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Department of Medical Assistance Services

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OUTPATIENT REHABILITATION SERVICES

Presented by:

Amy Burkett, Health Care Compliance Specialist II

Department of Medical Assistance Services

March 19, 2007

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AGENDA Rehabilitation Criteria Rehabilitation Services Documentation Requirements Quality Management

Utilization Review Appeals Process

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COMMONLY USED ACRONYMS

DMAS - Department of Medical Assistance Services

CMS – Centers for Medicare and Medicaid Services

PA - Preauthorization

POC - Plan of Care

IFSP – Individualized Family Service Plan

PCP - Primary Care Physician

KePro - Va. Medicaid Preauthorization Contract Agency

VAC - Virginia Administrative Code

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PROGRAM PROVISIONS

PHYSICAL THERAPY OCCUPATIONAL

THERAPY SPEECH-LANGUAGE

PATHOLOGY

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COVERED SERVICESMedically necessary rehab services are a covered service for Medicaid recipients.

Medical necessity is: Services ordered by a physician Recipient treatment plan of care Accepted medical standards of practice (not

experimental or investigational) Safe and cost-effective level of care

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PROVIDERS OF SERVICEOutpatient rehab services may be provided by:

Acute Care and Rehab Hospitals Nursing Facilities Rehabilitation Agencies School Divisions Early Infant Intervention Agencies

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Prior Authorization

KePro prior authorization information:

Toll Free Phone: 1-888-827-2884

Richmond Phone: 1-804-622-8900

http://dmas.kepro.org/

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REGULATIONS

Outpatient Rehab program criteria and policy guidelines may be found in:

42 CFR (Code of Federal Regulations) VAC (Virginia Administrative Code) Virginia Medicaid Rehabilitation Manual

NOTE: These regulations are accessible through the DMAS Agency Website

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DEFINITION OF A VISIT

A visit is defined as the tx session that a rehab therapist is with a recipient to provide covered services as prescribed by a physician.

A visit is not defined in measurements or increments of time.

Reimbursement is made on a per visit basis per discipline.

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DEFINITION OF A VISIT(continued)

Examples of therapy visits:

PT/OT co-treatment visit = 1 visit

(same therapy treatment goals) PT in the AM/ PT in the PM = 2 visits PT and OT in the PM = 1 visit per

discipline

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REHABILITATION THERAPISTS’

QUALIFICATIONS

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PHYSICAL THERAPY

Services may be provided by:

Physical therapist (LPT) licensed by

the Virginia Board of Physical Therapy Physical therapy assistant (LPTA)

licensed by the Virginia Board of Physical Therapy and supervised by the LPT

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OCCUPATIONAL THERAPYServices may be provided by:

Occupational Therapist (OTR) registered by the Nat’l Board for Certification in O.T. and licensed by the Virginia Board of Medicine

Certified Occupational Therapy Assistant (COTA) certified by Nat’l Board for Certification in O.T. and supervised by an OTR

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SPEECH-LANGUAGE PATHOLOGY

Services may be provided by: Licensed SLP who has (a) CCC’s from ASHA; or (b)

has completed the equivalent educ. requirements & work experience; or (c) has completed the academic program & acquiring work experience; OR

SLP licensed by the Board of Audiology & Speech-Language Pathology (BOA & SLP)

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SPEECH -LANGUAGE PATHOLOGY (cont’d)

Since Jan. 1, 2001, DMAS has reimbursed for provision of SLP services by speech-language assistants with supervision by a licensed SLP or CCC/SLP.

Speech-language assistants may be: Bachelor’s level Master’s level without licensure

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DOCUMENTATIONREQUIREMENTS

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MEDICAID REQUIRED DOCUMENTATION

Physician Physical therapist Occupational therapist Speech-language pathologist

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DOCUMENTATION REQUIREMENTS

Physician: Order for therapy evaluation Order for plan of care (IFSP) for

therapy services Review and Re-certification for

continued therapy annually Discharge order

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PHYSICIAN ORDER/POCMD order required prior to the provision of any therapy services.

The MD order for initial therapy evaluation and treatment may be in the form of:

Prescription for the evaluation Plan of Care (IFSP) with MD review and

MD signature/date of approval

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PHYSICIAN ORDER/POC(continued)

Discharge Order:

When services are no longer required, the therapist must obtain a physician discharge order when discontinuing therapy services to the recipient.

