Or. Admin. R. 410-131-0040 - Physical and Occupational Therapy
Current through Register Vol. 60, No. 12, December 1, 2021
(1) The Division's Physical and Occupational
Therapy (PT/OT) Services rules are designed to assist licensed physical and
occupational therapists deliver health care services and prepare health claims
for clients with medical assistance program coverage. 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 30 visits per year of rehabilitative therapy and a total of 30 visits per
year of habilitative therapy (physical and occupational therapy) are included
on these lines when medically appropriate. Additional visits, not to exceed 30
visits per year of rehabilitative therapy and 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
appropriate, as per guideline note 6 of the Prioritized List of Health
Services.
(3) OAR 410-131-0040
through 0160:
(a) Apply to services delivered
by home health agencies and by hospital-based therapists in the outpatient
setting. Billing and reimbursement for therapy services delivered by home
health agencies and hospital outpatient departments must comply with the rules
in their respective provider guides;
(b) Do not apply to services provided to
hospital inpatients; and
(c) May
not limit or effect 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 410-141-3420 (Managed Care Entity (MCE) Billing and Payment).
(4) The Division shall enroll only
the following types of providers as performing providers under the PT/OT
program:
(a) An individual licensed by the
relevant state licensing authority to practice physical therapy; and
(b) An individual licensed by the relevant
state licensing authority to practice occupational therapy.
(5) All Division rules are
intended to be used in addition to the General Rules for Health Systems
Division programs (OAR 410 division 120) and the Oregon Health Plan (OHP) (OAR
410 division 141).
(6) The Oregon
Health Evidence Review Commission's (HERC) Prioritized List of Health Services
is found in OAR 410-141-0520 and defines the covered services.
Notes
Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
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