| (a) Subject to the specifications, conditions, requirements,
and limitations established by the Texas Department of Health (department)
or its designee, physical therapy services, which include necessary equipment
and supplies provided by a licensed physical therapist, are covered by the
Texas Medical Assistance Program. Covered services also include the services
of a physical therapist assistant when the services are provided under the
direction of and billed by the licensed physical therapist.
(b) To be payable, the services must be:
(1) within the physical therapist's scope of practice, as defined
by state law;
(2) reasonable and medically necessary, as determined by the
department or its designee;
(3) expected to significantly improve the patient's condition
in a reasonable and generally predictable period of time, based on the physician's
assessment of the patient's restorative potential after any needed consultation
with the therapist (benefits are not provided when the patient has reached
the maximum level of improvement); and
(4) prescribed by a physician (MD or DO), who is licensed in
the state in which he practices.
(c) The licensed physical therapist must have on file and available
for inspection for each Medicaid recipient treated:
(1) a treatment plan established by the attending physician
and/or by the therapist based on the physician's prescription which addresses
diagnosis, modalities, frequency of treatment, expected duration of treatment,
and anticipated goals; and
(2) a written prescription by the recipient's attending physician
for the therapy services.
(d) Services related to activities for the general good and
welfare of patients such as general exercises to promote overall fitness and
flexibility and activities to provide diversion or general motivation are
not considered appropriate therapy services and are not reimbursable under
the Texas Medical Assistance Program (TMAP).
(e) Repetitive services designed to maintain function once
the maximum level of improvement has been reached are not a benefit of the
TMAP.
(f) Licensed physical therapists who are employed by or remunerated
by a physician, hospital, facility, or other provider may not bill TMAP directly
for physical therapy services if that billing would result in duplicate payment
for the same services. If the services are covered and reimbursable by TMAP,
payment may be made to the physician, hospital, or other provider (if approved
for participation in TMAP) who employs or reimburses the licensed physical
therapist. The basis and amount of Medicaid reimbursement depends on the services
actually provided, who provided the services, and the reimbursement methodology
utilized by TMAP as appropriate for the services and provider(s) involved.
(g) Services provided by or under the direction of a licensed
physical therapist in long-term care facilities must be billed to the Nursing
Home Program.
|
| Source Note: The provisions of this §354.1291 adopted to be effective February 19, 1990, 15 TexReg 658; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561 |