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DOCUMENTATION REQUIREMENTS

Therapist: Evaluation Annual Plan of Care (IFSP) prepared,

signed and dated by a licensed therapist

Progress Notes Discharge Summary

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THERAPY EVALUATION COMPONENTS

Medical History Medical Diagnosis Previous Treatments Functional limitations/deficits Medical findings Clinical signs and symptoms Therapist Recommendations

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RE-EVALUATIONS

Re-evaluations will be reimbursed by DMAS when there is :

Interruption in services, or Change in recipient’s condition

NOTE: “Program generated” evaluations are not reimbursed by DMAS

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THERAPY PLAN OF CARE COMPONENTS

Frequency/duration Modalities/interventions Anticipated functional improvement Measurable goals with time frames for

achievement (LTG/STG) Discharge plan and estimated date of

discharge

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THERAPY PLAN OF CARE COMPONENTS (continued)

Long and Short Term Goals must be: Patient-oriented Measurable Realistic Include time frames for goal

achievement (month/day/year)

NOTE: Long-term goals must be in place to cover the annual time frame requested

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THERAPY PLAN OF CARE COMPONENTS (continued)

Goals must be specific to the recipient’s needs identified in the initial evaluation

Identify discipline (PT/OT/SLP), frequency

(1x/wk, 2x/wk, 1-2x/wk), individual and/or group therapy, and treatment modalities/interventions

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THERAPY PLAN OF CARE

The plan must be reviewed/revised annually

Renewal or modification/revision of the plan must be signed and dated by a qualified therapist

Physician must review, sign and date the plan of care within 21 days of the implementation date

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PLAN OF CARE SIGNATURE REQUIREMENTS

Therapist’s name, title, and full date Physician name, title, and full date Dated signatures are required on the

POC/IFSP and any addendum orders

NOTE: All signatures must be dated by the author. For example, a therapist cannot date a physician’s signature.

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THERAPY PLAN OF CAREADDENDUM ORDER

POC Addendum Order must be signed by the physician when:

All LTG’s are achieved or one or more LTG’s are revised/added/deleted, or;

Recipient has a significant change in his/her condition, or;

Change in frequency or duration of tx

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THERAPIST PROGRESS NOTES

Progress notes must be written for each visit and must include:

Recipient’s response to treatment Treatment rendered Progress toward recipient goals Change in recipient’s condition Therapist, title, signature and date

NOTE: Not documented, not reimbursed!

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THERAPIST PROGRESS NOTES (continued)

Supervisory 30 day on-site review when an LPTA, COTA, or a speech-language assistant are providing treatment

Licensed therapist is not required to co-sign the progress notes written by an assistant

Licensed therapist must document the 30 day supervisory review (including signature, title, and date)

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TERMINATION OF SERVICES

Therapy services must be terminated when further progress toward the established goals is unlikely or therapy treatments can be maintained by the recipient or a caregiver.

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CONDITIONS OF DISCHARGE

Discharge from outpatient rehab must be considered when one of the following conditions exist:

No further potential for improvement is demonstrated

The skills of a qualified therapist are no longer required

The recipient has reached their maximum level of progress

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DISCHARGE SUMMARYThe discharge summary must describe:

Functional outcome Recipient LTG’s achieved Follow-up plans Discharge disposition

NOTE: Must complete within 30 days of recipient’s discharge from services. Must be signed, titled, and dated by the licensed therapist.

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Quality Management Utilization Review

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DMAS QUALITY MANAGEMENT UTILIZATION REVIEW

The purpose of UR is to ensure: Services are medically necessary Appropriate provision of services High quality of services Criteria for services are met Documentation requirements are

met

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DMAS UR RESPONSIBILITY

DMAS is responsible for validation of: Appropriateness of care provided Adequacy of services Necessity of continued participation Verification of documentation

requirements, including physician orders

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PROVIDER UR RESPONSIBILITY

Justify provision of services Identify the treatment provided Must meet all DMAS documentation

requirements Appropriate discontinuation of

services

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RETENTION OF MEDICAL RECORDS

Medical records must be retained for not less than 5 years after recipient discharge date

Medical records must be readily available, organized, and legible

Applicable to both open and closed medical records

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APPEALS PROCESS

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APPEAL PROCESS

RECIPIENT

PROVIDER

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APPEAL PROCESS

Recipient Appeal

If the denied rehab service has not been provided to the recipient, the denial may be appealed only by the recipient or his/her legally appointed representative.

Recipient appeals must be submitted within 30 days to DMAS Appeals Division.

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APPEAL PROCESS

Provider Appeal

The rehab provider has the right to request reconsideration of DMAS utilization review retractions.

The request for reconsideration and all supporting documentation, must be submitted to DMAS within 30 days of the denial notification.

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APPEAL PROCESSProvider Appeal (continued)

First Level Appeal - to the DMAS Supervisor of the Facility and Home Based Services Unit

Second Level Appeal - to the DMAS Appeals Division (IFFC Hearing)

Third Level Appeal - to the DMAS Appeals Division (Formal Hearing)

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GENERAL INFORMATION

Please feel free to visit our web site at:www.dmas.virginia.gov

For clinical questions you may call the DMAS Facility and Home Based Services Unit at 804-225-4222, option 1

The Unit fax number is 804-371-4986For billing questions call the DMAS

Provider Helpline at 1-800-552-8627