WAC 388-545-500   Physical therapy.  (1) The following providers are eligible to provide physical therapy services:

     (a) A licensed physical therapist or physiatrist; or

     (b) A physical therapist assistant supervised by a licensed physical therapist.

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

     (a) Categorically needy (CN);

     (b) Children's health;

     (c) General assistance-unemployable (GA-U) (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 (MIP) for emergency hospital-based services only; or

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

     (i) Twenty years of age or younger and referred under the early and periodic screening, diagnosis and treatment program (EPSDT/healthy kids program) as described in WAC 388-86-027; or

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

     (3) Physical therapy services that MAA eligible clients receive must be provided as part of an outpatient treatment program:

     (a) In an office, home, or outpatient hospital setting;

     (b) By a home health agency as described in chapter 388-551 WAC;

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

     (d) By a neurodevelopmental center;

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

     (f) For disabled children, age two and younger, in natural environments including the home and community settings in which children without disabilities participate, to the maximum extent appropriate to the needs of the child.

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

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

     (b) Medically necessary and ordered by a physician, physician's assistant (PA), or an advanced registered nurse practitioner (ARNP);

     (c) Begun within thirty days of the date ordered;

     (d) For conditions which are the result of injuries and/or medically recognized diseases and defects; and

     (e) Within accepted physical therapy standards.

     (5) Providers must document in a client's medical file that physical therapy services provided to clients age twenty-one and older are medically necessary. Such documentation may include justification that physical therapy services:

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

     (b) Assist a client in becoming employable;

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

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

     (6) MAA determines physical therapy program units as follows:

     (a) Each fifteen minutes of timed procedure code equals one unit; and

     (b) Each nontimed procedure code equals one unit, regardless of how long the procedure takes.

     (7) MAA does not limit coverage for physical therapy services listed in subsections (8) through (10) of this section if the client is twenty years of age or younger.

     (8) MAA covers, without requiring prior authorization, the following ordered physical therapy services per client, per diagnosis, per calendar year, for clients twenty-one years of age and older:

     (a) One physical therapy evaluation. The evaluation is in addition to the forty-eight program units allowed per year;

     (b) Forty-eight physical therapy program units;

     (c) Ninety-six additional outpatient physical therapy program units 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;

     (vi) Meningomyelocele;

     (vii) Down's syndrome;

     (viii) Cerebral palsy; or

     (ix) Symptoms involving nervous and musculoskeletal systems and lack of coordination;

     (d) Two durable medical equipment (DME) needs assessments. The assessments are in addition to the forty-eight physical therapy program units allowed per year. Two program units are allowed per DME needs assessment; and

     (e) One wheelchair needs assessment in addition to the two durable medical needs assessments. The assessment is in addition to the forty-eight physical therapy program units allowed per year. Four program units are allowed per wheelchair needs assessment.

     (f) The following services are allowed, per day, in addition to the forty-eight physical therapy program units allowed per year:

     (i) Two program units for orthotics fitting and training of upper and/or lower extremities.

     (ii) Two program units for checkout for orthotic/prosthetic use.

     (iii) One muscle testing procedure. Muscle testing procedures cannot be billed in combination with each other.

     (g) Ninety-six additional physical therapy program units are allowed following a completed and approved inpatient acute PM&R program. In this case, the client no longer needs nursing services but continues to require specialized outpatient physical 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 functions 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 quadriplegics only;

     (ix) Bilateral limb loss;

     (x) Open wound of lower limb; or

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

     (9) For clients age twenty-one and older, MAA covers physical therapy services which exceed the limitations established in subsection (8) of this section if the provider requests prior authorization and MAA approves the request.

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

     (11) Duplicate services for occupational therapy and physical therapy are not allowed for the same client when both providers are performing the same or similar procedure(s).

     (12) MAA does not cover physical 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.

     (13) MAA does not cover physical therapy services performed by a physical therapist in an outpatient hospital setting when the physical therapist is not employed by the hospital. Reimbursement for services must be billed by the hospital.



[Statutory Authority: RCW 74.08.090. 01-02-075, § 388-545-500, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.08.090 and 74.09.520. 00-04-019, § 388-545-500, filed 1/24/00, effective 2/24/00.]