Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part III - Amount, Duration, and Scope of Services › Section 12VAC30-50-200 - Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders

Current through Register Vol. 40, No. 24, July 15, 2024
A. Definitions. The following words and terms
				  when used in this section shall have the following meanings unless the context
				  clearly indicates otherwise:
"Acute conditions" means conditions that are expected to
					 be of brief duration (less than 12 months) and in which progress toward
					 established goals is likely to occur frequently.
"DMAS" means the Department of Medical Assistance
					 Services.
"Evaluation" means a thorough assessment completed by a
					 licensed therapist that is signed and fully dated and includes the following
					 components: a medical diagnosis, clinical signs and symptoms, medical history,
					 current functional status, summary of previous rehabilitative treatment and the
					 result, and the therapist's recommendation for treatment.
"Nonacute conditions" means conditions that are of long
					 duration (greater than 12 months) and in which progress toward established
					 goals is likely to occur slowly.
"Physical rehabilitation services" means any medical or
					 remedial services, as defined in
					 42 CFR
					 440.130, recommended by a physician or other
					 licensed practitioner of the healing arts, within the scope of his practice
					 under state law, for maximum reduction of physical or mental disability and
					 restoration of an eligible individual to his best possible functional
					 level.
"Plan of care" means a treatment plan developed by a
					 licensed therapist, which shall include medical diagnosis; current functional
					 status; individualized, measurable, participant-oriented goals (long-term and
					 short-term goals) that describe the anticipated level of functional
					 improvement; achievement timeframes for all goals; therapeutic interventions or
					 treatments to be utilized by the therapist; frequency and duration of the
					 therapies; and a discharge plan and anticipated discharge date.
"Reevaluation" means an assessment that contains all of
					 the same components as an evaluation and that shall be completed when an
					 individual has a significant change in his condition or when an individual is
					 readmitted to a rehabilitative service.
"SLP" means speech-language pathology.
B. Amount, duration, and scope of outpatient
				  rehabilitation therapy services. The application of a national standardized set
				  of medical necessity criteria in use in the industry, such as McKesson
				  InterQual® Criteria or an equivalent standard
				  authorized in advance by DMAS, shall be required for this service.
1. DMAS covers outpatient rehabilitation
				  therapy services provided in outpatient settings of acute care and
				  rehabilitation hospitals, nursing facilities, home health agencies, and
				  rehabilitation agencies. All providers of outpatient rehabilitation therapy
				  services shall have a current provider agreement with DMAS. All practitioners
				  and providers of services shall be required to meet applicable state and
				  federal licensing or certification requirements, or both.
2. Outpatient rehabilitation therapy
				  evaluations or therapy treatment, or both, when rendered solely for vocational
				  or educational purposes shall not be covered under the authority of this
				  section. Developmental or behavioral assessments shall not be covered under the
				  authority of this section. Individuals shall have a medical diagnosis, as
				  determined by a licensed physician or other licensed practitioner of the
				  healing arts within the scope of his practice under state law, and meet the
				  medical necessity criteria in order to qualify for a Medicaid-covered
				  outpatient rehabilitation therapy evaluation or therapy treatment, or
				  both.
3. Outpatient rehabilitation
				  services shall include physical therapy (PT), occupational therapy (OT), and
				  speech-language pathology (SLP) services. These services shall be prescribed by
				  a physician or a licensed practitioner of the healing arts within the scope of
				  his practice under state law, such as a nurse practitioner or a physician
				  assistant within the scope of his practice under state law, and be part of a
				  written plan of care that is personally and legibly signed and dated by the
				  licensed practitioner who ordered the services. Supervision for a licensed
				  practitioner shall be provided by a physician as required by 18VAC90-30 and
				  18VAC90-40 for nurse practitioners and 18VAC85-50 for physician assistants. Any
				  of these services may be offered as the sole rehabilitation service and is not
				  contingent upon the provision of another service.
