Or. Admin. Code § 410-129-0020 - Therapy Plan of Care, Goals, Outcomes, and Record Requirements
(1) Therapy shall
be based on a prescribing practitioner's written order and therapy treatment
plan with goals and objectives developed from an evaluation or re-evaluation.
The limits, authorization, and plan of treatment criteria apply to both
rehabilitative and habilitative therapy. The definition for both is the
following:
(a) "Rehabilitative Services"
means health care services that help an individual re-establish, restore, or
improve skills and functioning for daily living that have been lost or impaired
due to illness, injury, or disability;
(b) "Habilitative Services" means health care
services that help an individual keep, learn, or improve skills and functioning
for daily living, designed to establish skills that have not yet been acquired
at an age-appropriate level. Examples include therapy for a child who is not
walking or talking at the expected age.
(2) A total of thirty (30) visits per year of
rehabilitative therapy and a total of thirty (30) visits per year of
habilitative therapy (speech therapy) are included when medically appropriate.
Additional visits, not to exceed thirty (30) visits per year of rehabilitative
therapy and thirty (30) visits per year of habilitative therapy, may be
authorized in cases of a new acute injury, surgery, or other significant change
in functional status. Children under age 21 may have additional visits
authorized beyond these limits if medically necessary and medically
appropriate, pursuant to 42 CFR § 441 Subpart B.
(3) The therapist shall teach the therapy
regimen to individuals, including the client, family members, foster parents,
and caregivers who can assist in the achievement of the goals and objectives.
The client must be present when the therapy is appropriately demonstrated at
the time of teaching to assure that the therapy regimen is performed safely and
correctly. The Division may not authorize extra treatments for
teaching.
(4) All Speech-Language
Pathology (SLP) treatment services require a therapy plan of care that is
required for claims subject to prepayment review (PPR) or requiring Prior
Authorization (PA) for payment.
(5)
The Division shall provide authorization for the level of care or type of
service that meets the client's medical need consistent with the Health
Evidence Review Commission's (HERC) Prioritized List of Health Services
(Prioritized List) and the American Hippotherapy Association's (AHA) position
on coding and billing for equine related modalities.
(6) These rules do not limit or affect any
obligations of a school district or education entity eligible for reimbursement
for covered, health-related services provided in support of a child with a
disability education program required by state and federal law.
School-sponsored services are supplemental to other health plan therapy
services and are not considered duplicative. See OAR chapter 410, division 133
SBHS rules for services provided by public education providers and OAR
410-141-3565 (Managed Care
Entity (MCE) Billing).
(7) The SLP
therapy plan must adhere to the licensing board requirements of care and shall
include:
(a) Client's name and ICD diagnosis
code;
(b) The type, amount,
frequency, and duration of the proposed rehabilitative or habilitative
therapy;
(c) Individualized,
measurably objective, short-term and long-term functional goals;
(d) Dated signature of the therapist or the
prescribing practitioner establishing the therapy plan of care; and
(e) Evidence of certification of the therapy
plan of care by the prescribing practitioner.
(8) SLP therapy records must be compliant
with applicable record and documentation requirements (see Oregon
Administrative Rules in chapter 335, division 010).
(9) Documentation of clinical activities may
be supplemented using flowsheets or checklists; however, these may not
substitute for or replace detailed documentation of assessments and
interventions.
Notes
Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & ORS 414.065
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