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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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Frequency and Duration Criteria

Frequency must always be commensurate with the patient’s medical and skilled therapy needs, level of disability and standards of practice; it is not for the convenience of the patient or the responsible adult.

Exceptions to therapy limitations may be covered if the medically necessary criteria are met for the following:

    • Presentation of new acute condition
    • Therapist intervention is critical to the realistic rehabilitative/restorative goal, provided documentation proving medical necessity is received.

When therapy is initiated, the therapist must provide education and training of the patient and responsible caregivers, by developing and instructing them in a home treatment program to promote effective carryover of the therapy program and management of safety issues.

Requests for Services

Providers may request high, moderate, or low frequencies on the Texas Medicaid Physical, Occupational or Speech Therapy (PT, OT, ST) Prior Authorization Form by indicating 3, 2, or 1 time per week respectively. Providers may request low or maintenance level by requesting 1, 2, or 3 times per month. Additional documentation is required when requesting a frequency of 3 times a week or more.

Providers may request physical, occupational, or speech therapy services frequency by week for one or more visits per week, or by month for 1, 2, or 3 visits per month.

    • A week includes the day of the week on which the prior authorization period begins and continues for seven days. For example, if the prior authorization starts on a Thursday, the prior authorization week runs Thursday through Wednesday.
    • The number of therapy services authorized for a week or month must be contained in that prior authorization period.
    • Services billed, in excess of those authorized are subject to recoupment.

Missed Visits

Missed visits may be made up within the authorization period as long as total number of visits or units authorized does not exceed the amount authorized. Provider should document reason for visits outside of the weekly or monthly frequency in the patient’s medical record.

High Frequency

Moderate Frequency

Low Frequency

Maintenance Level/Prevent Deterioration

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