12VAC30-60 Standards Established and Methods Used to Assure High Quality Care

REGULATIONS

Vol. 32 Iss. 6 - November 16, 2015

TITLE 12. HEALTH

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

Chapter 60

Fast-Track Regulation

Titles of Regulations: 12VAC30-50. Amount, Duration, and Scope of Medical and Remedial Care Services (amending 12VAC30-50-200, 12VAC30-50-225).

12VAC30-60. Standards Established and Methods Used to Assure High Quality Care (amending 12VAC30-60-120, 12VAC30-60-150).

12VAC30-130. Amount, Duration and Scope of Selected Services (repealing 12VAC30-130-10 through 12VAC30-130-60).

Statutory Authority: § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.

Public Hearing Information: No public hearings are scheduled.

Public Comment Deadline: December 16, 2015.

Effective Date: January 1, 2016.

Agency Contact: Emily McClellan, Regulatory Supervisor, Department of Medical Assistance Services, Policy Division, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone [phone], FAX (804) 786-1680, or email [e-mail].

Basis: Section 32.1-325 of the Code of Virginia grants to the Board of Medical Assistance Services the authority to administer and amend the Plan for Medical Assistance. Section 32.1-324 of the Code of Virginia authorizes the Director of the Department of Medical Assistance Services to administer and amend the Plan for Medical Assistance according to the board's requirements. The Medicaid authority as established by § 1902(a) of the Social Security Act (42 USC § 1396a) provides governing authority for payments for services.

42 CFR 440.130(d) establishes rehabilitative services as a covered service under the authority of Title XIX of the Social Security Act. "Rehabilitative services …. includes any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of his practice under State law, for maximum reduction of physical or mental disability and restoration of a recipient to his best possible functional level."

Purpose: This regulatory action updates and clarifies the provision of inpatient and outpatient rehabilitation services and provider documentation requirements, conflates several regulatory sections into fewer sections by moving some existing requirements, and repeals several regulation sections that are no longer needed. The new text addresses health and safety issues regarding physician orders by other licensed practitioners of the healing arts in order to eliminate service delays for Medicaid individuals while awaiting physician signatures in patients' records. The new additions and changes to the regulations will provide a continuum of regulatory support by encompassing existing federal regulations and clarifying current Virginia Medicaid Rehabilitation Manual interpretive guidelines.

The goals of this regulatory action are to provide overall clarification of rehabilitation requirements based on provider feedback and utilization review findings, to eliminate delays in services while obtaining necessary signed/dated orders for services, and to reduce the volume of potential monetary retractions from providers when they are audited. Providers' patient documentation is the basis for all Medicaid claims payments and provider audit retractions.

Rationale for Using Fast-Track Process: The agency is using the fast-track rulemaking process because these changes are beneficial to both providers and enrollees and no controversy is expected. The new regulations preserve the health and safety of enrollees while enabling licensed practitioners other than physicians to originate service orders as permitted by their state professional licenses. These proposed changes also provide clarification on several key issues where there has been provider confusion, such as record documentation considered suitable to support filed claims and physician admission certification for inpatient rehabilitation. The clarifications are expected to assist providers with creating and maintaining improved patient records, which will ultimately avoid payment retractions from providers. These clarifications also streamline the process of service initiation and renewal of physician-ordered services to Medicaid individuals.

Substance: DMAS has covered inpatient rehabilitation services since 1987 and outpatient rehabilitation since 1978 under the authority of 42 CFR 440.130(d). These services are federally defined as "…any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of his practice under State law, for maximum reduction of physical or mental disability and restoration of a recipient to his best possible functional level." Medicaid individuals may receive medically necessary rehabilitative services as a result of either illnesses or injuries.

DMAS' coverage of all Medicaid services, including these rehabilitative services, must be based upon providers' documentation of services rendered and how such documentation supports providers' claims for reimbursement. DMAS conducted an internal review of these regulations and determined that they required updating and streamlining. In instances when providers' documentation did not support their claims, then providers have been subject to repayment of some of the amounts that they have received. These repayment determinations are made in the context of either DMAS' or its contractors' audits of providers' records. This action addresses those issues and is expected to reduce provider repayments.

DMAS' coverage of these rehabilitative services depends on either physicians' or other licensed practitioners' signed orders. Other licensed practitioners can be either nurse practitioners or physician assistants who are permitted by their Commonwealth-issued professional licenses to initiate such orders. Requiring physicians' or other practitioners' orders for rehabilitation services is identical to requiring physicians' orders for prescription drugs before pharmacists are permitted to provide drugs to patients. DMAS cannot claim federal matching dollars on services that have not been appropriately ordered; therefore, it does not cover any services that have not been ordered by either physicians or other licensed practitioners of the healing arts. Permitting physicians to use their nurse practitioners or physician assistants, or both, to write and sign orders for rehabilitation services makes it easier for these enrolled providers to meet DMAS' signature timeframe requirements.

These regulations set out the service limits and provider requirements for the Medicaid coverage of inpatient rehabilitation services, including comprehensive outpatient rehabilitation facilities (CORFs) services, and outpatient rehabilitation services. Because these rehabilitative services regulations have not been recently substantially revised, some of the elements have become outdated as compared to current industry standards and newer care criteria. For example, several of these changes are being proposed to match the industry standard McKesson Interqual^® Criteria for prior service authorization of intensive rehabilitation/CORF and outpatient rehabilitation.

CORFs, even though outpatient rehabilitation providers, render services at such an intensive rehabilitative level that they are treated in these regulations as inpatient rehabilitation facilities. CORFs are intensive day rehabilitation programs where patients receive full day long therapy services but they do not stay overnight as they would in an inpatient rehabilitation hospital.

The new regulation text intends to decrease delays in service delivery while obtaining physician signed orders for the provision of rehabilitation services. Previously, providers were required to obtain physician signed orders for many rehabilitation services. Due to changes in federal regulations and state law, physician providers can now rely upon orders from other types of licensed practitioners, including nurse practitioners and physician assistants, for many types of rehabilitation services.

For inpatient intensive and CORF services, new regulations are added and existing regulations clarified for (i) services ordered by licensed nurse practitioners or physician assistants for consistency with federal regulations and state law, (ii) requirements for physician admission certification and recertification, (iii) 60-day renewal of plans of care, (iv) physician verbal order timeframe limitations, (v) utilization review plans, (vi) discharge summary requirements, (vii) interdisciplinary team meetings and plans within seven days of admission, and (viii) corrective action plans that are the result of quality management review activities.

For outpatient rehabilitation services, amendments (i) add new regulations and clarify existing regulations for the 21-day physician plan of care signature requirement, (ii) make consistent with federal regulations and state law services ordered by licensed nurse practitioners or physician assistants, (iii) add no guarantee of reimbursement based on service authorization limitations, (iv) add timeframe limitations related to claims and service authorizations, (v) direct reimbursement to enrolled rehabilitation providers for provision of services to nursing facility residents, (vi) address coverage of speech-language assistants, and (vii) address therapy evaluations and reevaluations.

The limit on covered outpatient therapy service visits (i.e., physical therapy, occupational therapy, and speech-language therapy) before requesting service prior authorization was changed in 2003 from 24 visits to five visits. At the time of that policy change, DMAS did not change every regulatory occurrence of the 24-visit limit. This action also corrects that oversight.

Issues: The primary advantages are to the Virginia Medicaid individual who needs rehabilitation services and the providers who render these services. The additional language will expedite services so individuals may begin treatment as promptly as may be needed. The primary advantage to the Virginia enrolled Medicaid provider is more access of different types of licensed practitioners to meet the physician order requirements as well as clarification of documentation requirements.

There are no disadvantages to Medicaid individuals, Medicaid providers, the public, or the Commonwealth. These changes represent no expansion or reduction of currently existing services. The advantage for providers and consumers is that the new regulations allow for expansion of more licensed practitioner types who can order the rehabilitation services.

Department of Planning and Budget's Economic Impact Analysis:

Summary of the Proposed Amendments to Regulation. The proposed changes will clarify regulations for inpatient and outpatient rehabilitation services to reflect current practices.

Result of Analysis. The benefits likely exceed the costs for all proposed changes.

Estimated Economic Impact. The proposed changes will clarify regulations for inpatient and outpatient rehabilitation services, including services provided in comprehensive outpatient rehabilitation facilities, to reflect current practices. The proposed changes will incorporate in the regulations mainly 1) criteria already in the guidance documents such as McKesson InterQual^® Criteria to define medical necessity standards, 2) procedures already allowed under federal and state statutes such as permitting nurse practitioners and physician assistants to order rehabilitation related services, and 3) clarifications of various other rules and procedures already followed in practice.

Since the proposed changes have already been followed in practice, no significant direct effect on providers, recipients, or the Department of Medical Assistance Services is expected other than improving the clarity of the regulations and reducing possible billing mistakes and payment retractions that would follow.

Businesses and Entities Affected. These regulations apply to 35 rehabilitation hospitals, 3 comprehensive outpatient rehabilitation facilities, and 161 outpatient rehabilitation providers.

Localities Particularly Affected. The proposed regulations apply throughout the Commonwealth.

Projected Impact on Employment. No significant direct effect on employment is expected.

Effects on the Use and Value of Private Property. No significant direct effect on the use and value of private property is expected.

