Medicaid Guidelines - OCCUPATIONAL THERAPY SERVICES

OCCUPATIONAL THERAPY SERVICES

Occupational Therapy is provided by an appropriately licensed occupational therapist who evaluates the student's level of functioning and develops a KPOC. Licensed occupational therapist assistants functioning under the general supervision of the licensed occupational therapist may assist in the delivery of the POC.

Occupational Therapy evaluation and treatment includes: assessing, improving, developing, or restoring functions impaired or lost through illness, injury or deprivation; improving ability to perform tasks for independent functioning when functions are lost or impaired, preventing through early intervention, initial or further impairment or loss of function; obtaining and interpreting information; coordinating care and integrating services the student is receiving.

How to bill for therapy services

Enter one date of service per claim line (From and To dates must be the same). Include the appropriate modifier(i.e., GO) on all claims. After prior authorization is issued, billed services must match the approved authorization. Be sure to include the authorization number on all claims. Submit claims using Direct Data Entry through the Electronic Verification System (EVS) secure Provider WebPortal or use an approved Trading Partner to submit your claims. See EVS User Manual Chapter 3 Claims and the Professional Fee-for-Service 837PCompanion Guide for claim submission instructions. When a licensed therapy assistant provides a service under the supervision of a licensed therapist, the licensed therapist must bill with the appropriate modifier CO(Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant) or CQ (Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant).

Referral for Services

•Occupational therapy services must be ordered by a licensed physician or other licensed health care provider within their scope of practice per:Federal regulations (42 CFR 440.110) 

•For SBHS, licensed occupational therapists can evaluate, diagnose, and provide services per an IEP or IFSP without a script from a physician within their scope of practice per:

** Department of Health (DOH) regulations (Chapter 246-847 WAC).

** OTs should review DOH regulations to ensure they refer and provide services per their scope of practice.18

COVERED SERVICES

1. Evaluation and diagnosis to determine the extent of a student's disabilities in areas such as sensorimotor skills, self-care, daily living skills, play and leisure skills, and use of adaptive or corrective equipment;

2. Individual Therapy provided to a student to remediate and/or adapt skills necessary to promote the student's ability to function independently;

3. Group Therapy provided to more than one student but less than seven simultaneously to correct or ameliorate and/or adapt skills necessary to promote the students' ability to function independently;

4. Task-oriented activities to prevent or correct physical or emotional deficits to minimize the disabling effect of these deficits;

5. Exercise to enhance functional performance;

6. Medical Team Conference participation time for the development of medical relatedmservices in the POC. Payment is excluded for participation time of POC development for educational pr.

Billing for Evaluations and Reevaluations

•The SBHS program utilizes three occupational therapy evaluation codes and one reevaluation code:

Evaluations codes: 97165, 97166, 97167

Re-evaluation code: 97168•Even though time is associated with each  evaluation code, evaluation codes are untimed. 

•Times associated with the evaluation codes are provided as “guidance” for providers in order to determine which code is most appropriate to use.

•Providers should use their professional judgement to determine the most appropriate code to use

SPEECH THERAPY AND AUDIOLOGY SERVICES 

Speech, hearing, and language pathology services are those services necessary for the diagnosis and treatment of speech and language disorders that result in communication disabilities and for the diagnosis and treatment of swallowing disorders with or without the presence of a communication disability. The services must be of such a level of complexity and sophistication or the condition of the student must be such that the services required can be safely and effectively performed only by a qualified therapist.

The practice of audiology consists of rendering services for the measurement, testing, appraisal prediction, consultation, counseling, research, or treatment of hearing impairment for the purpose of modifying disorders in communication involving speech, language, and hearing. Audiology services must be performed by a certified and licensed audiologist.

Covered Services

1. Speech and Language evaluation and diagnosis of delays and/or disabilities including, but not limited to, voice, communication, fluency, articulation or language development. Audiological evaluation and diagnosis to determine the presence and extent of hearing impairments that affect the student's educational performance. Audiological evaluations include complete hearing and/or hearing aid evaluation, hearing aid fittings or reevaluations, and audiograms.

2. Individual Therapy provided to a student in order to correct or ameliorate delays and/or disabilities associated with speech, language, hearing, or communication.

3. Group Therapy provided to one student, but less than seven, simultaneously in order to correct or ameliorate delays and/or disabilities associated with speech, language, hearing, or communication.

4. Medical Team Conference participation time for the development of medical related services in the POC. Payment is excluded for participation time of POC development for educational processes and goals. ocesses and goals.