Virginia Law

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.

C. Authorization for outpatient rehabilitation services.

1. Physical therapy, occupational therapy, and speech-language pathology services provided in outpatient settings of acute and rehabilitation hospitals, rehabilitation agencies, nursing facilities, or home health agencies shall include authorization for up to five allowed visits, which do not require preceding service authorization, by each ordered rehabilitative service annually as long as the individual meets the medical necessity criteria as set out in subsection B of this section for the particular service. In situations when individuals require more than the initial five visits, providers shall submit to either DMAS or the service authorization contractor requests for service authorization and the required demonstration of medical necessity for such individuals. The provider shall maintain documentation to justify the need for services.

2. The provider shall request from DMAS or its contractor authorization for treatments deemed necessary by a physician or other licensed practitioner of the healing arts within the scope of his practice under state law beyond the initial five visits. Documentation for medical justification must include plans of care signed and dated by a physician or other licensed practitioner. Authorization for extended services shall be based on individual need. Payment shall not be made for additional services beyond the initial five visits unless the extended provision of services has been authorized by DMAS or its contractor.

3. Covered outpatient rehabilitative services for acute conditions shall include physical therapy, occupational therapy, and speech-language pathology services.

4. Covered outpatient rehabilitation services for long-term, nonacute conditions shall include physical therapy, occupational therapy, and speech-language pathology services.

5. Payment shall not be made for reimbursement requests submitted more than 12 months after the termination of services.

D. Service limitations. The following general conditions shall apply to reimbursable physical therapy, occupational therapy, and speech-language pathology services:

1. The individual must be under the care of a physician or other licensed practitioner who is legally authorized to practice and who is acting within the scope of his license.

2. The orders for evaluation of the need for therapy services shall identify the specific therapy discipline and must be personally signed and dated prior to the initiation of rehabilitative services.

3. The plan of care shall include the specific procedures and modalities to be used and indicate the frequency and duration for services. A written plan of care shall be reviewed by the physician or licensed practitioner every 60 days for acute conditions, as defined in subsection A of this section, or annually for nonacute conditions. The requested services shall be necessary to carry out the plan of care and shall be related to the individual's condition. The plan of care shall be signed and dated, as specified in this section, by the physician or other licensed practitioner who reviews the plan of care.

4. Quality management reviews, pursuant to 12VAC30-60-150, shall be performed by DMAS or its contractor.

5. Physical therapy, occupational therapy, and speech-language services are to be considered for termination regardless of the service authorized visits or services when any of the following conditions are met:

a. No further potential for improvement is demonstrated and the individual has reached his maximum progress.

b. Lack of participation on the part of the individual is evident.

c. The individual has an unstable condition that affects his ability to actively participate in a rehabilitative plan of care.

d. Progress toward an established goal or goals cannot be achieved within a reasonable period of time as determined by the licensed therapist.

e. The established goal serves no purpose to increase meaningful functional or cognitive capabilities.

f. The service no longer requires the skills of a qualified therapist.

g. A home maintenance program has been established to maintain the individual's function at the level to which it has been restored.

E. All providers of outpatient rehabilitation services shall be required to enroll as Medicaid providers using the outpatient rehabilitation services provider agreement.