Ala. Admin. Code r. 480-5-5-.19

Current through Register Vol. 43, No. 1, October 31, 2024

Section 480-5-5-.19 - Physical Therapy/Occupational Therapy/Speech Therapy Services

(1) Applicability - The following shall apply to non-physician therapy providers (hospital outpatient, freestanding, and independent practicing facilities). Practicing physical therapists, physical therapist assistant, occupational therapists, occupational therapists assistants and speech therapists shall be currently licensed or certified.

(2) The following criteria shall be met for therapy to qualify for reimbursement:

(a) The patient's condition shall have the potential for restoration of function and require a skilled level of care;

(b) The therapy shall be specific for the improvement of the patient's condition;

(c) The therapy shall be provided under a current plan of care which is developed by the therapist, a copy of which is sent to and approved by the referring physician and substantiated in the physician's office notes and in the therapist's office notes; and

(d) The referring physician shall concur, and upon request, submit to the employer/agent or RUE documentation substantiating the medical necessity of therapies ordered.

(e) For acute cases, up to three (3) visits during the certification process may be allowed after the initial evaluation, if same day certification cannot be obtained. If subsequent pre-certification results in an adverse determination, reimbursement shall be allowed for the initial evaluation and up to three visits during the certification process, if the treatment is medically necessary and is for a compensable work injury.

(3) Plan of Care

(a) On the initial visit, a therapist shall evaluate the patient's therapy needs and develop a written plan of care based upon the assessment of the patient's level of function and the referring physician's orders. The therapist shall obtain pre-certification for the treatment plan from the RUE or employer/agent subsequent to the initial evaluation.

(b) After the initial visit, the written plan of care shall be forwarded from the therapist to the RUE or employer/agent and to the referring physician within five (5) working days for review and retention in the patient's records.

(c) The referring physician shall acknowledge that the plan is approved and medically necessary by signing the plan of care. A signed copy of the original plan of care shall be returned to the therapist.

(d) At a minimum, but not limited to, the plan of care shall contain:

1. The potential degree of restoration and measurable goals;

2. The specific therapies to be provided including the frequency of each treatment; and

3. The estimated duration of the therapeutic regimen.

(4) Plan of Care Review

(a) The therapist shall review the plan of care at least every 30 days to evaluate the treatment results with the plan of care goals and make necessary revision recommendations to the referring physician and the RUE or employer/agent.

(b) When revisions are made to the plan per the referring physician's recommendations, the therapist shall forward the revised plan to the RUE or employer/agent and referring physician for review and approval.

(c) When a revised plan of care is approved, the referring physician shall sign the revised plan, retain a copy for the patient's record and return the revised plan to the therapist.

(d) Upon receipt of the approved, revised plan of care from the referring physician, the therapist shall forward a copy of the revised plan of care to the RUE or employer/agent for certification.

(5) Initial Assessment

(a) Billing - The initial, written assessment developed by the therapist shall be reported to the RUE or employer/agent using the appropriate HCPCS procedure code.

(b) Reimbursement

1. Only one initial evaluation treatment assessment per injury shall be recommended for reimbursement without prior approval of the RUE or employer/agent. Re-evaluations shall be billed using the appropriate HCPCS procedure code.

2. Reimbursement for the use of additional initial assessment time shall not be allowed, unless supported by documentation.

3. Assessment of the patient's status shall include assessment of the neuromuscular system and reimbursement shall not be made for neuromuscular testing codes, extremity testing codes and/or range of motion codes in addition to the initial evaluation. These codes shall not be used instead of the initial evaluation code when an initial assessment is performed.

(6) Modalities and Procedures

(a) Body Areas - The following three body areas, or any portions thereof, shall be recognized for the provision of modalities and procedures:

1. The trunk: the entire body including the spine excluding the head and limbs (Synonym: Torso);

2. Any two extremities;

(i) An upper extremity shall be the upper limb including the shoulder, upper arm, elbow, forearm, wrist and hand.

(ii) A lower extremity shall be the lower limb including the hip, thigh, knee, leg, ankle, and foot.

3. The head.

(b) Billing

1. Single Procedure/Modality.

(i) The appropriate CPT-4 procedure code and the unique descriptor for each shall be used when billing for a single (one) modality or procedure to a single body area.

(ii) Billing for single therapeutic procedures presumes up to 15 minutes unless otherwise indicated by the appropriate CPT-4 procedure code.

(iii) The appropriate CPT-4 procedure code shall be used when therapeutic exercises are performed regardless of whether or not mechanical equipment is used.

2. Multiple Body Areas

(i) When physical medicine therapies are provided to more than one body area, modifier-51 shall be added to the procedure code(s) billed for the additional body area.