Small Businesses: Costs and Other Effects. About 120 of the 161 outpatient rehabilitation providers are estimated to be small businesses. The same effects discussed above apply to these small businesses.

Small Businesses: Alternative Method that Minimizes Adverse Impact. The proposed regulations are not anticipated to have adverse impact on small businesses.

Real Estate Development Costs. No impact on real estate development costs is expected.

Agency's Response to Economic Impact Analysis: The agency has reviewed the economic impact analysis prepared by the Department of Planning and Budget and concurs with this analysis.

Summary:

The amendments update regulations for inpatient and outpatient rehabilitation services, including services provided in comprehensive outpatient rehabilitation facilities, to reflect current practices. The amendments (i) incorporate in the regulations McKesson InterQual^® Criteria to define medical necessity standards, (ii) provide for procedures already allowed under federal and state statutes such as permitting nurse practitioners and physician assistants to order rehabilitation related services, and (iii) clarify various other rules and procedures already followed in practice.

12VAC30-50-200. Physical therapy, occupational therapy, and related services for individuals with speech, hearing, and language disorders.

A. Definitions. The following words and terms when used in this section shall have the following meanings unless the context clearly indicates otherwise:

"Acute conditions" means conditions that are expected to be of brief duration (less than 12 months) and in which progress toward established goals is likely to occur frequently.

"DMAS" means the Department of Medical Assistance Services.

"Evaluation" means a thorough assessment completed by a licensed therapist that is signed and fully dated and includes the following components: a medical diagnosis, clinical signs and symptoms, medical history, current functional status, summary of previous rehabilitative treatment and the result, and the therapist's recommendation for treatment.

"Nonacute conditions" means conditions that are of long duration (greater than 12 months) and in which progress toward established goals is likely to occur slowly.

"Physical rehabilitation services" means any medical or remedial services, as defined in 42 CFR 440.130, recommended by a physician or other licensed practitioner of the healing arts, within the scope of his practice under state law, for maximum reduction of physical or mental disability and restoration of an eligible individual to his best possible functional level.

"Plan of care" means a treatment plan developed by a licensed therapist, which shall include medical diagnosis; current functional status; individualized, measurable, participant-oriented goals (long-term and short-term goals) that describe the anticipated level of functional improvement; achievement timeframes for all goals; therapeutic interventions or treatments to be utilized by the therapist; frequency and duration of the therapies; and a discharge plan and anticipated discharge date.

"Reevaluation" means an assessment that contains all of the same components as an evaluation and that shall be completed when an individual has a significant change in his condition or when an individual is readmitted to a rehabilitative service.

"SLP" means speech-language pathology.

B. Amount, duration, and scope of outpatient rehabilitation therapy services. The application of a national standardized set of medical necessity criteria in use in the industry, such as McKesson InterQual^® Criteria or an equivalent standard authorized in advance by DMAS, shall be required for this service.

1. DMAS covers outpatient rehabilitation therapy services provided in outpatient settings of acute care and rehabilitation hospitals, nursing facilities, home health agencies, and rehabilitation agencies. All providers of outpatient rehabilitation therapy services shall have a current provider agreement with DMAS. All practitioners and providers of services shall be required to meet applicable state and federal licensing or certification requirements, or both.

2. Outpatient rehabilitation therapy evaluations or therapy treatment, or both, when rendered solely for vocational or educational purposes shall not be covered under the authority of this section. Developmental or behavioral assessments shall not be covered under the authority of this section. Individuals shall have a medical diagnosis, as determined by a licensed physician or other licensed practitioner of the healing arts within the scope of his practice under state law, and meet the medical necessity criteria in order to qualify for a Medicaid-covered outpatient rehabilitation therapy evaluation or therapy treatment, or both.

A. Physical therapy and related 3. Outpatient rehabilitation services shall be defined as include physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) services. These services shall be prescribed by a physician or a licensed practitioner of the healing arts within the scope of his practice under state law, such as a nurse practitioner or a physician assistant within the scope of his practice under state law, and be part of a written physician's order/plan plan of care that is personally and legibly signed and dated by the licensed practitioner who ordered the services. Supervision for a licensed practitioner shall be provided by a physician as required by 18VAC90-30 and 18VAC90-40 for nurse practitioners and 18VAC85-50 for physician assistants. Any one of these services may be offered as the sole rehabilitation service and shall is not be contingent upon the provision of another service. All practitioners and providers of services shall be required to meet state and federal licensing and/or certification requirements. Services shall be provided according to guidelines found in the Virginia Medicaid Rehabilitation Manual.

B. Physical therapy.

1. Services for individuals requiring physical therapy are provided only as an element of hospital inpatient or outpatient service, nursing facility service, home health service, or when otherwise included as an authorized service by a cost provider who provides rehabilitation services.

2. Effective with dates of service on and after October 24, 1995, DMAS will provide for the direct reimbursement to enrolled rehabilitation providers for physical therapy services when such services are rendered to patients residing in nursing facilities. Such reimbursement shall not be provided for any sums that the rehabilitation provider collects, or is entitled to collect, from the nursing facility or any other available source, and provided further, that this amendment shall in no way diminish any obligation of the nursing facility to DMAS to provide its residents such services, as set forth in any applicable provider agreement.

C. Occupational therapy.

1. Services for individuals requiring occupational therapy are provided only as an element of hospital inpatient or outpatient service, nursing facility service, home health service, or when otherwise included as an authorized service by a cost provider who provides rehabilitation services.

2. Effective with dates of service on and after October 24, 1995, DMAS will provide for the direct reimbursement to enrolled rehabilitation providers for occupational therapy services when such services are rendered to patients residing in nursing facilities. Such reimbursement shall not be provided for any sums that the rehabilitation provider collects, or is entitled to collect, from the nursing facility or any other available source, and provided further, that this amendment shall in no way diminish any obligation of the nursing facility to DMAS to provide its residents such services, as set forth in any applicable provider agreement.

D. Services for individuals with speech, hearing, and language disorders (provided by or under the supervision of a speech pathologist or audiologist.)

1. These services are provided by or under the supervision of a speech pathologist or an audiologist only as an element of hospital inpatient or outpatient service, nursing facility service, home health service, or when otherwise included as an authorized service by a cost provider who provides rehabilitation services.

2. Effective with dates of service on and after October 24, 1995, DMAS will provide for the direct reimbursement to enrolled rehabilitation providers for speech/language therapy services when such services are rendered to patients residing in nursing facilities. Such reimbursement shall not be provided for any sums that the rehabilitation provider collects, or is entitled to collect, from the nursing facility or any other available source, and provided further, that this amendment shall in no way diminish any obligation of the nursing facility to DMAS to provide its residents such services, as set forth in any applicable provider agreement.

4. DMAS shall provide for the direct reimbursement to enrolled rehabilitation providers for covered outpatient rehabilitation therapy services when such services are rendered to individuals residing in nursing facilities. Such reimbursement shall not be provided for any sum that the rehabilitation provider collects, or is entitled to collect, from the nursing facility or any other available source, and provided further that the reimbursement shall in no way diminish any obligation of the nursing facility to DMAS to provide its residents such services as set forth in any applicable provider agreement.

5. The provision of physical therapy services shall meet all of the following conditions:

a. The services that the individual needs shall be directly and specifically related to a written plan of care developed, signed, and dated by a licensed physical therapist.

b. The services shall be of a level of complexity and sophistication or the condition of the individual shall be of a nature that the services can only be performed by a physical therapist licensed by the Virginia Board of Physical Therapy or a physical therapy assistant licensed by the Virginia Board of Physical Therapy and who is under the direct supervision of a licensed physical therapist.

c. When physical therapy services are provided by a qualified physical therapy assistant, such services shall be provided under the supervision of a qualified physical therapist who makes an onsite supervisory visit at least once every 30 days and documents the findings of the visit in the medical record. The supervisory visit shall not be reimbursable.

6. The provision of occupational therapy services shall meet all of the following conditions:

a. The services that the individual needs shall be directly and specifically related to a written plan of care developed, signed, and dated by a licensed occupational therapist.

b. The services shall be of a level of complexity and sophistication or the condition of the individual shall be of a nature that the services can only be performed by an occupational therapist certified by the National Board for Certification in Occupational Therapy and licensed by the Virginia Board of Medicine or an occupational therapy assistant certified by the National Board for Certification in Occupational Therapy who is under the direct supervision of a licensed occupational therapist.

c. When occupational therapy services are provided by a qualified occupational therapy assistant, such services shall be provided under the supervision of a qualified occupational therapist who makes an onsite supervisory visit at least once every 30 days and documents the visit findings in the medical record. The supervisory visit shall not be reimbursable.

7. The provision of speech-language pathology services shall meet all of the following conditions:

a. The services that the individual needs shall be directly and specifically related to a written plan of care developed, signed, and dated by a licensed speech-language pathologist.

b. The services shall be of a level of complexity and sophistication or the condition of the individual shall be of a nature that the services can only be performed by a speech-language pathologist licensed by the Virginia Board of Audiology and Speech-Language Pathology or who, if exempted from licensure by statute, meets the requirements in 42 CFR 440.110(c).

c. DMAS shall reimburse for the provision of speech-language pathology services when provided by a person considered by DMAS as a speech-language assistant (i.e., has a bachelor's level or a master's level degree without licensure by the Virginia Board of Audiology and Speech-Language Pathology and who does not meet the qualifications required for billing as a speech-language therapist). Speech-language assistants shall work under the direct supervision of a licensed professional therapist holding a Certificate of Clinical Competence (CCC) in SLP or a speech-language pathologist who meets the licensing requirements of the Virginia Board of Audiology and Speech-Language Pathology.

d. When services are provided by a therapist who is in his Clinical Fellowship Year (CFY) of an SLP Program or a speech-language assistant, a licensed professional therapist holding a CCC in SLP or a speech-language pathologist who shall make a supervisory visit at least every 30 days while therapy is being conducted and document the findings in the medical record. The supervisory visit shall not be reimbursable.

