WSR 11-21-066

PERMANENT RULES

HEALTH CARE AUTHORITY


(Medicaid Program)

[ Filed October 17, 2011, 1:43 p.m. , effective November 17, 2011 ]


Effective Date of Rule: Thirty-one days after filing.

Purpose: The health care authority is amending chapter 182-545 WAC, Therapies and WAC 182-551-2110 Home health services -- Covered specialized therapy, to create a new benefit package for rehabilitation services for clients twenty-one years of age and older. The new benefit limits apply to skilled therapy services through a medicare-certified home health agency as well as therapies provided by physical therapists, occupational therapists, and speech therapists in outpatient hospital clinics and free-standing therapy clinics.

HB 1086, passed by the legislature, and signed by the governor on February 18, 2011, included new budget cuts for the fiscal year. In response, the medicaid program reduced in amount physical, occupational and speech therapy services for clients twenty-one years of age and older. This permanent rule filing replaces the emergency rules in place, filed July 29, 2011, under WSR 11-16-054.

Citation of Existing Rules Affected by this Order: Repealing WAC 182-545-300, 182-545-500 and 182-545-700; and amending WAC 182-545-900 and 182-551-2110.

Statutory Authority for Adoption: RCW 41.05.021.

Adopted under notice filed as WSR 11-17-149 on August 24, 2011.

Changes Other than Editing from Proposed to Adopted Version: WAC 182-545-200 (2)(d) Outpatient rehabilitation (occupational therapy, physical therapy, and speech therapy) - The agency made the following change in accordance with ESHB 2082. Effective October 31, 2011, the disability lifeline program is discontinued and beginning November 1, 2011, the aged, blind, or disabled assistance program begins.

(2) Clients in the following agency programs are eligible to receive outpatient rehabilitation as described in this chapter:

(d) Disability lifeline (formerly general assistance unemployable) Medical care services as described in WAC 182-508-0005 (within Washington state or border areas only);

WAC 182-545-200 (4)(e) Outpatient rehabilitation (occupational therapy, physical therapy, and speech therapy) - The agency removed the terms "specific and effective treatment" in response to stakeholders concerns regarding the terms.

(4) The agency pays for outpatient rehabilitation when the services are:

(e) Within currently accepted standards of evidence-based medical practice and are specific and effective treatment for the client's existing condition;

WAC 182-545-200 (8)(a)(ii), (b)(ii), and (c)(ii) Outpatient rehabilitation (occupational therapy, physical therapy, and speech therapy) - The agency revised the language as a result of CR-102 comments received:

To continue treatment of the acute disease or medical condition or deficit which was the result of the injury or surgery original qualifying condition;

WAC 182-545-200(11) Outpatient rehabilitation (occupational therapy, physical therapy, and speech therapy) - The agency revised the language in subsection (11) of this section as follows:

(11) The agency evaluates a request for outpatient rehabilitation that is in excess of the limitations or restrictions, according to WAC 182-501-0169. Prior authorization may be requested for additional units to treat an acute medical condition, disease, or deficit, resulting from a new injury or postsurgery treatment beyond those allowed in this section when: (a) The criteria for an expedited prior authorization does not apply;

(b) The number of units available under the EPA have been used and services are requested beyond the limits;

(c) A new qualifying condition arises after the initial six visits are used.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 1, Amended 2, Repealed 3.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 1, Amended 2, Repealed 3.

Date Adopted: October 17, 2011.

Kevin M. Sullivan

Rules Coordinator

OTS-4187.5


NEW SECTION
WAC 182-545-200   Outpatient rehabilitation (occupational therapy, physical therapy, and speech therapy).   (1) The following health professionals may enroll with the 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 speech-language pathologist who has been granted a certificate of clinical competence by the American Speech, Hearing and Language Association; and

(g) A speech-language pathologist who has completed the equivalent educational and work experience necessary for such a certificate.