(ii) When therapy is billed for more than one body area, there shall be more than one diagnosis code and descriptor in Element 23 and the reference numbers 1, 2, 3, etc., shall be listed in 24D of the HCFA 1500 Form.

(iii) Reimbursement

(I) No more than one visit per day for the purpose of therapy shall be recommended for reimbursement without being precertified by the RUE or employer/agent.

(II) Reimbursement for additional time shall be in accordance with the certified plan of care, the nature and severity of the condition(s).

(III) The RUE or employer/agent shall compare the billing with the plan of care to ensure that only the services that are itemized in the plan of care are reimbursed.

(IV) Unless full immersion therapy is medically necessary and prescribed, the CPT-4 procedure code for Hubbard Tank shall not be recommended for reimbursement.

(7) Tests and Measurements

(a) Extremity Testing, Muscle Testing, and Range of Motion Measurement shall be recommended for reimbursement only once in a 30-day period.

(b) When two or more procedures from muscle testing or range of motion codes are performed on the same day, reimbursement shall not exceed the prevailing charge for total evaluation for the body, including hands, unless approved by the RUE or employer/agent.

(c) The physical performance test or measurement procedure code shall be used when physical performance test or measurement is performed by means of mechanical equipment or standardized testing procedures.

(d) The procedure code for physical performance test or measurement shall include a printout of test results Separate reimbursement shall not be made under the CPT-4 procedure code for analysis of information data stored in computer.

(8) Transcutaneous Electrical Nerve Stimulation (TENS)

(a) TENS shall be provided to the injured worker when ordered by the physician, itemized in the plan of care, and authorized by the RUE or employer/agent.

(b) The procedure code for application of TENS shall be used to report TENS testing and training.

(c) Reimbursement for TENS testing and training shall be limited to four sessions per injury unless prior approval is obtained from the RUE or employer/agent;

(d) The procedure code for application of surface (transcutaneous) neurostimulator shall not be used to bill for electrical stimulation therapy. Providers shall use the appropriate physical medicine CPT-4 procedure code for electrical stimulation therapy.

(e) Billing for TENS Equipment

1. When the physician recommends TENS for long-term therapy, authorization shall be obtained from the RUE or employer/agent for rental or purchase of equipment for the patient on the most cost-effective terms.

2. The appropriate HCPCS code shall be used for either rented or purchased TENS equipment.

(9) Medical Rehabilitation Supplies

(a) Dressings that must be removed before treatment and replaced after treatment shall be billed and reimbursed under the appropriate HCPCS code.

(b) Rehabilitation supplies that are patient specific shall be billed using the appropriate HCPCS code.

(10) Fabrication of Orthotics

(a) The appropriate CPT-4 procedure code shall be used by the therapist for orthotics training.

(b) Supplies shall be billed separately under the appropriate HCPCS code.

(c) The cost of the orthotic shall include the cost of fabrication.

(11) Work Conditioning/Hardening Program

(a) Work conditioning assessment or a work hardening assessment shall be conducted prior to the request for either program and submitted to the RUE or employer/agent. Services shall be precertified and authorization from the RUE or employer/agent shall be received prior to providing services. No health care provider shall refer the employee to another health care provider, diagnostic facility, work conditioning/hardening program, therapy center or other facility without prior authorization from the RUE or employer/agent. Providers shall render services that are medically necessary. Services shall be delivered in specific areas of expertise by registered, certified, licensed or degreed personnel or shall be performed substantially in their presence and shall be provided on a regular continuing basis.

(b) Billing Information

1. The HCFA 1500 (UB92 for hospitals) shall be used to bill for services rendered.

2. The facility shall enter the appropriate CPT-4 or HCPCS codes as identified in the Maximum Fee Schedule for Physical Therapists.

3. Services shall be billed using a total or global charge concept.

(i) The bill shall include charges for the performance of the basic professional service and the normal range of essential, associated services provided to achieve the objective of the program.

(ii) Licensed personnel, including physicians, serving as part of the interdisciplinary team, shall not bill separately for their services. These services shall be included in the total cost of the program and their reimbursement shall be made through the facility.

4. Any physician or other provider serving on a consulting basis whose services have been authorized by the RUE or employer/agent in addition to the interdisciplinary team's services, shall bill on HCFA 1500.

(c) Work Conditioning Program

1. Work conditioning program utilizes physical conditioning and functional activities related to work. Work conditioning shall not begin after 365 days have elapsed following the injury without a comprehensive interdisciplinary assessment.

2. With pre-authorization from the RUE or employer/agent, work conditioning shall be reimbursed a maximum of four weeks with provisions that additional two-week increments may be approved by the RUE or employer/agent if substantial improvement is demonstrated by the patient.