E. C. Authorization for outpatient rehabilitation services.

1. Physical therapy, occupational therapy, and speech-language pathology services provided in outpatient settings of acute and rehabilitation hospitals, rehabilitation agencies, school divisions nursing facilities, or home health agencies shall include authorization for up to 24 five allowed visits, which do not require preceding service authorization, by each ordered rehabilitative service annually as long as the individual meets the medical necessity criteria as set out in subsection B of this section for the particular service. In situations when individuals require more than the initial five visits, providers shall submit to either DMAS or the service authorization contractor requests for service authorization and the required demonstration of medical necessity for such individuals. The provider shall maintain documentation to justify the need for services.

2. The provider shall request from DMAS or its contractor authorization for treatments deemed necessary by a physician or other licensed practitioner of the healing arts within the scope of his practice under state law beyond the number authorized initial five visits. Documentation for medical justification must include physician orders/plans of care plans of care signed and dated by a physician or other licensed practitioner. Authorization for extended services shall be based on individual need. Payment shall not be made for additional service services beyond the initial five visits unless the extended provision of services has been authorized by DMAS or its contractor.

3. Covered outpatient rehabilitative services for acute conditions shall include physical therapy, occupational therapy, and speech-language pathology services. "Acute conditions" shall be defined as conditions which are expected to be of brief duration (less than 12 months) and in which progress toward goals is likely to occur frequently.

4. Covered outpatient rehabilitation services for long-term, nonacute conditions shall include physical therapy, occupational therapy, and speech-language pathology services. "Nonacute conditions" shall be defined as those conditions which are of long duration (greater than 12 months) and in which progress toward established goals is likely to occur slowly.

5. Payment shall not be made for reimbursement requests submitted more than 12 months after the termination of services.

F. D. Service limitations. The following general conditions shall apply to reimbursable physical therapy, occupational therapy, and speech-language pathology services:

1. Patient The individual must be under the care of a physician or other licensed practitioner who is legally authorized to practice and who is acting within the scope of his license.

2. The physician orders for evaluation of the need for therapy services shall include the specific procedures and modalities to be used, identify the specific therapy discipline to carry out the physician's order/plan of care, and indicate the frequency and duration for services. Physician orders/plans of care and must be personally signed and dated prior to the initiation of rehabilitative services. The certifying physician may use a signature stamp, in lieu of writing his full name, but the stamp must, at minimum, be initialed and dated at the time of the initialing (within 21 days of the order).

3. Services shall be furnished under a written plan of treatment and must be established, signed and dated (as specified in this section) and periodically reviewed by a physician. The requested services or items must be necessary to carry out the plan of treatment and must be related to the patient's condition. The plan of care shall include the specific procedures and modalities to be used and indicate the frequency and duration for services. A written plan of care shall be reviewed by the physician or licensed practitioner every 60 days for acute conditions, as defined in subsection A of this section, or annually for nonacute conditions. The requested services shall be necessary to carry out the plan of care and shall be related to the individual's condition. The plan of care shall be signed and dated, as specified in this section, by the physician or other licensed practitioner who reviews the plan of care.

4. A physician recertification shall be required periodically and must be signed and dated (as specified in this section) by the physician who reviews the plan of treatment. The physician recertification statement must indicate the continuing need for services and should estimate how long rehabilitative services will be needed. Certification and recertification must be signed and dated (as specified in this section) prior to the beginning of rehabilitation services. Quality management reviews, pursuant to 12VAC30-60-150, shall be performed by DMAS or its contractor.

5. Utilization review shall be performed to determine if services are appropriately provided and to ensure that the services provided to Medicaid recipients are medically necessary and appropriate. Services not specifically documented in the patient's medical record as having been rendered shall be deemed not to have been rendered and no coverage shall be provided.

6. 5. Physical therapy, occupational therapy, and speech-language services are to be considered for termination regardless of the preauthorized service authorized visits or services when any of the following conditions are met:

a. No further potential for improvement is demonstrated. (The patient and the individual has reached his maximum progress and a safe and effective maintenance program has been developed.)

b. There is limited motivation of Lack of participation on the part of the individual or caregiver is evident.

c. The individual has an unstable condition that affects his or her ability to actively participate in a rehabilitative plan of care.

d. Progress toward an established goal or goals cannot be achieved within a reasonable period of time as determined by the licensed therapist.

e. The established goal serves no purpose to increase meaningful functional or cognitive capabilities.

f. The service can be provided by someone other than a skilled rehabilitation professional no longer requires the skills of a qualified therapist.

g. A home maintenance program has been established to maintain the individual's function at the level to which it has been restored.

E. All providers of outpatient rehabilitation services shall be required to enroll as Medicaid providers using the outpatient rehabilitation services provider agreement.

12VAC30-50-225. Rehabilitative services; intensive physical rehabilitation and CORF services.

A. Definitions. The following words and terms when used in this section shall have the following meanings unless the context clearly indicates otherwise:

"Actively participate" means the individual regularly, as may be ordered by the physician, attends planned therapeutic activities and demonstrates progress towards goals established in the plan of care.

"Admission certification statement" means that the physician signs and dates an initial written statement in the individual's medical record of the need for intensive rehabilitation services. This statement shall be documented at the time of the rehabilitation admission.

"Comprehensive outpatient rehabilitation facility" or "CORF" means a facility that offers a coordinated intensive rehabilitation day program that uses an interdisciplinary team approach and includes, at a minimum, physicians' services and rehabilitation nursing in addition to at least two of the following four therapy services: (i) physical therapy, (ii) occupational therapy, (iii) cognitive rehabilitation therapy, or (iv) speech-language pathology.

"Licensed practitioner of the healing arts" means either a nurse practitioner, a physician assistant, or other practitioner as licensed by the Commonwealth to render covered services.

"Physical rehabilitation services" means medically prescribed treatments for improving or restoring functions that have been impaired by illness or injury, or where function has been permanently lost or reduced by illness or injury, for improving the individual's ability to perform those tasks required for independent functioning.

"Plan of care" means a written order signed and dated by a physician or other licensed practitioner that is specific to the individual that includes orders for rehabilitation therapies, including the frequency and duration of services; required medications; treatments; diet; and other services as needed, for example, psychological services, social work services, or therapeutic recreation services.

"Recertification" means that the physician or other licensed practitioner shall sign and date at least every 60 days a written statement in the individual's medical record of the continuing need for intensive rehabilitation services.

"Therapist plan of care" means a written treatment plan, developed by each licensed therapist involved with the individual's care, to include measurable long-term and short-term goals, interventions or modalities, frequency and duration, and a discharge disposition. These therapist plans of care shall be written, signed, and dated by either a licensed physical or occupational therapist, speech-language pathologist, cognitive rehabilitative therapist, psychologist, social worker, or certified therapeutic recreational specialist.

A. B. Medicaid covers intensive inpatient physical rehabilitation services as defined in subsection D of this section in facilities certified as physical rehabilitation hospitals or physical rehabilitation units in acute care hospitals which have been certified by the Department of Health to meet the requirements to be excluded from the Medicare Prospective Payment System.

B. C. Medicaid covers intensive outpatient physical rehabilitation services as defined in subsection D of this section in facilities which that are certified as Comprehensive Outpatient Rehabilitation Facilities comprehensive outpatient rehabilitation facilities (CORFs). With the exception of the physician admission certification statement, all of the service criteria for intensive rehabilitation services also apply to CORFs.

C. These facilities are excluded from the 21-day limit otherwise applicable to inpatient hospital services. Cost reimbursement principles are defined in 12VAC30-70-10 through 12VAC30-70-130.

D. The application of a national standardized set of medical necessity criteria in use in the industry, such as McKesson InterQual^® Criteria or an equivalent standard authorized in advance by DMAS, shall be required for this service. In addition, an individual qualifies for intensive inpatient rehabilitation or comprehensive outpatient physical rehabilitation as provided in a CORF if all of the following criteria are met:

1. Adequate treatment of the individual's medical condition requires an intensive physical rehabilitation program consisting of an interdisciplinary coordinated team approach to improve his ability to function as independently as possible.

2. It has been established that the rehabilitation program cannot be safely and adequately carried out in a less intensive setting.

3. In addition to the medical condition requirement, individuals shall meet the following criteria in order to be eligible for intensive inpatient rehabilitation or comprehensive outpatient physical rehabilitation provided in a CORF:

a. The individual shall require at least two of these four therapies in addition to requiring rehabilitative skilled nursing:

(1) Occupational therapy;

(2) Physical therapy;

(3) Cognitive rehabilitation therapy; or

(4) Speech-language pathology services.

b. The individual's medical condition shall be stable and compatible with an active rehabilitation program.