4. DMAS shall provide for the direct
				  reimbursement to enrolled rehabilitation providers for covered outpatient
				  rehabilitation therapy services when such services are rendered to individuals
				  residing in nursing facilities. Such reimbursement shall not be provided for
				  any sum that the rehabilitation provider collects, or is entitled to collect,
				  from the nursing facility or any other available source, and provided further
				  that the reimbursement shall in no way diminish any obligation of the nursing
				  facility to DMAS to provide its residents such services as set forth in any
				  applicable provider agreement.
5.
				  The provision of physical therapy services shall meet all of the following
				  conditions:
a. The services that the
				  individual needs shall be directly and specifically related to a written plan
				  of care developed, signed, and dated by a licensed physical
				  therapist.
b. The services shall be
				  of a level of complexity and sophistication or the condition of the individual
				  shall be of a nature that the services can only be performed by a physical
				  therapist licensed by the Virginia Board of Physical Therapy or a physical
				  therapy assistant licensed by the Virginia Board of Physical Therapy and who is
				  under the direct supervision of a licensed physical therapist.
c. When physical therapy services are
				  provided by a qualified physical therapy assistant, such services shall be
				  provided under the supervision of a qualified physical therapist who makes an
				  onsite supervisory visit at least once every 30 days and documents the findings
				  of the visit in the medical record. The supervisory visit shall not be
				  reimbursable.
6. The
				  provision of occupational therapy services shall meet all of the following
				  conditions:
a. The services that the
				  individual needs shall be directly and specifically related to a written plan
				  of care developed, signed, and dated by a licensed occupational
				  therapist.
b. The services shall be
				  of a level of complexity and sophistication or the condition of the individual
				  shall be of a nature that the services can only be performed by an occupational
				  therapist certified by the National Board for Certification in Occupational
				  Therapy and licensed by the Virginia Board of Medicine or an occupational
				  therapy assistant certified by the National Board for Certification in
				  Occupational Therapy who is under the direct supervision of a licensed
				  occupational therapist.
c. When
				  occupational therapy services are provided by a qualified occupational therapy
				  assistant, such services shall be provided under the supervision of a qualified
				  occupational therapist who makes an onsite supervisory visit at least once
				  every 30 days and documents the visit findings in the medical record. The
				  supervisory visit shall not be reimbursable.
7. The provision of speech-language pathology
				  services shall meet all of the following conditions:
a. The services that the individual needs
				  shall be directly and specifically related to a written plan of care developed,
				  signed, and dated by a licensed speech-language pathologist.
b. The services shall be of a level of
				  complexity and sophistication or the condition of the individual shall be of a
				  nature that the services can only be performed by a speech-language pathologist
				  licensed by the Virginia Board of Audiology and Speech-Language Pathology or
				  who, if exempted from licensure by statute, meets the requirements in
				  42 CFR
				  440.110(c).
c. DMAS shall reimburse for the provision of
				  speech-language pathology services when provided by a person considered by DMAS
				  as a speech-language assistant (i.e., has a bachelor's level or a master's
				  level degree without licensure by the Virginia Board of Audiology and
				  Speech-Language Pathology and who does not meet the qualifications required for
				  billing as a speech-language therapist). Speech-language assistants shall work
				  under the direct supervision of a licensed professional therapist holding a
				  Certificate of Clinical Competence (CCC) in SLP or a speech-language
				  pathologist who meets the licensing requirements of the Virginia Board of
				  Audiology and Speech-Language Pathology.
d. When services are provided by a therapist
				  who is in his Clinical Fellowship Year (CFY) of an SLP Program or a
				  speech-language assistant, a licensed professional therapist holding a CCC in
				  SLP or a speech-language pathologist who shall make a supervisory visit at
				  least every 30 days while therapy is being conducted and document the findings
				  in the medical record. The supervisory visit shall not be
				  reimbursable.