1 Tex. Admin. Code § 354.1291 - Benefits and Limitations

(a) Subject to the specifications, conditions, requirements, and limitations established by the Texas Department of Health (department) or its designee, physical therapy services, which include necessary equipment and supplies provided by a licensed physical therapist, are covered by the Texas Medical Assistance Program. Covered services also include the services of a physical therapist assistant when the services are provided under the direction of and billed by the licensed physical therapist.

(b) To be payable, the services must be:

(1) within the physical therapist's scope of practice, as defined by state law;

(2) reasonable and medically necessary, as determined by the department or its designee;

(3) expected to significantly improve the patient's condition in a reasonable and generally predictable period of time, based on the physician's assessment of the patient's restorative potential after any needed consultation with the therapist (benefits are not provided when the patient has reached the maximum level of improvement); and

(4) prescribed by a physician (MD or DO), who is licensed in the state in which he practices.

(c) The licensed physical therapist must have on file and available for inspection for each Medicaid recipient treated:

(1) a treatment plan established by the attending physician and/or by the therapist based on the physician's prescription which addresses diagnosis, modalities, frequency of treatment, expected duration of treatment, and anticipated goals; and

(2) a written prescription by the recipient's attending physician for the therapy services.

(d) Services related to activities for the general good and welfare of patients such as general exercises to promote overall fitness and flexibility and activities to provide diversion or general motivation are not considered appropriate therapy services and are not reimbursable under the Texas Medical Assistance Program (TMAP).

(e) Repetitive services designed to maintain function once the maximum level of improvement has been reached are not a benefit of the TMAP.

(f) Licensed physical therapists who are employed by or remunerated by a physician, hospital, facility, or other provider may not bill TMAP directly for physical therapy services if that billing would result in duplicate payment for the same services. If the services are covered and reimbursable by TMAP, payment may be made to the physician, hospital, or other provider (if approved for participation in TMAP) who employs or reimburses the licensed physical therapist. The basis and amount of Medicaid reimbursement depends on the services actually provided, who provided the services, and the reimbursement methodology utilized by TMAP as appropriate for the services and provider(s) involved.

(g) Services provided by or under the direction of a licensed physical therapist in long-term care facilities must be billed to the Nursing Home Program.

Notes

1 Tex. Admin. Code § 354.1291

The provisions of this §354.1291 adopted to be effective February 19, 1990, 15 TexReg 658; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561