4. The individual shall (i) have a rehabilitation potential such that the individual's condition can be expected, based on the physician's assessment, to improve significantly in a reasonable and generally predictable period of time or (ii) require rehabilitation services as necessary toward the establishment of a safe and effective home maintenance therapy program required in connection with a specific diagnosis.

E. Within 24 hours of an individual's admission to intensive physical rehabilitation services, all of the physician requirements of 12VAC30-60-120 A shall be met.

D. F. An intensive physical rehabilitation program provides medically necessary intensive skilled rehabilitation nursing, physical therapy, occupational therapy, and, if needed, speech-language pathology, cognitive rehabilitation, prosthetic-orthotic services, psychology, social work, and therapeutic recreation services. With the exception of CORF services, the physician or other licensed practitioner shall be responsible for admission and discharge orders. If verbal orders are given, written plans of care shall be signed and dated within 72 hours of the verbal order. The nursing staff must shall support the other disciplines in carrying out the activities of daily living, utilizing correctly the training received in therapy, individual's interdisciplinary plan of care treatment activities on the medical nursing unit and furnishing other needed nursing services. The day-to-day activities individual interdisciplinary plan of care must be carried out under the continuing direct supervision of a physician or other licensed practitioner with special training or experience in the field of physical medicine and rehabilitation. For CORF services, only physicians shall be permitted to initiate plans of care or orders.

1. For an individual with a potential for physical rehabilitation for which an outpatient assessment cannot be adequately performed, an admission to intensive inpatient rehabilitation for an evaluation of no more than seven calendar days in duration shall be allowed. During this admission, a comprehensive rehabilitation evaluation shall be made of (i) the individual's medical condition, functional limitations, prognosis, possible need for corrective surgery, and ability to participate in rehabilitation and (ii) the existence of any social problems affecting rehabilitation. After these evaluations have been made, the physician, in consultation with the interdisciplinary rehabilitation team, shall determine and justify the level of care required to achieve the stated goals.

2. If during a previous hospital admission the individual completed a rehabilitation program for essentially the same condition for which inpatient hospital rehabilitation care is now being considered, reimbursement for the evaluation shall not be covered unless there is a documented intervening circumstance, such as an injury or serious illness, that necessitates a reevaluation.

3. Admissions for evaluation or training, or both, for solely vocational or educational purposes or for developmental or behavioral assessments shall not be covered services under the authority of this section.

E. Nothing in this regulation is intended to preclude DMAS from negotiating individual contracts with in-state intensive physical rehabilitation facilities for those individuals with special intensive rehabilitation needs.

G. All providers of rehabilitation services shall be enrolled as a Medicaid provider. Inpatient rehabilitation providers and CORFS shall enroll via the Rehabilitation Hospital Participation Agreement, and Comprehensive Outpatient Rehab Facility Participation Agreement, respectively.

F H. To receive continued intensive rehabilitation services, the patient individual must demonstrate an ability to actively participate in goal-related therapeutic interventions developed by the interdisciplinary team. This shall be evidenced by regular attendance in planned therapy activities and demonstrated progress toward the established goals.

G. I. Intensive rehabilitation services shall be considered for termination regardless of the preauthorized service authorized length of stay when any one or more of the following conditions are met:

1. No further potential for improvement is demonstrated. The patient and the individual has reached his maximum progress and a safe and effective maintenance program has been developed.;

2. There is limited motivation Lack of participation on the part of the individual or caregiver. is evident;

3. The individual has an An unstable condition that affects his the individual's ability to actively participate, as defined in subsection A of this section, in a rehabilitative plan. of care;

4. Progress toward an established goal or goals cannot be achieved within a reasonable period of time. as determined by the licensed therapist;

5. The established goal serves no purpose to increase meaningful functional or cognitive capabilities.;

6. The service can be provided by someone other than a skilled rehabilitation professional no longer requires the skills of a qualified therapist; or

7. A home maintenance program has been established to maintain the individual's function to the level to which it has been restored.

NOTICE: The following forms used in administering the regulation were filed by the agency. The forms are not being published; however, online users of this issue of the Virginia Register of Regulations may click on the name of a form with a hyperlink to access it. The forms are also available from the agency contact or may be viewed at the Office of the Registrar of Regulations, General Assembly Building, 2nd Floor, Richmond, Virginia 23219.

FORMS (12VAC30-50)

Virginia Uniform Assessment Instrument, UAI, Virginia Long-Term Care Council (1994).

I.V. Therapy Implementation Form, DMAS-354 (eff. 6/98).

Health Insurance Claim Form, Form HCFA-1500 (12/90).

Certificate of Medical Necessity-Durable Medical Equipment and Supplies, DMAS-352 (rev. 7/10).

Questionnaire to Assess an Applicant's Ability to Independently Manage Personal Attendant Services in the CD-PAS Waiver or DD Waiver, DMAS-95 Addendum (eff. 8/00).

DD Waiver Enrollment Request, DMAS-453 (eff. 1/01).

DD Waiver Consumer Service Plan, DMAS-456 (eff. 1/01).

DD Medicaid Waiver -- Level of Functioning Survey -- Summary Sheet, DMAS-458 (eff. 1/01).

Documentation of Recipient Choice between Institutional Care or Home and Community-Based Services (eff. 8/00).

Comprehensive Outpatient Rehab Facility Participation Agreement (undated; filed 11/2015)

Rehabilitation Hospital Participation Agreement (undated; filed 11/2015)

12VAC30-60-120. Utilization control Quality management: Intensive physical rehabilitative rehabilitation or CORF services.

A. A patient qualifies for intensive inpatient rehabilitation or comprehensive outpatient physical rehabilitation as provided in a comprehensive outpatient rehabilitation facility (CORF) if the following criteria are met:

1. Adequate treatment of his medical condition requires an intensive rehabilitation program consisting of an interdisciplinary coordinated team approach to improve his ability to function as independently as possible; and

2. It has been established that the rehabilitation program cannot be safely and adequately carried out in a less intense setting.

B. In addition to the disability requirement, participants shall meet the following criteria:

1. Require at least two of the listed therapies in addition to rehabilitative nursing:

a. Occupational therapy.

b. Physical therapy.

c. Cognitive rehabilitation.

d. Speech/language pathology services.

2. Medical condition stable and compatible with an active rehabilitation program.

3. For continued intensive rehabilitation services, the patient must demonstrate an ability to actively participate in goal-related therapeutic interventions developed by the interdisciplinary team. This is evidenced by regular attendance in planned activities and demonstrated progress toward the established goals.

4. Intensive rehabilitation services are to be considered for termination regardless of the preauthorized length of stay when any of the following conditions are met:

a. No further potential for improvement is demonstrated. The patient has reached his maximum progress and a safe and effective maintenance program has been developed.

b. There is limited motivation on the part of the individual or caregiver.

c. The individual has an unstable condition that affects his ability to participate in a rehabilitative plan.

d. Progress toward an established goal or goals cannot be achieved within a reasonable length of time.

e. The established goal serves no purpose to increase meaningful function or cognitive capabilities.

f. The service can be provided by someone other than a skilled rehabilitation professional.

A. Within 24 hours of an individual's admission for either intensive inpatient rehabilitation or CORF services, a physician shall be required to complete and sign and date the admission certification statement, as defined in 12VAC30-50-225 and 42 CFR 456.60, of the need for intensive rehabilitation or CORF services and the initial plan of care or orders.

1. Excluding CORF services, all other plans of care for inpatient rehabilitation services, including 60-day recertifications and the 60-day plan of care renewal orders shall be ordered by either a physician or a licensed practitioner of the healing arts including, but not limited to, nurse practitioners or physician assistants, within the scope of their licenses under state law.

2. If therapy services are recertified by a practitioner of the healing arts other than a physician, supervision shall be performed by a physician as required by §§ 54.1-2952 and 54.1-2957.01 of the Code of Virginia and 42 CFR 456.60.

3. For CORF providers, federal requirements do not permit nurse practitioners or physician assistants to order CORF intensive rehabilitation services. A physician shall be responsible for all documentation requirements including, but not limited to, admission certifications, recertifications, plans of care, progress notes, discharge orders, and any other required documentation (42 CFR 485.58(a)(i)).

4. Admission certification requirements shall apply to all individuals who are currently Medicaid eligible and to those individuals for whom a retroactive Medicaid eligibility determination is anticipated for coverage of an inpatient rehabilitative stay or for CORF services.

C. B. Within 72 hours of a patient's an individual's admission to an intensive rehabilitation or CORF program, or within 72 hours of upon notification to the facility provider of the patient's individual's Medicaid eligibility or that his Medicare benefits are exhausted, the facility provider shall notify the Department of Medical Assistance Services DMAS or its contractor in writing, or as required, of the patient's individual's admission and the medical need for service authorization.

1. This notification shall include a description of the admitting diagnoses diagnosis, plan of treatment care, and expected progress and a physician's written admission certification statement that the patient individual meets the rehabilitation admission criteria. The Department of Medical Assistance Services will make a determination as to the appropriateness of the admission for Medicaid payment DMAS or its contractor shall review such requests for service authorization and make a determination based on medical necessity criteria (see 12VAC30-50-225) as designated by DMAS, and notify the facility provider of its decision. If payment is services are approved, the department will DMAS or its contractor shall establish and notify the facility provider of an approved length of stay. Additional lengths of stay shall be requested in writing by the provider prior to the end date of the initial service authorization and must be approved by the department DMAS or its contractor for reimbursement. Admissions or lengths of stay not authorized by the Department of Medical Assistance Services will DMAS or its contractor shall not be approved for payment reimbursement.