(2) Clients in the following agency programs are eligible to receive outpatient rehabilitation as described in this chapter:

(a) Categorically needy program (CNP);

(b) Categorically needy program-state children's health insurance program (CNP-SCHIP);

(c) Children's healthcare programs as defined in WAC 388-505-0210;

(d) Medical care services as described in WAC 182-508-0005 (within Washington state or border areas only);

(e) Alcoholism and Drug Addiction Treatment and Support Act (ADATSA) (within Washington state or border areas only);

(f) Medically needy program (MNP) only when the client is either:

(i) Twenty years of age or younger and referred by a screening provider under the early and periodic screening, diagnosis and treatment program (healthy kids program) as described in chapter 182-534 WAC; or

(ii) Receiving home health care services as described in chapter 182-551 WAC, subchapter II.

(3) Clients who are enrolled in an agency-contracted managed care organization (MCO) must arrange for outpatient rehabilitation directly through his or her 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 client's medical care program;

(d) Ordered by a physician, physician's assistant (PA) or an advanced registered nurse practitioner (ARNP);

(e) Within currently accepted standards of evidence-based medical practice;

(f) Authorized, as required within this chapter, chapters 182-501 and 182-502 WAC, and the agency's published billing instructions and numbered memoranda;

(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 numbered memoranda; 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, twenty years of age and younger, the agency covers unlimited outpatient rehabilitation.

(6) For clients twenty-one years of age and older, the agency covers a limited outpatient rehabilitation benefit.

(7) Outpatient rehabilitation services for clients twenty-one years of age and older must:

(a) Restore, improve, or maintain the client'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 and/or the client's caregiver to support timely discharge and continued progress.

(8) For eligible adults, twenty-one years of age and older, the agency limits coverage of outpatient rehabilitation as follows:

(a) Occupational therapy, per client, 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 equals 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 and/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 and/or functional deficits;

(V) Lymphedema;

(VI) Major joint surgery - Partial or total replacement only;

(VII) Muscular-skeletal disorders such as complex fractures which required surgical intervention or surgeries involving spine or extremities (e.g., arm, hand, shoulder, leg, foot, knee, or hip);

(VIII) Neuromuscular disorders which 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 face, head, or neck;

(XI) Spinal cord injury which occurred within the past twenty-four months, resulting in paraplegia or quadriplegia; or

(XII) As part of a botulinum toxin injection protocol when botulinum toxin has been prior authorized by the agency.

(b) Physical therapy, per client, 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 equals 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 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 functional deficits;

(III) Burns - Second and/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 which required surgical intervention or surgeries involving spine or extremities (e.g., arm, hand, shoulder, leg, foot, knee, or hip);

(VIII) Neuromuscular disorders which 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 approved by the agency.

(c) Speech therapy, per client, 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 equals 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 client's diagnosis is any of the following:

(I) Brain injury, which occurred within the past twenty-four months, with residual cognitive and/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 which require surgical intervention or surgery involving the vault, base of the skull, face, cervical column, larynx, or trachea;

(VI) Neuromuscular disorders which are affecting function (e.g., amyotrophic lateral sclerosis (ALS), active infection polyneuritis (Guillain-Barre));

(VII) Speech deficit due to injury or surgery to face, head, or neck;

(VIII) Speech deficit which requires a speech generating device;

(IX) Swallowing deficit due to injury or surgery to face, head, or neck; or

(X) As part of a botulinum toxin injection protocol when botulinum toxin has been prior approved by the agency.

(d) Durable medical equipment (DME) needs assessments, two per client, per year.

(e) Orthotics management and training of upper and/or lower extremities, two program units, per client, per day.

(f) Orthotic/prosthetic use, two program units, per client, per year.

(g) Muscle testing, one procedure, per client, 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 client, 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 client'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 client's condition and achieve the client'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 client's condition met the criteria for EPA; and

(d) A provider may request expedited prior authorization once per year, per client, per each therapy type.

