery to the face, head, or
neck;
(XII) Spinal cord injury that
occurred within the past 24 months, resulting in paraplegia or quadriplegia;
or
(XIII) As part of a botulinum
toxin injection protocol when botulinum toxin has been prior authorized by the
agency.
(b) Physical therapy, per person, per year:
(i) Without authorization:
(A) One physical therapy
evaluation;
(B) One physical
therapy reevaluation at time of discharge; and
(C) Twenty-four units of physical therapy,
which is approximately six hours.
(ii) With expedited prior authorization, up
to 24 additional units of physical therapy may be available to continue
treatment initiated under the original 24 units when the criteria below is met:
(A) To continue treatment of the original
qualifying condition; and
(B) The
person's diagnosis is any of the following:
(I) Acute, open, or chronic nonhealing
wounds;
(II) Brain injury, which
occurred within the past 24 months, with residual functional
deficits;
(III) Burns - Second or
third degree only;
(IV) Cerebral
vascular accident, which occurred within the past 24 months, with residual
functional deficits;
(V)
Lymphedema;
(VI) Major joint
surgery - Partial or total replacement only;
(VII) Muscular-skeletal disorders such as
complex fractures that required surgical intervention, or surgery involving the
spine or extremities (e.g., arm, hand, shoulder, leg, foot, knee, or
hip);
(VIII) Neuromuscular
disorders that are affecting function (e.g., amyotrophic lateral sclerosis
(ALS), active infective polyneuritis (Guillain-Barre));
(IX) Reflex sympathetic dystrophy;
(X) Spinal cord injury, which occurred within
the past 24 months, resulting in paraplegia or quadriplegia; or
(XI) As part of a botulinum toxin injection
protocol when botulinum toxin has been prior authorized by the
agency.
(c) Speech therapy, per person, per year:
(i) Without authorization:
(A) One speech language pathology
evaluation;
(B) One speech language
pathology reevaluation at the time of discharge; and
(C) Six units of speech therapy, which is
approximately six hours.
(ii) With expedited prior authorization, up
to six additional units of speech therapy may be available to continue
treatment initiated under the original six units when the criteria below is
met:
(A) To continue treatment of the original
qualifying condition; and
(B) The
person's diagnosis is any of the following:
(I) Brain injury, which occurred within the
past 24 months, with residual cognitive or functional deficits;
(II) Burns of internal organs such as nasal
oral mucosa or upper airway;
(III)
Burns of the face, head, and neck - Second or third degree only;
(IV) Cerebral vascular accident, which
occurred within the past 24 months, with residual functional
deficits;
(V) Muscular-skeletal
disorders such as complex fractures that require surgical intervention or
surgery involving the vault, base of the skull, face, cervical column, larynx,
or trachea;
(VI) Neuromuscular
disorders that are affecting function (e.g., amyotrophic lateral sclerosis
(ALS), active infection polyneuritis (Guillain-Barre));
(VII) Speech deficit due to injury or surgery
to the face, head, or neck;
(VIII)
Speech deficit that requires a speech generating device;
(IX) Swallowing deficit due to injury or
surgery to the face, head, or neck; or
(X) As part of a botulinum toxin injection
protocol when botulinum toxin has been prior authorized by the
agency.
(d) Durable medical equipment (DME) needs
assessments, two per person, per year.
(e) Orthotics management and training of
upper or lower extremities, or both, two program units, per person, per
day.
(f) Orthotic or prosthetic
use, two program units, per person, per year.
(g) Muscle testing, one procedure, per
person, per day. Muscle testing procedures cannot be billed in combination with
each other. These procedures can be billed alone or with other physical and
occupational therapy procedures.
(h) Wheelchair needs assessment, one per
person, per year.
(9)
For the purposes of this chapter:
(a) Each 15
minutes of timed procedure code equals one unit; and
(b) Each nontimed procedure code equals one
unit, regardless of how long the procedure takes.
(10) For expedited prior authorization (EPA):
(a) A provider must establish that:
(i) The person's condition meets the
clinically appropriate EPA criteria outlined in this section; and
(ii) The services are expected to result in a
reasonable improvement in the person's condition and achieve the person's
therapeutic individual goal within 60 calendar days of initial
treatment;
(b) The
appropriate EPA number must be used when the provider bills the
agency;
(c) Upon request, a
provider must provide documentation to the agency showing how the person's
condition met the criteria for EPA; and
(d) A provider may request expedited prior
authorization once per year, per person, per each therapy type.
(11) If the client does not meet
the EPA clinical criteria in this section, the agency uses the process in WAC
182-501-0165 to consider prior
authorization requests and approves services that are medically
necessary.
(12) The agency
evaluates limitation extension (LE) requests regarding scope, amount, duration,
and frequency of covered health care services under WAC
182-501-0169. Providers may
submit LE requests for additional units when:
(a) The criteria for an expedited prior
authorization does not apply;
(b)
The number of available units under the EPA have been used and services are
requested beyond the limits; or
(c)
A new qualifying condition arises after the initial six visits are
used.
(13) Duplicate
services for outpatient rehabilitation are not allowed for the same person when
both providers are performing the same or similar procedure(s).
(14) The agency does not pay separately for
outpatient rehabilitation that are included as part of the reimbursement for
other treatment programs. This includes, but is not limited to, hospital
inpatient and nursing facility services.
(15) The agency does not reimburse a health
care professional for outpatient rehabilitation performed in an outpatient
hospital setting when the health care professional is not employed by the
hospital. The hospital must bill the agency for the services.
Statutory Authority:
RCW
41.05.021. 11-21-066, §182-545-200,
filed 10/17/11, effective 11/17/11.
