WSR 00-04-019

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed January 24, 2000, 10:35 a.m. ]

Date of Adoption: January 24, 2000.

Purpose: The department is establishing new chapter 388-545 WAC to combine all medical therapy rules. Therefore, WAC 388-86-090 Physical therapy and 388-87-090 Payment -- Physical therapy and related services, are being repealed and WAC 388-545-0500 Physical therapy, is being established. The new chapter reorganizes rule sections and updates the language to comply with the Governor's Executive Order 97-02.

Citation of Existing Rules Affected by this Order: Repealing WAC 388-86-090 and 388-87-090.

Statutory Authority for Adoption: RCW 74.08.090 and 74.09.520.

Adopted under notice filed as WSR 99-20-106 on October 6, 1999.

Changes Other than Editing from Proposed to Adopted Version: (1) WAC 388-545-500 (1)(b): "A physical therapy therapist assistant supervised by a licensed physical therapist; or"

(2) WAC 388-545-500 (1)(c), deleted: "A physical therapy aide, in schools, trained and supervised by a licensed physical therapist."

(3) WAC 388-545-500 (3)(f), added (f): "For disabled children, age two and younger, in natural environments including the home and community settings in which children without disabilities participate, to the maximum extent appropriate to the needs of the child."

(4) WAC 388-545-500 (4)(b): "Medically necessary and prescribed ordered by a physician, physicians's assistant (PA), or an advanced registered nurse practitioner (ARNP);"

(5) WAC 388-545-500 (4)(c): "Begun within thirty days of the date prescribed ordered;

(6) WAC 388-545-500 (4)(e), deleted: "Within accepted medical physical therapy standards."

(7) WAC 388-545-500(5), changed wording: "Physical therapy for Providers must document in a client's medical file that physical therapy services provided to clients age twenty-one and older when prescribed by a physician, PA, or an ARNP must are medically necessary. Such documentation may include justification that physical therapy services:"

(8) WAC 388-545-500 (5)(d): "Be a Are part of a treatment program..."

(9) WAC 388-545-500(8): "MAA covers, without requiring prior authorization, the following prescribed ordered physical therapy services per client, per diagnosis, per calendar year, for clients..."

(10) WAC 388-545-500(9), reworded: "Additional medically necessary physical therapy services, regardless of the diagnosis, require prior authorization For clients age twenty-one years of age and older., MAA covers physical therapy services which exceed the limitations established in subsection (8) of this section if the provider requests prior authorization and MAA approves the request.

(11) WAC 388-545-500(1), deleted: "The following providers are eligible to enroll with the medical assistance administration (MAA) to provide physical therapy services:..."

The changes were made because:

(1) WAC 388-545-500 (1)(b), changed reference to "physical therapy assistant" to "physical therapist assistant" per public request to use same language as cited in RCW.

(2) WAC 388-545-500 (1)(c), per public request, deleted requirement, "in schools," as physical therapist assistants are not limited to the school setting.

(3) WAC 388-545-500 (3)(f), added section (f), per public request, to incorporate language allowing disabled children age two and younger to receive physical therapy in natural environments, per 34 C.F.R. 303.12(b).

(4) WAC 388-545-500 (4)(b), changed "prescribed" to "ordered." Public commented that a physician "refers" a patient to a physical therapist, rather than "prescribing" certain physical therapy treatments. MAA determined that using the term "ordered" to replace "prescribed" is appropriate.

(5) WAC 388-545-500 (4)(c), changed "prescribed" to "ordered." See (4) above.

(6) WAC 388-545-500 (4)(e), deleted "medical" per public request as it is not needed in language.

(7) WAC 388-545-500(5), changed wording, per public request, to eliminate language that required physical therapy services provided to clients age twenty-one and older to meet the specific requirements of (5)(a), (b), (c), or (d). New language states that providers must document in a client's medical file that physical therapy services for client's age twenty-one and older are medically necessary and cites examples of justification that may be included in the documentation.

(8) WAC 388-545-500 (5)(d), changed wording from "Be a part of a treatment program" to "Are part of a treatment program" because the language changes in subsection (5) requires the wording in (5)(d) to refer to "such documentation."

(9) WAC 388-545-500(8), changed "prescribed" to "ordered," for reasons stated in (4) above.

(10) WAC 388-545-500(9), deleted the phrase, "regardless of the diagnosis," per public request, and rewrote to clarify that the provider must request prior authorization for physical therapy services which exceed the limitations established in subsection (8), and MAA must approve the request.

(11) WAC 388-545-500(1), deleted the phrase, "to enroll with the medical assistance administration (MAA)" as the rule already states that "providers are eligible." A provider is already enrolled with MAA so an explanation is not needed here.

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 1, Amended 0, Repealed 2.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 1, Amended 0, Repealed 2.

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 0, Repealed 2. Effective Date of Rule: Thirty-one days after filing.

January 24, 2000

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

2619.10
NEW SECTION
WAC 388-545-500
Physical therapy.

(1) The following providers are eligible to provide physical therapy services:

(a) A licensed physical therapist or physiatrist; or

(b) A physical therapist assistant supervised by a licensed physical therapist.