(11) The agency evaluates a request for outpatient rehabilitation that is in excess of the limitations or restrictions, according to WAC 182-501-0169. Prior authorization may be requested 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;

(c) A new qualifying condition arises after the initial six visits are used.

(12) Duplicate services for outpatient rehabilitation are not allowed for the same client when both providers are performing the same or similar procedure(s).

(13) 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.

(14) The agency does not reimburse a healthcare professional for outpatient rehabilitation performed in an outpatient hospital setting when the healthcare professional is not employed by the hospital. The hospital must bill the agency for the services.

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AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-545-900   Neurodevelopmental centers.   (1) This section describes:

(a) Neurodevelopmental centers that may be reimbursed by the ((department)) agency;

(b) Clients who may receive covered services at a neurodevelopmental center; and

(c) Covered services that may be provided at and reimbursed to a neurodevelopmental center.

(2) In order to provide and be reimbursed for the services listed in subsection (4) of this section, the ((department)) agency requires a neurodevelopmental center provider to do all of the following:

(a) Be contracted with the department of health (DOH) as a neurodevelopmental center;

(b) Provide documentation of the DOH contract to the ((department)) agency; and

(c) ((Sign a)) Have an approved core provider agreement with the ((department; and

(d) Receive a neurodevelopmental center provider number from the department)) agency.

(3) Clients ((who are)), twenty years of age or younger ((and who meet the following eligibility criteria)), may receive ((covered services from)) outpatient rehabilitation (occupational therapy, physical therapy, and speech therapy) in agency-approved neurodevelopmental centers((:

(a) For occupational therapy, refer to WAC 388-545-300(2);

(b) For physical therapy, refer to WAC 388-545-500(2);

(c) For speech therapy and audiology services, refer to WAC 388-545-700(2); and

(d) For early and periodic screening, diagnosis and treatment (EPSDT) screening by physicians, refer to WAC 388-534-0100)).

(4) The ((department)) agency reimburses neurodevelopmental centers for providing the following services to clients ((who meet the requirements in subsection (3) of this section)):

(a) ((Occupational therapy services as described in WAC 388-545-300)) Outpatient rehabilitation services as described in WAC 182-545-200; and

(b) ((Physical therapy services as described in WAC 388-545-500;

(c) Speech therapy and audiology services as described in WAC 388-545-700; and

(d))) Specific pediatric evaluations and team conferences that are:

(i) Attended by the center's medical director; and

(ii) Identified as payable in the ((department's)) agency's billing instructions.

(5) In order to be reimbursed, neurodevelopmental centers must meet the ((department's)) agency's billing requirements in WAC 182-502-0020, 182-502-0100 and 182-502-0150.

[11-14-075, recodified as 182-545-900, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, 388-545-900, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.09.080, 74.09.520 and 74.09.530. 01-20-114, 388-545-900, filed 10/3/01, effective 11/3/01.]


REPEALER

     The following sections of the Washington Administrative Code are repealed:
WAC 182-545-300 Occupational therapy.
WAC 182-545-500 Physical therapy.
WAC 182-545-700 Speech/audiology services.

OTS-4188.3


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-551-2110   Home health services--Covered specialized therapy.   (((1))) The ((department limits)) agency covers specialized therapy ((visits to one per client, per day, per type of specialized therapy)) (also known as outpatient rehabilitation) in an in-home setting by a home health agency. See chapter 182-545 WAC outpatient rehabilitation for coverage and limitations. Specialized therapy is defined in WAC ((388-551-2010)) 182-551-2010.

(((2) The department does not allow duplicate services for any specialized therapy for the same client when both providers are performing the same or similar procedure(s).))

[11-14-075, recodified as 182-551-2110, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, chapter 74.09 RCW, and 2009 c 326. 10-10-087, 388-551-2110, filed 5/3/10, effective 6/3/10. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.530, and 74.09.500. 02-15-082, 388-551-2110, filed 7/15/02, effective 8/15/02. Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, 388-551-2110, filed 8/2/99, effective 9/2/99.]

Washington State Code Reviser's Office