Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy. Note: For Medicare members, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs, LCDs,
from the current manuals and those included herein are not intended to be all- inclusive ... Please refer to the state Medicaid manual for any coverage provisions ...
Clinical Policy: Rehabilitative Therapy Site of Care Optimization Reference Number: FL.CP.MP.500 Coding Implications Last Review Date: 08/19 Revision Log See Important Reminder at the end of this policy for important regulatory and legal information. Description Rehabilitative therapy services including physical and occupational therapy develop, maintain, improve, or restore neuro-muscular or sensory motor function to relieve pain, acquire a skill set, restore a skill set or control postural deviations. Speech language pathology services provide for the evaluation and treatment of speech language disorders to remediate and maintain communication functioning, acquire a skill set, restore a skill set and enhance communication. Physical therapy, occupational therapy, and speech-language pathology services may be provided in hospitals, private practices, outpatient clinics, nursing homes and rehabilitation facilities, and in the home. The appropriate location of services is determined by the physical and medical condition of the member, the need for specialized equipment or personnel, and the location of the individual in relation to the needed services. The medical necessity of physical therapy, occupational therapy, and speech-language pathology services may be separately reviewed against the appropriate criteria. This guideline is for the determination of medical necessity for physical or occupational therapy services, or speechlanguage pathology services provided in a hospital outpatient department or hospital outpatient clinic. Policy/Criteria I. It is the policy of Sunshine Health that outpatient physical therapy (PT), occupational therapy (OT) and speech language pathology (ST) services provided in the outpatient hospital department or hospital outpatient clinic setting is considered medically necessary when any of the following are met: A. The PT, OT or ST treatment requires specialized equipment or services which would only routinely be available in the hospital outpatient department or hospital outpatient clinic setting; or B. The PT, OT or ST regimen can only be performed safely and effectively by or under the general supervision of skilled medical personnel in the hospital outpatient department or hospital outpatient clinic setting; or C. The member's medical status requires close monitoring beyond what is routinely needed for physical therapy, occupational therapy or speech language pathology services; or D. The type or size of equipment is not available in a freestanding facility; or E. There is significant risk of sudden life-threatening changes in the member's clinical condition and immediate access to acute or emergency level of care and services in a medical center/hospital setting is considered advisable (for example, access to emergency resuscitation equipment and personnel, inpatient admission or intensive care facilities). Clinical conditions that may require the acute or emergency level of care include, but are not limited to: 1. Acute mental status changes; Page 1 of 5 CLINICAL POLICY Rehabilitative Therapy Site of Care Optimization 2. History of falls with significant bleeding; 3. History or significant risk of major cardiac event; 4. History or significant risk of major thromboembolic event; 5. Significant burn care management; F. There are no appropriate alternate sites within the member's geographic area to receive the prescribed PT, OT or ST services. II. It is the policy of Sunshine Health that requests for PT, OT and ST not meeting the above listed criteria should be provided in an alternate, less intensive site of care. Background The Health Plan may also use tools developed by third parties, such as the InterQualTM Guidelines, and other consensus guidelines and evidence-based medicine, to assist us in administering health benefits. The InterQualTM Care Guidelines and other are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. Coding Implications This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2019, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services. CPT® Codes 97168 97530 92597 97542 97164 97110 Description Re-evaluation of occupational therapy established plan of care, requiring these components: An assessment of changes in patient functional or medical status with revised plan of care; An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required. Typically, 30 minutes are spent face-to-face with the patient and/or family. Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech Wheelchair management (eg, assessment, fitting, training), each 15 minutes Re-evaluation of physical therapy established plan of care, requiring these components: An examination including a review of history and use of standardized tests and measures is required; and Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome Typically, 20 minutes are spent face-to-face with the patient and/or family. Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility Page 2 of 5 Reviews, Revisions, and Approvals Policy developed. Date 08/19 Approval Date 10/19 References 1. American Physical Therapy Association. American Physical Therapy Association's Guide to Physical Therapist Practice 3.0. Available at http://guidetoptpractice.apta.org 2. American Physical Therapy Association. American Physical Therapy Association. Physical therapy for older adults. 2012. Available at: http://www.apta.org/Policies/Practice/. Accessed on August 20, 2019. 3. American Physical Therapy Association. Standards of practice for physical therapy. 2013. Available at: http://www.apta.org/Policies/Practice/. Accessed on January 29, 2019. 4. American Physical Therapy Association. Access to, admission to, and patient/client rights within physical therapy services. 2018. Available at: http://www.apta.org/Policies/Practice/. Accessed on August 20, 2019. 5. American Physical Therapy Association. Role of a Physical Therapist. 2003. Available at: http://www.apta.org/Policies/Practice/. Accessed on August 20, 2019. 6. Student Doctor Network. Occupational Therapy Clinical Practice Settings. 2018. Available at: https://www.studentdoctor.net/2018/08/30/occupational-therapy-practice-settings/ . Accessed on August 20, 2019. 7. American Occupational Therapy Association, Inc. Occupational Therapy in Acute Care. 2017. Available at: https://www.aota.org/About-Occupational Therapy/Professionals/RDP/AcuteCare.aspx . Accessed on August 20, 2019. 8. Centers for Medicare & Medicaid Services (CMS). Pub. 100-02, Chapter 15, Section 220. Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance and Section 230 Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology. November 30, 2018. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed on August 20, 2019. 9. Centers for Medicare & Medicaid Services. National Coverage Determination for Institutional and Home Care Patient Education Programs. NCD#170.1. Effective date not posted. Available at: https://www.cms.gov/medicare-coverage-database/overview-and-quick search.aspx. Accessed on August 20, 2019. Important Reminder This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. "Health Plan" means a health Page 3 of 5 CLINICAL POLICY Rehabilitative Therapy Site of Care Optimization plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan's affiliates, as applicable. The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures. This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time. This clinical policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members. This clinical policy is not intended to recommend treatment for members. Members should consult with their treating physician in connection with diagnosis and treatment decisions. Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan. This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members and their representatives agree to be bound by such terms and conditions by providing services to members and/or submitting claims for payment for such services. Note: For Medicaid members, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy. Note: For Medicare members, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs, LCDs, and Medicare Coverage Articles should be reviewed prior to applying the criteria set forth in this clinical policy. Refer to the CMS website at http://www.cms.gov for additional information. Page 4 of 5 CLINICAL POLICY Rehabilitative Therapy Site of Care Optimization ©2017 Centene Corporation. All rights reserved. All materials are exclusively owned by Centene Corporation and are protected by United States copyright law and international copyright law. No part of this publication may be reproduced, copied, modified, distributed, displayed, stored in a retrieval system, transmitted in any form or by any means, or otherwise published without the prior written permission of Centene Corporation. You may not alter or remove any trademark, copyright or other notice contained herein. Centene® and Centene Corporation® are registered trademarks exclusively owned by Centene Corporation. Page 5 of 5Sunshine Health Adobe PDF Library 15.0