Effective Date of Rule: July 29, 2011.

     Purpose: Upon order of the governor, the health care authority (HCA) must reduce its budget expenditures for the current fiscal year ending June 30, 2011, by 6.3 percent. To achieve this expenditure reduction, HCA is changing the benefit limit for adults, twenty-one years of age and older, receiving medical assistance outpatient rehabilitation (which includes occupational therapy, physical therapy, and speech therapy). 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.

     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 74.08.090.

     Other Authority: Chapter 564, Laws of 2011 (2ESSHB [2E2SHB] 1738).

     Under RCW 34.05.350 the agency for good cause finds that immediate adoption, amendment, or repeal of a rule is necessary for the preservation of the public health, safety, or general welfare, and that observing the time requirements of notice and opportunity to comment upon adoption of a permanent rule would be contrary to the public interest; and that in order to implement the requirements or reductions in appropriations enacted in any budget for fiscal years 2009, 2010, or 2011, which necessitates the need for the immediate adoption, amendment, or repeal of a rule, and that observing the time requirements of notice and opportunity to comment upon adoption of a permanent rule would be contrary to the fiscal needs or requirements of the agency.

     Reasons for this Finding: The implementation of these emergency rules are necessitated by: (1) The supplemental 2010 state budget bill in which the legislature required the department to take steps to reduce expenditures, including the elimination of optional services, when the agency estimates program expenditures will exceed legislative appropriations; and (2) HB 1248 which extends the allowance of emergency filing through fiscal year 2013. Delaying the adoption of these changes in benefit limits to optional services could jeopardize the state's ability to maintain the mandatory medicaid services for the majority of HCA clients. This emergency rule is necessary to continue the current emergency rule adopted under WSR 11-08-021 while the permanent rule-making process is completed. A CR-102 is being filed shortly.

     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: July 28, 2011.

Kevin M. Sullivan

Rules Coordinator

OTS-4187.3

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 to provide outpatient rehabilitation (which includes occupational therapy, physical therapy, and speech therapy) within their scope of practice to eligible clients:

     (a) A licensed occupational therapist;

     (b) A licensed occupational therapy assistant (OTA) supervised by a licensed occupational therapist;

     (c) A licensed physical therapist or physiatrist;

     (d) A physical therapist assistant supervised by a licensed physical therapist;

     (e) A speech-language pathologist who has been granted a certificate of clinical competence by the American Speech, Hearing and Language Association; and

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

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

     (g) Provided by one of the health professionals listed in subsection (1) of this section;

     (h) Billed according to this chapter, chapters 182-501 and 182-502 WAC, and the agency's published billing instructions and numbered memoranda; and

     (i) 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) The agency pays for outpatient rehabilitation for adults twenty-one years of age and older as a short-term benefit to treat an acute medical condition, disease, or deficit resulting from a new injury or post-surgery.

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

     (a) Meet reasonable medical expectation of significant functional improvement within sixty days of initial treatment;

     (b) Restore or improve the client to a prior level of function that has been lost due to medically documented injury or illness;

     (c) Meet currently accepted standards of medical practice and be specific and effective treatment for the client's existing condition; and

     (d) 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 when medically necessary and the client's diagnosis is any of the following:

     (A) Acute, open, or chronic nonhealing wounds;

     (B) Brain injury with residual functional deficits within the past twenty-four months;

     (C) Burns - Second or third degree only;

     (D) Cerebral vascular accident with residual functional deficits within the past twenty-four months;

     (E) Lymphedema;

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

     (G) New onset 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);

     (H) New onset neuromuscular disorders which are affecting function (e.g., amyotrophic lateral sclerosis (ALS), active infective polyneuritis (Guillain-Barre));

     (I) Reflex sympathetic dystrophy;

     (J) Swallowing deficits due to injury or surgery to face, head, or neck;

     (K) Spinal cord injury resulting in paraplegia or quadriplegia within the past twenty-four months; or

     (L) 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 when medically necessary and the client's diagnosis is any of the following:

     (A) Acute, open, or chronic nonhealing wounds;

     (B) Brain injury with residual functional deficits within the past twenty-four months;

     (C) Burns - Second and/or third degree only;

     (D) Cerebral vascular accident with residual functional deficits within the past twenty-four months;

     (E) Lymphedema;

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

     (G) New onset 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);

     (H) New onset neuromuscular disorders which are affecting function (e.g., amyotrophic lateral sclerosis (ALS), active infective polyneuritis (Guillain-Barre));

     (I) Reflex sympathetic dystrophy;

     (J) Spinal cord injury resulting in paraplegia or quadriplegia within the past twenty-four months; or

     (K) 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 when medically necessary and the client's diagnosis is any of the following:

     (A) Brain injury with residual functional deficits within the past twenty-four months;

     (B) Burns of internal organs such as nasal oral mucosa or upper airway;

     (C) Burns of the face, head, and neck - Second or third degree only;

     (D) Cerebral vascular accident with residual functional deficits within the past twenty-four months;

     (E) New onset 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;

     (F) New onset neuromuscular disorders which are affecting function (e.g., amyotrophic lateral sclerosis (ALS), active infection polyneuritis (Guillain-Barre));

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

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

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

     (J) 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 the client's condition meets the clinically appropriate EPA criteria outlined in this section and in the agency's published outpatient rehabilitation billing instructions;

     (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.

     (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.

[]

     (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.]

     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.]

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