2. For continued intensive rehabilitation or CORF services, the individual must demonstrate an ability to actively participate in goal-related therapeutic interventions developed by the interdisciplinary team.

D. C. Documentation of rehabilitation services shall, at a minimum required by DMAS for reimbursement for all disciplines of intensive rehabilitation or CORF services shall include all of the following:

1. A written physician admission certification statement.

2. A 60-day written recertification statement if a continued stay is determined to be medically necessary by the physician or other licensed practitioner of the healing arts within the scope of his license. Admission certification or recertification statements for CORF services shall be signed and dated only by licensed physicians.

3. A physician's written initial plan of care shall include orders for medications, the frequency and duration of services, required rehabilitation therapies, diet, medically necessary treatments, and other required services such as psychology, social work, and therapeutic recreation services.

a. Except for CORF services, the plan of care may be written by either a physician or by a licensed practitioner of the healing arts within the scope of his license.

b. For CORF services, the plan of care shall be written, signed, and dated only by a licensed physician.

1. Describe 4. An initial evaluation that describes the individual's clinical signs and symptoms of the patient necessitating admission to the rehabilitation program;.

2. Describe 5. A description of any prior treatment and attempts to rehabilitate the patient; individual.

3. Document an 6. An accurate and complete chronological picture description of the patient's individual's clinical course and progress in treatment;.

7. Documentation, by each participating therapy discipline, of a comprehensive plan of care developed by the licensed therapist.

4. Document 8. Documentation that an interdisciplinary coordinated treatment team plan of care specifically designed for the patient individual has been developed; within seven days of admission.

5. Document in detail 9. Detailed documentation of all treatment rendered to the patient individual in accordance with the interdisciplinary each discipline's plan of care with specific attention to frequency, duration, modality, the individual's response to treatment, and identify the identification of the licensed therapist or therapy assistant and dated signature of who provided such treatment;.

6. Document change 10. Documentation of all changes in the patient's individual's condition or conditions;.

7. Describe responses to and the outcome of treatment; and

8. Describe 11. Documentation describing a discharge plan which that includes the anticipated improvements in functional levels, the time frames timeframes necessary to meet these the individual's goals, and the patient's individual's discharge destination.

12. Discharge summary shall be completed by each licensed discipline offering services to include goal outcomes. The provider may complete the discharge summary before the individual's discharge or up to 30 days after the date of the individual's discharge.

D. Services not specifically documented in the patient's individual's medical record as having been rendered will be deemed not to have been rendered and no reimbursement will be provided. All intensive rehabilitative services shall be provided in accordance with guidelines found in the Virginia Medicaid Rehabilitation Manual.

E For a patient with a potential for physical rehabilitation for which an outpatient assessment cannot be adequately performed, an intensive evaluation of no more than seven calendar days will be allowed. A comprehensive assessment will be made of the patient's medical condition, functional limitations, prognosis, possible need for corrective surgery, attitude toward rehabilitation, and the existence of any social problems affecting rehabilitation. After these assessments have been made, the physician, in consultation with the rehabilitation team, shall determine and justify the level of care required to achieve the stated goals.

If during a previous hospital stay an individual completed a rehabilitation program for essentially the same condition for which inpatient hospital care is now being considered, reimbursement for the evaluation will not be covered unless there is a justifiable intervening circumstance which necessitates a reevaluation.

Admissions for evaluation or training, or both, for solely vocational or educational purposes or for developmental or behavioral assessments are not covered services.

E. Intentional altering of medical record documentation shall be prohibited. If corrections in medical records are indicated, then they shall be made consistent with the procedures in the agency's provider-specific rehabilitation guidance documents (see https://www.virginiamedicaid.dmas.virginia.gov/wps/
portal/ProviderManual).

F. The interdisciplinary rehabilitative team shall meet and prepare written documentation of the interdisciplinary team plan of care within seven days of admission. Interdisciplinary rehabilitative team conferences shall be held as needed but at least every two weeks to assess and document the patient's individual's progress or problems impeding progress. The interdisciplinary rehabilitative team shall assess the validity of the rehabilitation goals established at the time of the initial evaluation, determine if rehabilitation criteria continue to be met, and revise patient the individual's goals as needed. A simple reading review by the various interdisciplinary rehabilitative team members of each others' notes does shall not constitute a an interdisciplinary rehabilitative team conference. Where practical, the patient individual or family or both shall participate in the interdisciplinary rehabilitative team conferences. A dated summary of the conferences, noting documenting the names and professional titles of the interdisciplinary rehabilitative team members present, shall be recorded in the clinical record and shall reflect the reassessments of the various contributors interdisciplinary rehabilitative team members.

Rehabilitation care is to be considered for termination, regardless of the approved length of stay, when further progress toward the established rehabilitation goal is unlikely or further rehabilitation can be achieved in a less intensive setting.

Utilization review shall be performed G. DMAS or its contractor shall perform quality management reviews to determine if services are were appropriately provided as verified in the medical record documentation and to ensure that the services provided to Medicaid recipients are individuals were medically necessary and appropriate and that the patient continues individual continued to meet intensive rehabilitation criteria throughout the entire admission in the rehabilitation program. Services not specifically documented in the patient's medical record as having been rendered shall be deemed not to have been rendered and no reimbursement shall be provided.

H. When a provider has been determined during a quality management review as not complying with DMAS regulations, DMAS or its contractor may request corrective action plans from the provider. The corrective action plan shall address how the provider will become compliant with DMAS regulations and requirements in the areas for which the provider has been cited for noncompliance.

G. I. Properly documented medical reasons for furlough visits away from the inpatient rehabilitation provider may be included as part of an overall rehabilitation program. Unoccupied beds (or days) resulting from an overnight therapeutic furlough will shall not be reimbursed by the Department of Medical Assistance Services DMAS.

H. J. Discharge planning shall be an integral part of the overall treatment plan which of care that is developed at the time of admission to the program. The plan shall identify the anticipated improvements in functional abilities and the probable discharge destination. The patient individual, unless unable to do so, or the responsible party shall participate in the discharge planning. Notations concerning changes in the discharge plan shall be entered into the record at least every two weeks, as a part of the required interdisciplinary team conference.

I. Rehabilitation services are medically prescribed treatment for improving or restoring functions which have been impaired by illness or injury or, where function has been permanently lost or reduced by illness or injury, to improve the individual's ability to perform those tasks required for independent functioning. The rules pertaining to them are: K. Each of the following intensive rehabilitation professionals have specific licensure and documentation requirements based on their disciplines that shall be adhered to. This subsection outlines these requirements for physician, nursing, physical therapy, occupational therapy, speech-language pathology, cognitive rehabilitation therapy, psychology, social work, therapeutic recreation, and prosthetic/orthotic services as follows:

1. Physician services are those services furnished to an individual that meet all of the following conditions:

a. The individual shall be under the care of a physician who is legally authorized to practice and is acting within the scope of his license, or a licensed practitioner of the healing arts as defined in 12VAC30-50-225. The physician shall be licensed by the Virginia Board of Medicine and have specialized training or experience in the field of physical medicine and rehabilitation;

b. Within 24 hours of an individual's admission, the physician shall provide a written initial admission certification consistent with 42 CFR 456.60. The physician shall provide a 60-day written recertification statement of the continued need for intensive physical rehabilitation services. DMAS shall not provide reimbursement for services that are not supported by physician written admission certifications and 60-day recertifications;

c. The physician plan of care shall be written to include orders for medications, rehabilitation therapies, treatments, diet, and other required services pursuant to 42 CFR 456.80. Failure to obtain the physician written renewal of the plan of care every 60 days shall result in nonpayment for services rendered; and

d. The service shall be specific and provide effective treatment for the individual's condition in accordance with accepted standards of medical practice.

1. 2. Rehabilitative nursing requires education, training, or and experience that provides special knowledge and clinical skills to diagnose nursing needs and treat individuals who have health problems characterized by alteration in either cognitive and or functional ability, or both. Rehabilitative nursing services are those services furnished a patient which to an individual that meet all of the following conditions:

a. The services shall be directly and specifically related to an active a written treatment plan approved by a physician after any needed consultation with of care developed by a registered nurse licensed by the Virginia Board of Nursing who is experienced in physical rehabilitation;

b. The services shall be of a level of complexity and sophistication, or the individual's condition of the patient shall be of a nature, that the services can only be performed by a registered nurse or licensed professional nurse, nursing assistant, or rehabilitation technician under the direct supervision of a registered nurse who is experienced in physical rehabilitation;

c. The services shall be provided with the expectation, based on the physician's assessment made by the physician of the patient's individual's rehabilitation potential, that the individual's condition of the patient will improve significantly, as determined by the physician and the interdisciplinary rehabilitative team, in a reasonable and generally predictable period of time as determined by the nurse or therapist, or these services shall be necessary to the establishment of a safe and effective maintenance therapy program required in connection with a specific diagnosis; and

d. The service shall be specific and provide effective treatment for the patient's individual's condition. The amount, frequency, and duration of the service shall comport in accordance with accepted standards of medical practice and include the intensity of rehabilitative nursing services which can only be provided in an intensive rehabilitation setting.

