Author: The Carolinas Center for Medical Excellence
Effective Sept. 15, 2018, Clinical Coverage Policy 10A, Outpatient Specialized Therapies, was updated to increase therapy visit limits for recipients 21 years of age and older. A summary of the most significant changes follows.
In section 3.2.1.5 Evaluation Services, the following language was added:
An evaluation visit also incorporates any immediate treatment warranted based on the evaluation results. No prior authorization is needed for evaluation visits or for treatment rendered as part of an evaluation visit.
In section 3.2.1.8 Re-evaluation Services, and 5.2 Prior Approval Requirements, Section 5.2.2 Specific, the following language was deleted:
The re-evaluation report must report the frequency at which the beneficiary receives the same type of health-related service provided as part of the public school’s special education program or as part of an early intervention program when applicable.
In section 5.2 Prior Approval Requirements, Section 5.2.2 Specific, the following language was also deleted:
For audiology services (AUD) and speech/language services (ST) prior approval, a written report of an evaluation must occur within six (6) months of the requested beginning date of treatment. When continued treatment is requested, an annual re-evaluation of the beneficiary’s status and performance must be documented in a written evaluation report. The re-evaluation report must include the frequency at which the beneficiary receives the same type of health-related service provided as part of the public school’s special education program or as part of an early intervention program when applicable.
In section 5.4 Visit Limitations Beneficiaries 21 Years of Age and Older, the language specific to the annual and episodic visit limits for beneficiaries 21 years of age and older was deleted and replaced with:
The first prior approval request within a calendar year shall be for no more than three therapy treatment visits and one month. The PA review vendor will authorize these three treatment visits to begin as early as the day following the submission of the PA request. Any subsequent PA may be obtained for up to 12 therapy treatment visits and six months. A beneficiary can receive a maximum of 27 therapy treatment visits per calendar year across all therapy disciplines combined (occupational therapy, physical therapy and speech/language therapy). Each reauthorization request must document the efficacy of treatment.
In section 7.5 Requirements When the Type of Treatment Services Are the Same as Those Provided by the Beneficiary’s Public School or Early Intervention Program, the following language was deleted:
the combined frequency of services must be medically necessary to address the beneficiary’s deficits. The provider must document on the PA request as well as on the Treatment Plan the frequency at which the beneficiary receives the same type of health-related treatment services provided as part of the public school’s special education program or as part of an early intervention program Services
In Attachment A: Claims-Related Information, Section B. International Classification of Diseases and Related Health Problems, Tenth Revisions, Clinical Modification (ICD-10-CM) and Procedural Coding System (PCS), all tables containing ICD-10-CM diagnosis codes were removed.
In Attachment A: Claims-Related Information, Section C. Code(s), all tables containing surgical CPT codes were removed.
In Attachment A: Claims-Related Information, Section E. Billing Units, the following language was added:
Billing for co-treatment services, therapy treatment services provided by OT and PT for a single Medicaid or NCHC beneficiary as a single visit, shall not exceed the total amount of time spent with the beneficiary. OT and PT must split the time and bill only timed CPT codes. Co-treatment visits including speech therapy must be at least 38 minutes in session length to bill both one event of speech therapy and one unit of a timed CPT code for occupational or physical therapy. Additional timed CPT codes for occupational or physical therapy may be billed only when the session length is extended by an additional 15 minutes for either the occupational therapy or physical therapy treatment.
Additional Resources
The full text of Clinical Coverage Policy 10A is available at NC Medicaid’s Outpatient Specialized Therapy Services web page. Additional information can also be found at the ChoicePA website.