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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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Definitions

Physical Therapy

The practice of physical therapy includes:

  • Measurement or testing of the function of the musculoskeletal, or neurological, system.
  • Rehabilitative treatment concerned with restoring function or preventing disability caused by illness, injury, or birth defect.
  • Treatment, consultative, educational, or advisory services to reduce the incidence or severity of disability or pain to enable, train, or retrain a person to perform the independent skills and activities of daily living.

Texas Medicaid limits physical therapy to the skilled treatment of clients who have acute or acute exacerbation of chronic disorders or chronic medical condition of the musculoskeletal and neuromuscular systems.

Occupational Therapy

The practice of occupational therapy includes:

  • Evaluation and treatment of a person whose ability to perform the tasks of living is threatened or impaired by developmental deficits, sensory impairment, physical injury, or illness.
  • Using therapeutic goal-directed activities to:
  • Evaluate, prevent, or correct physical dysfunction.
  • Maximize function in a person’s life.
  • Applying therapeutic goal-directed activities in treating patients on an individual basis, in groups, or through social systems, by means of direct or monitored treatment or consultation.

Texas Medicaid limits occupational therapy to the skilled treatment of clients whose ability to function in life roles is impaired.

Occupational therapy uses purposeful activities to obtain or regain skills needed for activities of daily living (ADL) and/or functional skills needed for daily life lost through acute medical condition, acute exacerbation of a medical condition, or chronic medical condition related to injury, disease, or other medical causes. ADLs are basic self-care tasks such as feeding, bathing, dressing, toileting, grooming, and mobility.

Speech Therapy

Speech therapy is a benefit of Texas Medicaid for the treatment of chronic (for clients who are 20 years of age and younger), acute, or acute exacerbations of pathological or traumatic conditions of the head or neck, which affect speech production, speech communication and oral motor, feeding and swallowing disorders. Speech therapy may be provided by a physician or speech language pathologist within their licensed scope of practice.

Speech-language pathologists treat speech sound and motor speech disorders, stuttering, voice disorders, aphasia and other language impairments, cognitive disorders, social communication disorders and swallowing (dysphagia) deficits.

Speech therapy is designed to ameliorate, restore, or rehabilitate speech language communication and swallowing disorders that have been lost or damaged as a result of a chronic, acute or acute exacerbation of a medical condition due to a recent injury, disease or other medical conditions, or congenital anomalies or injuries.

There are three types of communication disorders:

Language Disorders—Impaired comprehension and/or use of spoken, written and/or other symbol systems. This disorder may involve the following components: forms of language (phonology, morphology, and syntax), content and meaning of language (pragmatics) and/or the perception/ processing of language. Language disorders may involve one, all or a combination of the above components.

Speech Production Disorders—Impairment of the articulation of speech sounds, voice and/or fluency. Speech Production Disorders may involve one, all or a combination of these components of the speech production system. An articulation disorder may manifest as an individual sound deficiency, i.e., traditional articulation disorder, incomplete or deviant use of the phonological system, i.e., phonological disorder, or poor coordination of the oral-motor mechanism for purposes of speech production, i.e., verbal and/or apraxia, dysarthria.

Oral Motor/Swallowing/Feeding Disorders—Impairment of the muscles, structures and/or functions of the mouth (physiological or sensory-based) involved with the entire act of deglutition from placement and manipulation of food in the mouth through the oral and pharyngeal phases of the swallow. These disorders may or may not result in deficits to speech production.

Acute PT and OT Services

Acute PT and OT services are benefits of Texas Medicaid for the medically necessary short-term treatment of an acute medical condition or an acute exacerbation of a chronic medical condition.

Treatments are expected to significantly improve, restore or develop physical functions diminished or lost as a result of a recent trauma, illness, injury, disease, surgery, or change in medical condition, in a reasonable and generally predictable period of time (60 days), based on the prescribing provider’s and therapist’s assessment of the client’s restorative potential.

Note: Recent is defined as occurring within the past 90 days of the prescribing provider’s evaluation of condition.

  • Treatments are directed towards restoration of or compensation for lost function. Services do not duplicate those provided concurrently by any other therapy.
  • Services must meet acceptable standards of medical practice and be specific and effective treatment for the client’s condition. Services are provided within the provider’s scope of practice, as defined by state law.
  • Acute is defined as an illness or trauma with a rapid onset and short duration.
  • A medical condition is considered chronic when 120 days have passed from the start of therapy or the condition is no longer expected to resolve or may be slowly progressive over an indefinite period of time.
  • With documentation of medical need physical, occupational, and speech therapy may continue for a maximum of 120 days for an acute medical condition or an acute exacerbation of a chronic medical condition.
  • Once the client’s condition is no longer considered acute, continued therapy for a chronic condition will only be considered for clients who are 20 years of age or younger.

Chronic Services

Chronic physical, occupational, and speech therapy services are benefits of Texas Medicaid for the medically necessary treatment of chronic medical conditions and developmental delay when a medical need is established for the developmental delay as indicated in this handbook. All eligible clients who are birth through 20 years of age may continue to receive all medically necessary therapy services, with documentation proving medical necessity.

The goals of the services provided are directed at maintaining, improving, adapting, or restoring functions which have been lost or impaired due to a recent illness, injury, loss of body part, congenital abnormality, degenerative disease, or developmental delay.

  • Services do not duplicate those provided concurrently by any other therapy.
  • Services must meet acceptable standards of medical practice and be specific and effective treatment for the client’s condition.
  • Services are provided within the provider’s scope of practice, as defined by state law.
  • Treatment for chronic medical conditions and developmental delay will only be considered for clients who are birth through 20 years of age.

Reference

Texas Medicaid Provider Manual

Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook

June 2020

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