2. 3. Physical therapy services are those services furnished a patient which to an individual that meet all of the following conditions:

a. The services shall be directly and specifically related to an active a written treatment plan designed by a physician after any needed consultation with of care developed by a physical therapist licensed by the Virginia Board of Medicine Physical Therapy;

b. The services shall be of a level of complexity and sophistication, or the individual's condition of the patient shall be of a nature, that the services can only be performed by a physical therapist licensed by the Virginia Board of Medicine Physical Therapy or a physical therapy assistant who is licensed by the Virginia Board of Medicine Physical Therapy and under the direct supervision of a qualified licensed physical therapist licensed by the Board of Medicine;

c. The services shall be provided with the expectation, based on the physician's assessment made by the physician of the patient's individual's rehabilitation potential, that the individual's condition of the patient will improve significantly, as determined by the physician and the interdisciplinary rehabilitative team, in a reasonable and generally predictable period of time, or these services shall be necessary to the establishment of a safe and effective maintenance therapy program required in connection with a specific diagnosis; and

d. The services shall be specific and provide effective treatment for the patient's individual's condition. The amount, frequency, and duration of the services shall comport in accordance with accepted standards of medical practice; this includes the requirement that the amount, frequency and duration of the services shall be reasonable.

3. 4. Occupational therapy services are those services furnished a patient which to an individual that meet all of the following conditions:

a. The services shall be directly and specifically related to an active a written treatment plan designed by the physician after any needed consultation with of care developed by an occupational therapist registered and certified by the American Occupational Therapy Certification Board National Board for Certification in Occupational Therapy and licensed by the Virginia Board of Medicine;

b. The services shall be of a level of complexity and sophistication, or the individual's condition of the patient shall be of a nature, that the services can only be performed by an occupational therapist registered and certified by the American Occupational Therapy Certification Board National Board for Certification in Occupational Therapy or an occupational therapy assistant certified by the American Occupational Therapy Certification Board National Board for Certification in Occupational Therapy and licensed by the Virginia Board of Medicine under the direct supervision of a qualified occupational therapist as defined above in subdivision 4 a of this subsection;

c. The services shall be provided with the expectation, based on the physician's assessment made by the physician of the patient's individual's rehabilitation potential, that the individual's condition of the patient will improve significantly, as determined by the physician and the interdisciplinary rehabilitative team, in a reasonable and generally predictable period of time, or these services shall be necessary to the establishment of a safe and effective maintenance therapy program required in connection with a specific diagnosis; and

d. The services shall be specific and provide effective treatment for the patient's individual's condition. The amount, frequency, and duration of the services shall comport in accordance with accepted standards of medical practice; this includes the requirement that the amount, frequency and duration of the services shall be reasonable.

4. 5. Speech-language pathology therapy services are those services furnished a patient which to an individual that meet all of the following conditions:

a. The services shall be directly and specifically related to an active a written treatment plan designed by a physician after any needed consultation with of care developed by a speech-language pathologist licensed by the Virginia Board of Audiology and Speech-Language Pathology or, if exempted from licensure by statute, meeting the requirements in 42 CFR 440.1109 (c) 42 CFR 440.110(c);

b. The services shall be of a level of complexity and sophistication, or the individual's condition of the patient shall be of a nature, that the services can only be performed by either a speech-language pathologist licensed by the Virginia Board of Audiology and Speech-Language Pathology or by a speech-language assistant who has been certified by the board and who is under the direct supervision of the speech-language pathologist;

c. The services shall be provided with the expectation, based on the physician's assessment made by the physician of the patient's individual's rehabilitation potential, that the individual's condition of the patient will improve significantly, as determined by the physician and the interdisciplinary rehabilitative team, in a reasonable and generally predictable period of time, or these services shall be necessary to the establishment of a safe and effective maintenance therapy program required in connection with a specific diagnosis; and

d. The services shall be specific and provide effective treatment for the patient's individual's condition. The amount, frequency, and duration of the services shall comport in accordance with accepted standards of medical practice; this includes the requirement that the amount, frequency and duration of the services shall be reasonable.

5. 6. Cognitive rehabilitation therapy services are those services furnished a patient which to an individual that meet all of the following conditions:

a. The services shall be directly and specifically related to an active a written treatment plan designed by the physician after any needed consultation with of care developed by a clinical psychologist experienced in working with the neurologically impaired and licensed by the Virginia Board of Medicine Psychology;

b. The services, based on the findings of the neuropsychological evaluation, shall be of a level of complexity and sophistication, or the individual's condition of the patient shall be of a nature, that the services can only be rendered after a neuropsychological evaluation administered by a licensed clinical psychologist or licensed physician experienced in the administration of neuropsychological assessments and licensed by the Board of Medicine and in accordance with a plan of care based on the findings of the neuropsychological evaluation;

c. Cognitive rehabilitation therapy services may shall be provided by occupational therapists, speech-language pathologists, and or psychologists, or all of these, who have experience in working with the neurologically impaired individuals when provided under a plan recommended and coordinated by a physician or clinical psychologist licensed by the Board of Medicine such services have been ordered by a physician or other licensed practitioner;

d. The cognitive rehabilitation services shall be an integrated part of the individual's interdisciplinary patient care plan plan of care and shall relate to information processing deficits which are a consequence of and related to a neurologic event;

e. The services include therapeutic activities to improve a variety of cognitive functions such as, for example orientation, attention/concentration, reasoning, memory, recall, discrimination, and behavior; and

f. The services shall be provided with the expectation, based on the physician's or psychologist's assessment made by the physician of the patient's individual's rehabilitation potential, that the individual's condition of the patient will improve significantly in a reasonable and generally predictable period of time, or these services shall be necessary to the establishment of a safe and effective maintenance therapy program required in connection with a specific diagnosis.

6. Psychology 7. Psychological services are those services furnished a patient which to an individual that meet all of the following conditions:

a. The services Services shall be directly and specifically related to an active written treatment plan ordered by a physician or other licensed practitioner;

b. The services shall be of a level of complexity and sophistication, or the individual's condition of the patient shall be of a nature, that the services as set out in the written plan of care can only be developed and performed by a qualified, licensed psychologist as required by state law the Virginia Board of Psychology or a licensed clinical social worker, a licensed professional counselor, or a licensed clinical nurse specialist-psychiatric;

c. The services shall be provided with the expectation, based on the assessment made by the physician of the patient's individual's rehabilitation potential, that the individual's condition of the patient will improve significantly in a reasonable and generally predictable period of time, or these services shall be necessary to the establishment of a safe and effective maintenance therapy program required in connection with a specific diagnosis; and

d. The services shall be specific and provide effective treatment for the patient's individual's condition. The amount, frequency, and duration of the services shall comport in accordance with accepted standards of medical practice; this includes the requirement that the amount, frequency and duration of the services shall be reasonable.

7. 8. Social work services are those services furnished a patient which to an individual that meet all of the following conditions:

a. The services Services shall be directly and specifically related to an active written treatment plan ordered by a physician or other licensed practitioner;

b. The services shall be of a level of complexity and sophistication, or the individual's condition of the patient shall be of a nature, that the services as set out in the written plan of care can only be performed by a qualified social worker as required licensed by state law the Virginia Board of Social Work;

c. The services shall be provided with the expectation, based on the assessment made by the physician of the patient's individual's rehabilitation potential, that the condition of the patient individual will improve significantly in a reasonable and generally predictable period of time, or these services shall be necessary to the establishment of a safe and effective maintenance therapy program required in connection with a specific diagnosis; and

d. The services shall be specific and provide effective treatment for the patient's individual's condition. The amount, frequency, and duration of the services shall comport in accordance with accepted standards of practice; this includes the requirement that the amount, frequency and duration of the services shall be reasonable.

8. Recreational therapy 9. Therapeutic recreation services are those services furnished a patient which to an individual that meet all of the following conditions:

a. The services Services shall be directly and specifically related to an active written treatment plan ordered by a physician or other licensed practitioner;

b. The services shall be of a level of complexity and sophistication, or the individual's condition of the patient shall be of a nature, that the services as set out in the written plan of care are performed as an integrated part of a comprehensive rehabilitation plan of care by a recreation therapist certified with the National Council for Therapeutic Recreation at the professional level;

c. The services shall be provided with the expectation, based on the assessment made by the physician of the patient's individual's rehabilitation potential, that the individual's condition of the patient will improve significantly in a reasonable and generally predictable period of time, or these services shall be necessary to the establishment of a safe and effective maintenance therapy program required in connection with a specific diagnosis; and

d. The services shall be specific and provide effective treatment for the patient's individual's condition. The amount, frequency, and duration of the services shall comport in accordance with accepted standards of practice; this includes the requirement that the amount, frequency and duration of the services shall be reasonable.

9. 10. Prosthetic/orthotic services.

a. Prosthetic services furnished to a patient include prosthetic devices that replace all or part of an external body member, and services necessary to design the device, including measuring, fitting, and instructing the patient in its use.

b. Orthotic device services furnished to a patient include orthotic devices that support or align extremities to prevent or correct deformities, or to improve functioning, and services necessary to design the device, including measuring, fitting and instructing the patient in its use.

c. Maxillofacial prosthetic and related dental services are those services that are specifically related to the improvement of oral function not to include routine oral and dental care.

d. The services shall be directly and specifically related to an active written treatment a written plan of care approved by a physician after consultation with a prosthetist, orthotist, or a licensed, board eligible prosthodontist, who shall be certified in Maxillofacial maxillofacial prosthetics.

e. The services shall be provided with the expectation, based on the physician's or other licensed practitioner's assessment made by the physician of the patient's individual's rehabilitation potential, that the individual's condition of the patient will improve significantly in a reasonable and predictable period of time, or these services shall be necessary to establish an improved functional state of maintenance the establishment of a safe and effective maintenance therapy program.

f. The services shall be specific and provide effective treatment for the patient's individual's condition. The amount, frequency, and duration of the services shall comport in accordance with accepted standards of medical and dental practice; this includes the requirement that the amount, frequency, and duration of the services be reasonable.

