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Texas Medicaid Coverage for Children

The Texas Medicaid program covers both acute and chronic PT, OT, and SLP services for children (under 20 years of age) in outpatient and home settings. Physical, occupational and speech therapy services must be medically necessary to the treatment of the individual’s chronic or acute need. A diagnosis alone is not sufficient documentation to support the medical necessity of therapy. To be considered medically necessary, all of the following conditions must be met:

  • The services requested must be considered under the accepted standards of practice to be a specific and effective treatment for the patient’s condition.
  • The services requested must be of a level of complexity or the patient’s condition must be such that the services required can only be effectively performed by or under the supervision of a licensed occupational therapist, physical therapist, or speech-language pathologist, and requires the skills and judgment of the licensed therapist to perform education and training.
  • Functional goals refer to a series of behaviors or skills that allow the client to achieve an outcome relevant to his/her health, safety, or independence within the context of everyday environments. Functional goals must be specific to the client, objectively measurable within a specified time frame, attainable in relation to the client’s prognosis or developmental delay, relevant to client and family, and based on a medical need.  
Acute PT, OT, and SLP Services Chronic Therapy Services

Developmental Delay Criteria

Authorization Requirements for PT, OT, and SLP Services

  • Initial Evaluation and Considerations for Prior Authorization for Treatment
  • Initial Evaluation for Acute and Chronic Therapy Services
  • Additional Evaluation and Documentation Requirements for Speech Therapy
  • Documentation for Initial Requests
  • Written and Verbal Orders

Requests for Recertification - Acute Therapy Services

  • When to File the Request
  • Documentation Supporting Medical Necessity
  • Progress Summary

Requests for Recertification - Chronic Therapy Services

  • Reevaluation (every 180 days)
  • Prior Authorization for Recertification
  • Requests for Revisions to Existing Prior Authorizations or Recertification for Acute and Chronic Therapy Services
  • Age Adjustment for Children Born Prematurely

PT, OT, and SLP Therapy Procedure Codes

    • Timed PT and OT Treatment Procedure Codes
    • Untimed PT and OT Treatment Procedure Codes
    • SLP Treatment Procedure Codes
    • PT, OT and SLP Evaluation and Re-evaluation Codes

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