WSR 00-12-039

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed May 31, 2000, 3:37 p.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 00-08-020.

Title of Rule: WAC 388-545-500 Physical therapy.

Purpose: Requires providers who furnish physical therapy through an early intervention program under the Individuals with Disabilities Education Act (IDEA) to comply with the requirements of IDEA. Corrects a cross-reference to a repealed WAC section that has been updated and established under a new section.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.520, 34 C.F.R. 303.12 (4)(b).

Statute Being Implemented: RCW 74.08.090, 74.09.520, [34] C.F.R. 303.12 (4)(b).

Summary: The department recently amended this rule to update policy and to comply with the Governor's Executive Order 97-02. Stakeholders' comments indicated that certain program requirements listed in WAC 388-545-500(3) were unclear as to requirement and intent. The department is amending this rule to refer those providers who furnish physical therapy through an early intervention program under the Individuals with Disabilities Education Act (IDEA) to that act to meet the requirements. The amendment will also correct a cross-reference to a repealed WAC section that has been updated and established under a new section.

Reasons Supporting Proposal: To require providers to meet the requirements for services provided under IDEA. To correct a WAC cross-reference section.

Name of Agency Personnel Responsible for Drafting: Kathy Sayre, MAA/DPS, 925 Plum Street S.E., Olympia, WA 98501, (360) 725-1342; Implementation and Enforcement: Patty Balestra, MAA/DOSS, 623th Avenue S.E., Olympia, WA 98501, (360) 725-1840.

Name of Proponent: Department of Social and Health Services, Medical Assistance Administration, governmental.

Rule is not necessitated by federal law, federal or state court decision.

Explanation of Rule, its Purpose, and Anticipated Effects: The new rule clarifies certain program requirements listed in WAC 388-545-500(3) for clients who receive physical therapy through an early intervention program under the federal Individuals with Disabilities Education Act (IDEA). It also corrects a cross-reference to a repealed WAC section that has been updated and established in a new WAC section.

Proposal Changes the Following Existing Rules: The rule proposed below adds language to clarify program requirements listed in WAC 388-545-500(3) for clients provided physical therapy through an early intervention program under the IDEA. It also corrects a cross-reference to a repealed WAC section that has been updated and established in a new WAC section.

A small business economic impact statement has been prepared under chapter 19.85 RCW.

Small Business Economic Impact Statement

SUMMARY OF PROPOSED RULES: The Department of Social and Health Services, Medical Assistance Administration (MAA) is amending WAC 388-545-500 (3)(f) by incorporating a reference to federal requirements. The amended language follows; deleted language is shown with strikeout, and added language is underlined.
WAC 388-545-500 (3)(f) ((For disabled children, age two and younger, in natural settings in which children without disabilities participate, to the maximum extent appropriate to the needs of the child)) In accordance with the requirements of the Individuals with Disabilities Education Act (IDEA), for early intervention services for children age two and younger.
SMALL BUSINESS ECONOMIC IMPACT STATEMENT: Chapter 19.85 RCW, the Regulatory Fairness Act, requires that the economic impact of proposed regulations be analyzed in relation to small business and outlines the information that must be included in a small business economic impact statement (SBEIS). Preparation of an SBEIS is required when a proposed rule has the potential of placing a more than minor economic impact on business.

MAA has analyzed the proposed rule amendment and concludes that no new costs are being imposed on the small businesses affected by them. However, in response to stakeholder request, a SBEIS has been prepared as follows:

1. Requirements of the Proposed Rule: Disabled children age two or younger receive physical therapy services in accordance with the requirements of the Individuals with Disabilities Education Act (IDEA) for early intervention services.

2. Brief Description of the Reporting, Recordkeeping, and Other Compliance Requirements of the Proposed Rule: Since the federal regulation has been in effect since 1993, the department assumes that providers have been following the regulation since that time. If there were additional requirements that providers had to meet at that time, the department assumes that those requirements were met and any changes that providers made to meet those requirements have been in use since then. Referring providers to the federal requirement should therefore have no impact on providers' recordkeeping and other compliance requirements.

3. Revenue/Sales Lost Because of Compliance with the Proposed Rule: Since the federal regulation has been in effect since 1993, the department assumes that providers have been following the regulation since that time. If any sales/revenue were lost because of the regulation, the department assumes the brunt of any loss was felt at the time of implementation; no additional revenue should be lost as providers comply with the proposed rule.

4. Comparison of the Cost of Compliance for Small Businesses with the Cost of Compliance for the 10% of Businesses That Are the Largest Businesses Required to Comply with the Proposed Rules: Because of the nature of the service provided, there should be no difference in the cost of compliance for small businesses and large businesses. The percentage of MAA-program eligible children under the age two or younger receiving physical therapy services in calendar year 1999 was 15%. The department assumes that the percentage of children that are part of an early intervention program under the Individuals with Disabilities Education Act (IDEA) would be less than 15%.

5. Steps the Department Will Take to Reduce the Proposed Rule's Costs or a Fair Reason for Not Reducing Costs: The department concludes that the proposed rule will not impose any new costs on the providers affected by it. This is because providers are not required to make any change in the location of where they currently provide services; they are merely required to comply with the federal IDEA requirements, which have been in effect since 1993.

6. List the Affected Businesses: Any physical therapist who has an agreement with the department to furnish services to eligible MAA clients.

7. How the Department Involved Businesses in Developing the Proposed Rule: A draft copy of the rule was mailed to any independent physical therapist or facility that provides outpatient physical therapy services and who is on MAA's mailing list.

COST - BENEFIT ANALYSIS: As required by RCW 34.05.328 (1)(c), MAA has analyzed the probable costs and probable benefits of the proposed amendments. MAA has determined that the proposed rules are not "significant" as defined by the legislature. MAA is not adopting new or making significant amendments to policy; the proposed amendment is merely to require providers to meet federal program requirements that have been in effect since 1993.

A copy of the statement may be obtained by writing to Kathy Sayre, 925 Plum Street S.E., Olympia, WA 98501, phone (360) 725-1342, fax (360) 586-9727.

RCW 34.05.328 does not apply to this rule adoption. The rule does not fit the definition of a significant legislative rule.

Hearing Location: Lacey Government Center (behind Tokyo Bento Restaurant), 1009 College Street S.E., Room 104-B, Lacey, WA 98503, on July 11, 2000, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Fred Swenson by June 30, 2000, phone (360) 664-6097, TTY (360) 664-6178, e-mail swensfh@dshs.wa.gov.

Submit Written Comments to: Identify WAC Numbers, DSHS Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, by July 11, 2000.

Date of Intended Adoption: July 12, 2000.

May 25, 2000

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

2715.3
AMENDATORY SECTION(Amending WSR 00-04-019, filed 1/24/00, effective 2/24/00)

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)) 388-537-0100; 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)) In accordance with the requirements of the Individuals with Disabilities Education Act (IDEA), for early intervention services for disabled children age two and younger.

(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.

[Statutory Authority: RCW 74.08.090 and 74.09.520. 00-04-019, 388-545-500, filed 1/24/00, effective 2/24/00.]

Washington State Code Reviser's Office