12VAC30-60-150. General outpatient physical Quality management review of outpatient rehabilitation therapy services.

A. Scope. The following general conditions shall apply to reimbursable outpatient rehabilitation therapy services:

1. Medicaid covers general outpatient physical rehabilitative services provided in outpatient settings of acute and rehabilitation hospitals, in school divisions, by home health agencies, and by rehabilitation agencies which have a provider agreement with the Department of Medical Assistance Services (DMAS). The covered services and medical necessity criteria as set out in 12VAC30-50-200 shall apply to these outpatient rehabilitation therapy services.

2. Outpatient rehabilitative therapy services, as defined in 42 CFR 440.130, shall be prescribed by a licensed physician or a licensed practitioner of the healing arts, specifically either a nurse practitioner or physician assistant, and be part of a written plan of care.

3. Outpatient rehabilitative services shall be provided in accordance with guidelines found in the Virginia Medicaid Rehabilitation Manual with the exception of such services provided in school divisions which shall be provided in accordance with guidelines found in the Virginia Medicaid School Division Manual. Utilization review shall include determinations that providers meet all the requirements of Virginia state regulations found in (12VAC30-130-10 through 12VAC30-130-80). Utilization review Quality management reviews shall be performed by DMAS or its contractor to ensure that all rehabilitative services are appropriately provided and that services provided to Medicaid recipients individuals are medically necessary and appropriate. Services not specifically documented in the individual's medical record as having been rendered shall be deemed not to have been rendered and no reimbursement shall be provided.

B. Covered outpatient rehabilitative therapy services. Rehabilitation services shall be initiated by a physician or licensed practitioner for the evaluation and plan of care. Both require a physician or licensed practitioner signature, title, and full date.

1. Covered outpatient rehabilitative services for acute conditions shall include physical therapy, occupational therapy, and speech-language pathology services. Any one of these services may be offered as the sole rehabilitative service and shall not be contingent upon the provision of another service. Such services may be provided by outpatient settings of hospitals, rehabilitation agencies, and home health agencies

2. Covered outpatient rehabilitative services for long-term, chronic conditions shall include physical therapy, occupational therapy, and speech-language pathology services. Any one of these services may be offered as the sole rehabilitative service and shall not be contingent upon the provision of another service. Such services may be provided by outpatient settings of acute and rehabilitation hospitals, rehabilitation agencies, and school divisions.

C. Eligibility criteria for outpatient rehabilitative services. To be eligible for general outpatient rehabilitative services, the patient must require at least one of the following services: physical therapy, occupational therapy, speech-language pathology services, and respiratory therapy. All rehabilitative services must be prescribed by a physician.

A plan of care for therapy services shall (i) include the specific procedures and modalities to be used (ii) identify the specific discipline to carry out the plan of care and (iii) indicate the frequency and duration of services.

D. Criteria for the provision of outpatient rehabilitative services. C. All practitioners and providers of therapy services shall be required to meet state and federal licensing and/or or certification requirements, or both as may be applicable. Services not specifically documented in the patient's medical record as having been rendered shall be deemed not to have been rendered, and no coverage shall be provided.

D. Documentation of physical therapy, occupational therapy, and speech-language pathology services provided in outpatient settings of acute and rehabilitation hospitals, nursing facilities, home health agencies, and rehabilitation agencies shall at a minimum include:

1. An initial evaluation that describes the clinical signs and symptoms of the individual's condition, including an accurate and complete chronological picture of the individual's clinical course and treatments. The initial evaluation or the reevaluation shall be signed, titled, and dated by the licensed therapist (i) when an individual is initially admitted to a service, (ii) when there is a significant change in the individual's condition, or (iii) when an individual is readmitted to a service.

2. A written plan of care specifically developed for the individual shall be signed, titled, and fully dated by a licensed therapist. Within 21 days of the plan of care start date, the physician or a licensed practitioner shall sign, title, and fully date the plan of care and it shall:

a. Describe specifically the anticipated goal-related improvements in functional level, frequency and duration of the ordered therapy or therapies, and the anticipated timeframes necessary to meet these long-term and short-term individual goals, including participation by the appropriate rehabilitation therapist or therapists, the individual, and the family or caregiver, as may be appropriate; and

b. Include a discharge plan that contains the anticipated improvements in functional levels and the anticipated timeframes necessary to meet the individual goals:

(1) For outpatient rehabilitative services for acute conditions, as defined in 12VAC30-50-200, the plan of care must be reviewed, updated, and signed and dated at least every 60 days by the licensed therapist and the physician or other licensed practitioner;

(2) For outpatient services for long-term, nonacute conditions, as defined in 12VAC30-50-200, the plan of care must be reviewed, updated, and signed and dated at least every 12 months by the licensed therapist and the physician or other licensed practitioner.

3. The documentation of all treatment rendered to the individual in the progress notes, in accordance with the written plan of care with specific attention to frequency, duration, modality, and the individual's response to treatment. The licensed therapist must sign, title, and fully date all progress notes in the medical record. If therapy assistants provide the treatment under the supervision of a licensed therapist, the assistant shall also sign, title, and fully date the progress notes in the medical record.

4. A description of all changes in the individual's condition, response to the rehabilitative written plan of care, and appropriate revisions to the written plan of care.

5. A discharge summary to be completed by the licensed therapist who is providing the service at the time that the service is terminated, including a description of the individual's response to services, level of independence in carrying out learned skills and abilities, assistive technology necessary to carry out and maintain activities and skills, and recommendations for continued services (i.e., referrals to alternate providers, home maintenance programs, training to individuals or caregivers, etc.).

6. The therapist's signature, title, and full date (month/day/year) shall appear on all documentation; if therapy assistants provide the treatment, under the supervision of a licensed therapist, the supervising licensed therapist must document the findings of the supervisory onsite visit every 30 days.

E. Restrictions.

1. The intentional altering of medical record documentation shall be prohibited and is fraudulent. If corrections are indicated, then they shall be made in medical records consistent with the procedures in the agency's provider-specific guidance documents (see https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/ProviderManual).

2. DMAS shall not reimburse for evaluations provided prior to the date of the physician's or other licensed practitioner's signature. DMAS shall not reimburse for provider-initiated additional reevaluations that are not specific to DMAS requirements and that are in excess of DMAS' requirements.

Part I
Outpatient Physical Rehabilitative Services (Repealed)

12VAC30-130-10. Scope. (Repealed.)

A. Medicaid covers outpatient physical rehabilitative services provided in outpatient settings. Services may be provided by acute and rehabilitation hospitals, by home health agencies, and by rehabilitation agencies which have a provider agreement with the Department of Medical Assistance Services.

B. Physical therapy and related services shall be prescribed by a physician and be part of a written plan of care that is personally signed and dated by the physician prior to the initiation of rehabilitation services. The physician may use a signature stamp, in lieu of writing his full name, but the stamp must, at a minimum, be initialed and dated at the time of the initialing within 21 days of the order.

C. Any one of these services may be offered as the sole rehabilitative service and is not contingent upon the provision of another service.

D. All practitioners and providers of services shall be required to meet State and Federal licensing or certification requirements.

E. Covered outpatient rehabilitative services for short-term, acute conditions shall include physical therapy, occupational therapy, and speech-language pathology services. "Acute conditions" shall be defined as conditions which are expected to be of brief duration (less than 12 months) and in which progress toward established goals is likely to occur frequently.

F. Covered outpatient rehabilitative services for long-term, nonacute conditions shall include physical therapy, occupational therapy, and speech-language pathology services. "Nonacute conditions" shall be defined as those conditions which are of long duration (greater than 12 months) and in which progress toward established goals is likely to occur slowly.

G. All services shall be specific and provide effective treatment for the patient's condition in accordance with accepted standards of medical practice; this includes the requirement that the amount, frequency, and duration of the services shall be reasonable.

H. Rehabilitative services may be provided when all the following conditions are evidenced:

1. There is potential for improvement in the patient's condition or the patient has reached his maximum progress and requires the development of a safe and effective maintenance program;

2. There is motivation on the part of the patient and caregiver;

3. The patient's medical condition is stable; and

4. Progress toward goal achievement is expected within a reasonable time frame consistent with expectations for acute conditions and nonacute conditions.

I. Continued rehabilitation services may be provided when there is documentation of a positive history of response to previous therapy or evidence that a change in patient potential for improvement has occurred, or that a new or different therapeutic approach may effect a positive outcome.

J. Rehabilitative services shall be provided according to guidelines found in the Virginia Medicaid Rehabilitation Manual.

12VAC30-130-15. Eligibility criteria for outpatient rehabilitative services. (Repealed.)

To be eligible for outpatient rehabilitative services for an acute or long-term, nonacute condition, the patient must require at least one of the following services: physical therapy, occupational therapy, and speech-language pathology services.

