WAC 388-545-300   Occupational therapy.  (1) The following providers are eligible to enroll with medical assistance administration (MAA) to provide occupational therapy services:

     (a) A licensed occupational therapist;

     (b) A licensed occupational therapy assistant supervised by a licensed occupational therapist; and

     (c) An occupational therapy aide, in schools, trained and supervised by a licensed occupational therapist.

     (2) Clients in the following MAA programs are eligible to receive occupational therapy services described in this chapter:

     (a) Categorically needy;

     (b) Children's health;

     (c) General assistance unemployable (within Washington state or border areas only);

     (d) Alcoholism and drug addiction treatment and support act (ADATSA) (within Washington state or border areas only);

     (e) Medically indigent program for emergency hospital-based services only; or

     (f) Medically needy program only when the client is either:

     (i) Twenty years of age or younger and referred by a screening provider under the early and periodic screening, diagnosis and treatment program (healthy kids program) as described in chapter 388-534 WAC; or

     (ii) Receiving home health care services as described in chapter 388-551 WAC, subchapter II.

     (3) Occupational therapy services received by MAA eligible clients must be provided:

     (a) As part of an outpatient treatment program for adults and children;

     (b) By a home health agency as described under chapter 388-551 WAC, subchapter II;

     (c) As part of the physical medicine and rehabilitation (PM&R) program as described in WAC 388-550-2551;

     (d) By a neurodevelopmental center;

     (e) By a school district or educational service district as part of an individual education program or individualized family service plan as described in WAC 388-537-0100; or

     (f) When prescribed by a provider for clients age twenty-one or older. The therapy must:

     (i) Prevent the need for hospitalization or nursing home care;

     (ii) Assist a client in becoming employable;

     (iii) Assist a client who suffers from severe motor disabilities to obtain a greater degree of self-care or independence; or

     (iv) Be a part of a treatment program intended to restore normal function of a body part following injury, surgery, or prolonged immobilization.

     (4) MAA pays only for covered occupational therapy services listed in this section when they are:

     (a) Within the scope of an eligible client's medical care program;

     (b) Medically necessary, when prescribed by a provider; and

     (c) Begun within thirty days of the date prescribed.

     (5) MAA covers the following occupational therapy services per client, per calendar year:

     (a) Unlimited occupational therapy program visits for clients twenty years of age or younger;

     (b) One occupational therapy evaluation. The evaluation is in addition to the twelve program visits allowed per year;

     (c) Two durable medical equipment needs assessments. The assessments are in addition to the twelve program visits allowed per year;

     (d) Twelve occupational therapy program visits;

     (e) Twenty-four additional outpatient occupational therapy program visits when the diagnosis is any of the following:

     (i) A medically necessary condition for developmentally delayed clients;

     (ii) Surgeries involving extremities, including:

     (A) Fractures; or

     (B) Open wounds with tendon involvement;

     (iii) Intracranial injuries;

     (iv) Burns;

     (v) Traumatic injuries;

     (f) Twenty-four additional occupational therapy program visits following a completed and approved inpatient PM&R program. In this case, the client no longer needs nursing services but continues to require specialized outpatient therapy for any of the following:

     (i) Traumatic brain injury (TBI);

     (ii) Spinal cord injury (paraplegia and quadriplegia);

     (iii) Recent or recurrent stroke;

     (iv) Restoration of the levels of function due to secondary illness or loss from multiple sclerosis (MS);

     (v) Amyotrophic lateral sclerosis (ALS);

     (vi) Cerebral palsy (CP);

     (vii) Extensive severe burns;

     (viii) Skin flaps for sacral decubitus for quads only;

     (ix) Bilateral limb loss; or

     (x) Acute, infective polyneuritis (Guillain-Barre' syndrome).

     (g) Additional medically necessary occupational therapy services, regardless of the diagnosis, must be approved by MAA.

     (6) MAA will pay for one visit to instruct in the application of transcutaneous neurostimulator (TENS), per client, per lifetime.

     (7) MAA does not cover occupational therapy services that are included as part of the reimbursement for other treatment programs. This includes, but is not limited to, hospital inpatient and nursing facility services.



[Statutory Authority: RCW 74.08.090. 01-02-075, § 388-545-300, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.08.090 and 74.09.520. 99-16-068, § 388-545-300, filed 8/2/99, effective 9/2/99.]