(2) Clients in the following MAA programs are eligible to receive physical therapy services described in this chapter:

(a) Categorically needy (CN);

(b) Children's health;

(c) General assistance-unemployable (GA-U) (within Washington state or border areas only);

(d) Alcoholism and drug addiction treatment and support act (ADATSA) (within Washington state or border areas only);

(e) Medically indigent program (MIP) for emergency hospital-based services only; or

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

(i) Twenty years of age or younger and referred under the early and periodic screening, diagnosis and treatment program (EPSDT/healthy kids program) as described in WAC 388-86-027; or

(ii) Receiving home health care services as described in chapter 388-551 WAC.

(3) Physical therapy services that MAA eligible clients receive must be provided as part of an outpatient treatment program:

(a) In an office, home, or outpatient hospital setting;

(b) By a home health agency as described in chapter 388-551 WAC;

(c) As part of the acute physical medicine and rehabilitation (acute PM&R) program as described in the acute PM&R subchapter under chapter 388-550 WAC;

(d) By a neurodevelopmental center;

(e) By a school district or educational service district as part of an individual education or individualized family service plan as described in WAC 388-86-022; or

(f) For disabled children, age two and younger, in natural environments including the home and community settings in which children without disabilities participate, to the maximum extent appropriate to the needs of the child.

(4) MAA pays only for covered physical therapy services listed in this section when they are:

(a) Within the scope of an eligible client's medical care program;

(b) Medically necessary and ordered by a physician, physician's assistant (PA), or an advanced registered nurse practitioner (ARNP);

(c) Begun within thirty days of the date ordered;

(d) For conditions which are the result of injuries and/or medically recognized diseases and defects; and

(e) Within accepted physical therapy standards.

(5) Providers must document in a client's medical file that physical therapy services provided to clients age twenty-one and older are medically necessary. Such documentation may include justification that physical therapy services:

(a) Prevent the need for hospitalization or nursing home care;

(b) Assist a client in becoming employable;

(c) Assist a client who suffers from severe motor disabilities to obtain a greater degree of self-care or independence; or

(d) Are part of a treatment program intended to restore normal function of a body part following injury, surgery, or prolonged immobilization.

(6) MAA determines physical therapy program units as follows:

(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.

(7) MAA does not limit coverage for physical therapy services listed in subsections (8) through (10) of this section if the client is twenty years of age or younger.

(8) MAA covers, without requiring prior authorization, the following ordered physical therapy services per client, per diagnosis, per calendar year, for clients twenty-one years of age and older:

(a) One physical therapy evaluation. The evaluation is in addition to the forty-eight program units allowed per year;

(b) Forty-eight physical therapy program units;

(c) Ninety-six additional outpatient physical therapy program units when the diagnosis is any of the following:

(i) A medically necessary condition for developmentally delayed clients;

(ii) Surgeries involving extremities, including:

(A) Fractures; or

(B) Open wounds with tendon involvement.

(iii) Intracranial injuries;

(iv) Burns;

(v) Traumatic injuries;

(vi) Meningomyelocele;

(vii) Down's syndrome;

(viii) Cerebral palsy; or

(ix) Symptoms involving nervous and musculoskeletal systems and lack of coordination;

(d) Two durable medical equipment (DME) needs assessments. The assessments are in addition to the forty-eight physical therapy program units allowed per year. Two program units are allowed per DME needs assessment; and

(e) One wheelchair needs assessment in addition to the two durable medical needs assessments. The assessment is in addition to the forty-eight physical therapy program units allowed per year. Four program units are allowed per wheelchair needs assessment.

(f) The following services are allowed, per day, in addition to the forty-eight physical therapy program units allowed per year:

(i) Two program units for orthotics fitting and training of upper and/or lower extremities.

(ii) Two program units for checkout for orthotic/prosthetic use.

(iii) One muscle testing procedure. Muscle testing procedures cannot be billed in combination with each other.

(g) Ninety-six additional physical therapy program units are allowed following a completed and approved inpatient acute PM&R program. In this case, the client no longer needs nursing services but continues to require specialized outpatient physical therapy for any of the following:

(i) Traumatic brain injury (TBI);

(ii) Spinal cord injury (paraplegia and quadriplegia);

(iii) Recent or recurrent stroke;

(iv) Restoration of the levels of functions due to secondary illness or loss from multiple sclerosis (MS);

(v) Amyotrophic lateral sclerosis (ALS);

(vi) Cerebral palsy (CP);

(vii) Extensive severe burns;

(viii) Skin flaps for sacral decubitus for quadriplegics only;

(ix) Bilateral limb loss;

(x) Open wound of lower limb; or

(xi) Acute, infective polyneuritis (Guillain-Barre'syndrome).

(9) For clients age twenty-one and older, MAA covers physical therapy services which exceed the limitations established in subsection (8) of this section if the provider requests prior authorization and MAA approves the request.

(10) MAA will pay for one visit to instruct in the application of transcutaneous neurostimulator (TENS) per client, per lifetime.

(11) Duplicate services for occupational therapy and physical therapy are not allowed for the same client when both providers are performing the same or similar procedure(s).

(12) MAA does not cover physical therapy services 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.

(13) MAA does not cover physical therapy services performed by a physical therapist in an outpatient hospital setting when the physical therapist is not employed by the hospital. Reimbursement for services must be billed by the hospital.

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REPEALER

     The following sections of the Washington Administrative Code are repealed:
WAC 388-86-090 Physical therapy.
WAC 388-87-090 Payment -- Physical therapy and related services.

Washington State Code Reviser's Office