12VAC30-130-20. Physical therapy. (Repealed.)

A. Services for individuals requiring physical therapy are provided only as an element of hospital outpatient service, nursing facility service, home health service, rehabilitation agency service; or when otherwise included as an authorized service by a cost provider who provides rehabilitation services.

B. Effective July 1, 1988, the Program will not provide direct reimbursement to enrolled providers for physical therapy service rendered to patients residing in long-term care facilities. Reimbursement for these services is and continues to be included as a component of the nursing facilities' operating cost.

C. Physical therapy services meeting all of the following conditions shall be furnished to patients:

1. The services shall be directly and specifically related to an active written treatment plan designed and personally signed and dated (as in 12VAC30-130-10 B) by a physician after any needed consultation with a physical therapist licensed by the Board of Physical Therapy; and

2. The services shall be of a level of complexity and sophistication, or the condition of the patient shall be of a nature that the services can only be performed by a physical therapist licensed by the Board of Physical Therapy, or a physical therapy assistant who is licensed by the Board of Physical Therapy and is under the direct supervision of a physical therapist licensed by the Board of Physical Therapy. When physical therapy services are provided by a qualified physical therapy assistant, such services shall be provided under the supervision of a qualified physical therapist who makes an onsite supervisory visit at least once every 30 days. This supervisory visit shall not be reimbursable.

12VAC30-130-30. Occupational therapy. (Repealed.)

A. Services for individuals requiring occupational therapy are provided only as an element of hospital outpatient service, nursing facility service, home health service, rehabilitation agency; or when otherwise included as an authorized service by a cost provider who provides rehabilitation services.

B. Effective September 1, 1990, Virginia Medicaid will not make direct reimbursement to providers for occupational therapy services for Medicaid recipients residing in long-term care facilities. Reimbursement for these services is and continues to be included as a component of the nursing facilities' operating cost.

C. Occupational therapy services shall be those services furnished a patient which meet all the following conditions:

1. The services shall be directly and specifically related to an active written treatment plan designed and personally signed and dated (as in 12VAC30-130-10 B) by the physician after any needed consultation with an occupational therapist registered and certified by the American Occupational Therapy Certification Board; and

2. The services shall be of a level of complexity and sophistication, or the condition of the patient shall be of a nature that the services can only be performed by an occupational therapist registered and certified by the American Occupational Therapy Certification Board, a graduate of a program approved by the Council on Medical Education of the American Medical Association and engaged in the supplemental clinical experience required before registration by the American Occupational Therapy Association under the supervision of an occupational therapist as defined above, or an occupational therapy assistant who is certified by the American Occupational Therapy Certification Board under the direct supervision of an occupational therapist as defined above. When occupational therapy services are provided by a qualified occupational therapy assistant or a graduate engaged in supplemental clinical experience required before registration, such services shall be provided under the supervision of a qualified occupational therapist who makes an onsite supervisory visit at least once every 30 days. This supervisory visit shall not be reimbursable.

12VAC30-130-40. Services for individuals with speech, hearing, and language disorders. (Repealed.)

A. These services are provided by or under the supervision of a speech pathologist or an audiologist only as an element of hospital outpatient service, nursing facility service, home health service, rehabilitation agency; or when otherwise included as an authorized service by a cost provider who provides rehabilitation services.

B. Effective September 1, 1990, Virginia Medicaid will not make direct reimbursement to providers for speech-language pathology services for Medicaid recipients residing in long-term care facilities. Reimbursement for these services is and continues to be included as a component of the nursing facilities' operating cost.

C. Speech-language therapy services shall be those services furnished a patient which meet all the following conditions:

1. The services shall be directly and specifically related to an active written treatment plan designed and personally signed and dated by a physician after any needed consultation with a speech-language pathologist licensed by the Board of Audiology and Speech-Language Pathology, or, if exempted from licensure by statute, meeting the requirements in 42 CFR 440.110(c); and

2. The services shall be of a level of complexity and sophistication, or the condition of the patient shall be of a nature that the services can only be performed by a speech-language pathologist licensed by the Board of Audiology and Speech-Language Pathology.

12VAC30-130-42. Service limitations. (Repealed.)

The following general conditions shall apply to reimbursable outpatient physical therapy, occupational therapy, and speech-language pathology services:

1. Patient must be under the care of a physician who is legally authorized to practice and who is acting within the scope of his license.

2. Services shall be furnished under a written plan of treatment and must be established, personally signed and dated (as in 12VAC30-130-10 B), and periodically reviewed by a physician. The requested services or items must be necessary to carry out the plan of treatment and must be related to the patient's condition.

3. A physician recertification shall be required at least every 60 days for acute rehabilitation services and at least annually for long-term, nonacute services and must be personally signed and dated (as in 12VAC30-130-10 B) by the physician who reviews the plan of treatment. The physician recertification statement must indicate the continuing need for services and should estimate how long rehabilitative services will be needed. Certification and recertification must be personally signed and dated (as in 12VAC30-130-10 B) prior to the initiation or continuation of rehabilitation services.

4. The physician orders for therapy services shall include the specific procedures and modalities to be used, identify the specific discipline to carry out the plan of care, and indicate the frequency and duration of services.

5. Utilization review shall be performed to determine if services are appropriately provided and to ensure that services provided to Medicaid recipients are medically necessary and appropriate. Services not specifically documented in the patient's medical record as having been rendered shall be deemed not to have been rendered and no coverage shall be provided.

6. Rehabilitation services are to be considered for termination regardless of the preauthorized visits or services when any of the following conditions are met:

a. No further potential for improvement is demonstrated.

b. Limited motivation on the part of the individual or caregiver is evident.

c. The individual has an unstable condition that affects his ability to participate in a rehabilitative plan.

d. Progress toward an established goal or goals cannot be achieved within a reasonable period of time.

e. The established goal or goals serve no purpose toward achieving a significant, meaningful improvement in functional or cognitive capabilities.

f. The service can be provided by someone other than a skilled rehabilitation professional.

12VAC30-130-50. Authorization for services. (Repealed.)

A. Physical therapy, occupational therapy, and speech-language pathology services provided in outpatient settings of acute and rehabilitation hospitals, rehabilitation agencies, or home health agencies shall include authorization for up to five visits by each ordered rehabilitative service annually. School-based rehabilitation services shall not be subject to any prior authorization requirements. The provider shall maintain documentation to justify the need for services. A visit shall be defined as the treatment session that a rehabilitative therapist is with a client to provide services prescribed by the physician. Visits shall not be defined as modality-specific or in measurements or in increments of time.

B. The provider shall request from DMAS authorization for visits deemed necessary by a physician beyond the number of visits not requiring preauthorization (five). Documentation for medical justification must include personally signed and dated (as in 12VAC30-130-10 B) physician orders or a plan of care signed and dated by the physician which includes the elements described in 12VAC30-130-42. Authorization for extended services shall be based on individual need. Payment shall not be made for additional service unless the extended provision of services has been authorized by DMAS. Care rendered beyond the five visits allowed annually which have not been authorized by DMAS shall not be approved for payment.

C. Payment shall not be made for requests submitted more than 12 months after the termination of services.

12VAC30-130-60. Documentation requirements. (Repealed.)

A. Documentation of physical therapy, occupational therapy, and speech-language pathology services provided by a hospital-based outpatient setting, home health agency, a rehabilitation agency, or a school division shall, at a minimum:

1. Describe the clinical signs and symptoms of the patient's condition;

2. Include an accurate and complete chronological picture of the patient's clinical course and treatments;

3. Document that a plan of care specifically designed for the patient has been developed based upon a comprehensive assessment of the patient's needs;

4. Include all treatment rendered to the patient in accordance with the plan with specific attention to frequency, duration, modality, response, and shall identify who provided care (include full name and title);

5. Include a copy of the personally signed and dated (as in 12VAC30-130-10 B) physician's orders / plan of care;

6. Describe changes in the patient's condition, response to the rehabilitative treatment plan, and appropriate revisions to the plan of care;

7. Describe a discharge plan which includes the anticipated improvements in functional levels and the time frames necessary to meet the goals;

8. Include an individualized plan of care which describes the anticipated goal-related improvements in functional level and the time frames necessary to meet these goals. The plan of care shall include participation by the appropriate rehabilitation therapist or therapists, the patient, and the family or caregiver:

a. For outpatient rehabilitative services for acute conditions, the plan of care must be reviewed and updated at least every 60 days by the interdisciplinary team.

b. For outpatient services for long-term, nonacute conditions, the plan of care must be reviewed and updated at least annually. In school divisions, the plan of care shall cover outpatient rehabilitative services provided during the school year, and

9. Include discharge summary to be completed by the discipline providing the service at the time that the service is terminated and to include a description of the patient's response to services, level of independence in carrying out learned skills and abilities, assistive technology necessary to carry out and maintain activities and skills, and recommendations for continued services (i.e., referrals to alternate providers, training to caregivers, etc.). When services are provided by school divisions, a discharge summary shall not be required when services are interrupted at the end of a school term; a discharge summary shall be necessary when rehabilitative services are terminated because the patient no longer needs the services.

B. Services not specifically documented in the patient's medical record as having been rendered shall be deemed not to have been rendered and no coverage shall be provided.

VA.R. Doc. No. R16-2606; Filed October 23, 2015, 2:10 p.m.