3. To be eligible for work conditioning the patient shall:

(i) Have stated or demonstrated a willingness to participate;

(ii) Have identified systemic neuro-musculo-skeletal physical and functional deficits that interfere with work; and

(iii) Be at the point of resolution of the initial or principal injury that participation in the work conditioning program would not be prohibited.

4. The work conditioning program requires a maximum of four hours per day, five days per week, up to eight weeks.

5. The work conditioning program shall be provided by or under the direct supervision of a licensed physical therapist although other professionals may be work conditioning providers.

6. Progress shall be documented and reviewed to ensure continued progress.

7. The exit/discharge criteria for work conditioning shall include, but is not limited to, the patient:

(i) Meeting the program goals;

(ii) Developing behavioral or vocational problems which are not being addressed and which interfere with return to work;

(iii) Having medical contraindications;

(iv) Failing to comply with the requirements of participation;

(v) Reaching a plateau prior to meeting goals; or

(vi) Being discontinued by the referral source.

8. The exit/discharge summary shall include:

(i) Reason(s) for program termination;

(ii) The patient's clinical and functional status;

(iii) Recommendation(s) regarding return to work; and

(iv) Recommendation(s) for follow-up services.

9. The appropriate CPT-4 procedure code shall be used to bill for work conditioning.

(d) Work Hardening Program

1. Work hardening is a highly structure, goal Oriented, individualized treatment program designed to maximize the employee's ability to return to work. A work hardening program shall include real or realistically simulated job tasks based on a job description or analysis of the actual job, if a specific job is available, or on the physical demand factor of the occupational objective of the employee. These programs utilize real or simulated work activities in conjunction with conditioning tasks.

2. With pre-authorization from the RUE or employer/agent, work hardening shall be reimbursed a maximum of four weeks with provisions that additional two-week increments may be approved by the RUE or employer/agent if substantial improvement is demonstrated by the patient.

3. Entrance/admission criteria shall enable the program to admit:

(i) Persons who are likely to benefit from the program;

(ii) Persons whose current level of functioning due to illness or injury interferes with their ability to carry out specific tasks required in the work place; and

(iii) Persons whose medical condition does not prohibit participation in the program.

4. The Work Hardening Program requires a minimum of four hours per day except for the initial phase (one week) due to the patient's inability to tolerate the full session. During the initial phase there is a two-hour per day minimum. Eight hour days shall be allowed only for the final week of work hardening. The Work Hardening Program may continue up to eight weeks.

5. The individualized work hardening plan shall be supervised by a licensed physical or occupational therapist and/or physician within a therapeutic environment. Although some time is spent on a 1:1 basis, more than 50 percent (50%) of the time is self-monitored under the supervision of a physical or occupational therapist and/or physician. Recommended group size is no larger than 5:1.

6. Progress shall be documented and reviewed to ensure continued progress.

7. Simultaneous utilization of work conditioning and work hardening shall not be allowed. Prior authorization shall be required for either one of these services and requires documentation of specific goals and outcomes.

8. The exit/discharge criteria for work hardening shall include, but is not limited to, the patient's:

(i) Returning to work;

(ii) Meeting program goals;

(iii) Declining further services;

(iv) Noncompliance with organizational policies;

(v). Limited potential to benefit; or

(vi) Requiring further health care interventions.

9. The exit/discharge summary shall delineate the person's:

(i) Present functional status and potential; and

(ii) Functional status related to the targeted job, alternative occupations, or competitive labor market.

10. The appropriate CPT-4 procedure code for the initial 2 hours and the appropriate CPT-4 procedure code for each additional hour shall be used to bill work hardening.

(e) A Functional Capacity Evaluation (FCE) may be performed to evaluate the injured worker's functional/vocational status and when performed shall document a bench mark from which to establish an initial plan. This process shall follow the guidelines of the Commission for Accreditation of Rehabilitation Facilities, to include one or more of the following FCEs:

1. Baseline Evaluation of functional ability to perform work activities that includes the physical demand factors in the Dictionary of Occupational Titles;

2. Job Capacity Evaluation of the match between the individual's capabilities and the critical demands of a specific job;

3. Occupational Capacity Evaluation of the match between the individual's capabilities and the critical demands of an occupational group; or

4. Work Capacity Evaluation of the match between the individual's capabilities and the demands of competitive employment.

Author: Workers' Compensation Division

Ala. Admin. Code r. 480-5-5-.19

New Rule: Filed August 9, 1996; effective September 13, 1996.

Statutory Authority:Code of Ala. 1975, § 25-5-293.