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Updates to Clinical Coverage Policy 10B: Independent Practitioners

Monday, July 1, 2019

On June 1, 2019, an amended version of Clinical Coverage Policy 10B, Independent Practitioners, was posted to the North Carolina Medicaid website. The following updates were made in accordance with State Plan Amendment (SPA) NC 18-0005 which allowed an expansion of the universe of documentation that a Local Education Agency (LEA) can use as a basis for providing school-based health services from beyond a student beneficiary’s Individualized Education Program (IEP) to also include the Individual Family Service Plan (IFSP), Individual Health Plan (IHP), Behavior Intervention Plan (BIP) or 504 Plan.

The following SPA-related updates became effective October 1, 2018:

In Subsection 3.2.1.7 Treatment Services, criterion e., was updated to include the following language, effective 10/01/2018:

  • For a Local Education Agency (LEA), the prior approval process is deemed met by the Individualized Education Program (IEP) Individual Family Service Plan (IFSP), Individual Health Plan (IHP), Behavior Intervention Plan (BIP), or 504 Plan processes. An LEA provider shall review, renew and revise the IEP, IFSP, IHP, BIP or 504 Plan annually along with obtaining a dated physician order with signature.

In Subsection 5.2.2 Prior Approval Requirements, Specific was updated to include the following language, effective 10/01/2018:

  • For an LEA, the prior approval process is deemed met by the IEP, IFSP, IHP, BIP or 504 Plan processes.

These additional updates, unrelated to the SPA, became effective June 1, 2019:

In Subsection Related Clinical Coverage Policies, the title of related policy 5A-1 was updated to Physical Rehabilitation Equipment and Supplies

In Subsection 1.0 Description of the Procedure, Product, or Service, the following language was moved to section 2.1.2 Eligibility Requirements, Specific:

  • The IPP provider may only render services to Medicaid beneficiaries under 21 years of age.

In Subsection 3.2.1.3(a)(1) Speech/ Language Therapy, criterion I. was updated to read:

  • Neuromuscular degenerative disease likely to affect swallowing regardless of the presence of a communication difficulty

In Subsection 3.2.1.5 Evaluation Services, the following language was added as the last sentence:

  • 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 Subsection 3.2.1.6 Treatment Plan (Plan of Care), criterion h. was deleted:

  • 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; and

In Subsection 3.2.1.8 Re-evaluation Services, the following language was deleted:

  • 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 Subsection 5.1 Prior Approval, the following language was added:

  • To obtain prior approval, the request must clearly indicate that the service of a licensed therapist is required.

In Subsection 5.2.2 Prior Approval Requirements, Specific, the following updates were made:

  • Deleted: For occupational therapy (OT) and physical therapy (PT) prior approval, a written report of an evaluation must occur within six (6) months of the requested beginning date of treatment.
  • Added: For prior approval, a written report of an evaluation must occur within three months of the requested beginning date of treatment.
  • Deleted: The re-evaluation report must document 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.
  • 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 document 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 Subsection 6.1, Provider Qualifications and Occupational Licensing Entity Regulations, updated references to Federal Register qualifications for OT, PT, SLP and audiology.

In Subsection 7.5 Requirements When the Type of Treatment Services Are the Same as Those Provided by the Child’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 (that is, Head Start, early childhood intervention service or developmental day care program).

In Attachment A: Claims-Related Information, Section C: Code(s), the following updates were made:

  • End-dated CPT code 97762 was removed and replaced with 97763.

In Attachment A: Claims-Related Information, Section E: Billing Units, the following updates were made:

  • Deleted: Evaluation services are the administration of an evaluation protocol, involving testing and/or clinical observation as appropriate for chronological or developmental age, which results in the generation of a written evaluation report. This protocol may include interviews with family, caregivers, other service providers, and teachers as a means to collect assessment data from inventories, surveys, and questionnaires.
  • Added: Evaluation services: refer to Subsection 3.2.1.5.

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, must 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 10B is available at North Carolina Medicaid’s Outpatient Specialized Therapy Services web page. Additional information can also be found at the ChoicePA website.