Current through Register Vol. 24-06, March 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 thirty 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;
or
(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.
(5) For eligible clients age
twenty and younger, the agency covers unlimited outpatient
rehabilitation.
(6) For clients age
twenty-one and older, the agency covers a limited outpatient rehabilitation
benefit.
(7) Outpatient
rehabilitation services for clients age twenty-one and older must:
(a) Restore, improve, or maintain the
person's level of function that has been lost due to medically documented
injury or illness; and
(b) Include
an on-going management plan for the client or the client's caregiver to support
timely discharge and continued progress.
(8) For eligible clients age twenty-one and
older, the agency limits coverage of outpatient rehabilitation as follows:
(a) Occupational therapy, per person, per
year:
(i) Without authorization:
(A) One occupational therapy
evaluation;
(B) One occupational
therapy reevaluation at time of discharge; and
(C) Twenty-four units of occupational
therapy, which is approximately six hours.
(ii) With expedited prior authorization, up
to twenty-four additional units of occupational therapy may be available to
continue treatment initiated under the original twenty-four 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) Brain
injury, which occurred within the past twenty-four months, with residual
cognitive or functional deficits;
(III) Burns - Second or third degree
only;
(IV) Cerebral vascular
accident, which occurred within the past twenty-four months, with residual
cognitive or 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) Swallowing deficits due to injury or
surgery to the face, head, or neck;
(XI) Spinal cord injury that occurred within
the past twenty-four months, resulting in paraplegia or quad-riplegia;
or
(XII) 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 twenty-four additional units of physical therapy may be available to
continue treatment initiated under the original twenty-four 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 twenty-four months, with residual
functional deficits;
(III) Burns -
Second or third degree only;
(IV)
Cerebral vascular accident, which occurred within the past twenty-four 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 twenty-four 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 twenty-four 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 twenty-four 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
fifteen 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 sixty 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.