Wash. Admin. Code § 296-23-230
Practitioners should refer to WAC 296-20-010 through 296-20-125 for general information and rules pertaining to the care of workers.
Refer to WAC 296-20-132 and 296-20-135 for information regarding the conversion factors.
All supplies and materials must be billed using HCPCS Level II codes, refer to the department's billing instructions for additional information.
Occupational therapy treatment will be reimbursed only when ordered by the worker's attending doctor and rendered by a licensed occupational therapist or an occupational therapist assistant serving under the direction of a licensed occupational therapist. In addition, physician assistants may order occupational therapy under these rules for the attending doctor. Vocational counselors assigned to injured workers by the department or self-insurer may request an occupational therapy evaluation. However, occupational therapy treatment must be ordered by the worker's attending doctor or by the physician assistant.
An occupational therapy progress report must be submitted to the attending doctor and the department or self-insurer following 12 treatment visits or one month, whichever occurs first. Occupational therapy treatment beyond the initial 12 treatments will be authorized only upon substantiation of improvement in the worker's condition. An outline of the proposed treatment program, the expected restoration goals, and the expected length of treatment will be required.
The department or self-insurer will review the quality and medical necessity of occupational therapy services. Practitioners should refer to WAC 296-20-01002 for the department's definition of medically necessary and to WAC 296-20-024 for the department's rules regarding utilization review and quality assurance.
The department will pay for a maximum of one occupational therapy visit per day. When multiple treatments (different billing codes) are performed on one day, the department or self-insurer will pay either the sum of the individual fee maximums, the provider's usual and customary charge, or $147.97 whichever is less. These limits will not apply to occupational therapy which is rendered as part of a physical capacities evaluation, work hardening program, or pain management program, provided a qualified representative of the department or self-insurer has authorized the service.
The department will publish specific billing instructions, utilization review guidelines, and reporting requirements for occupational therapists who render care to workers.
Occupational therapy services rendered in the worker's home and/or places other than the practitioner's usual and customary office, clinic, or business facility will be allowed only upon prior authorization by the department or self-insurer.
No inpatient occupational therapy treatment will be allowed when such treatment constitutes the only or major treatment received by the worker. See WAC 296-20-030 for further information.
The department may discount maximum fees for treatment performed on a group basis in cases where the treatment provided consists of a nonindividualized course of therapy (e.g., pool therapy; group aerobics; and back classes).
Billing codes, reimbursement levels, and supporting policies for occupational therapy services are listed in the fee schedules.
Wash. Admin. Code § 296-23-230
Statutory Authority: RCW 51.04.020(1) and 51.04.030. 12-11-107, § 296-23-230, filed 5/22/12, effective 7/1/12; 08-09-121, § 296-23-230, filed 4/22/08, effective 7/1/08; 07-10-082, § 296-23-230, filed 5/1/07, effective 7/1/07; 06-09-071, § 296-23-230, filed 4/18/06, effective 7/1/06. Statutory Authority: RCW 51.04.020 and 51.04.030. 05-18-030, § 296-23-230, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 51.04.020(1) and 51.04.030. 05-09-062, § 296-23-230, filed 4/19/05, effective 7/1/05; 04-09-100, § 296-23-230, filed 4/20/04, effective 7/1/04; 03-14-043, § 296-23-230, filed 6/24/03, effective 8/1/03; 02-10-129, § 296-23-230, filed 5/1/02, effective 7/1/02; 01-10-026, § 296-23-230, filed 4/24/01, effective 7/1/01; 00-09-077, § 296-23-230, filed 4/18/00, effective 7/1/00. Statutory Authority: RCW 51.04.020(4) and 51.04.030. 99-10-043, § 296-23-230, filed 4/30/99, effective 7/1/99; 98-09-125, § 296-23-230, filed 4/22/98, effective 7/1/98; 97-10-017, § 296-23-230, filed 4/28/97, effective 7/1/97; 96-10-086, § 296-23-230, filed 5/1/96, effective 7/1/96; 95-05-072, § 296-23-230, filed 2/15/95, effective 3/18/95. Statutory Authority: RCW 51.04.020, 51.04.030 and 1993 c 159. 94-02-045, § 296-23-230, filed 12/30/93, effective 3/1/94; 93-16-072, § 296-23-230, filed 8/1/93, effective 9/1/93.