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2.10.1.1 Enrollment

HHSC allows enrollment of independently-practicing licensed occupational therapist under CCP. The information in this section applies to CCP services only.

2.10.1.2 Services/Benefits and Limitations

A procedural modifier is required when submitting claims for OT services. Providers must use modifier GO for OT services. Procedural modifiers are not required for evaluations and re-evaluations.

Evaluations (procedure code 97003) are limited to once every 180 days any provider. Re-evaluations (procedure code 97004) are limited once per 30 days, any provider.

An evaluation or re-evaluation performed on the same day as therapy from a different therapy type must be performed at distinctly separate times to be considered for reimbursement.

If a therapy evaluation or re-evaluation procedure code and like therapy procedure codes are billed for the same date of service by any provider, the like therapy evaluation or re-evaluation will be denied. Physical therapy evaluation (procedure code 97003) or re-evaluation (procedure code 97004) will be denied as part of the following occupational therapy procedure codes billed with Modifier GO.

The following procedure codes are billed in 15-minute increments:

Procedure codes that may be billed in multiple quantities (i.e., 15 minutes each) are limited to two hours (eight units) per day individual, group, or a combination of individual and group therapy, per therapy type (two hrs. of OT and two hrs. of PT). Each 15 minutes equals one unit.

Procedure Codes 97012 97014 97016 97018 97022 97024 97026 97028 97032 97033 97034 97035 97036 97039 97110 97112 97113 97116 97124 97139 97140 97150 97530 97535 97537 97542 97750 97760 97761 97762 97799 S8990 Procedure Codes 97032 97033 97034 97035 97036 97039 97110 97112 97113 97116 97124 97139 97140 97530 97535 97537 97542 97750 97760 97761 97762 97799 S8990

All 15-minute increment procedure codes are based on the actual amount of billable time associated with the service. For those services for which the unit of service is 15 minutes (1 unit = 15 minutes), partial units must be rounded up or down to the nearest quarter hour.

The documentation retained in the client’s file must include the billable start time, billable stop time, total billable minutes, and activity that was performed.

To calculate billing units, count the total number of billable minutes for the calendar day for the client, and divide by 15 to convert to billable units of service. If the total billable minutes are not evenly divisible by 15, minutes greater than 7 are converted to 1 unit and 7 or fewer minutes are converted to 0 unit. For example, 68 total billable minutes/15 = 4 units + 8 minutes. Since the 8 minutes are more than 7 minutes, those 8 minutes are converted to 1 unit. Consequently, 68 total billable minutes = 5 units of service. The following table indicates the time intervals for 0 through 8 units:

The following procedure codes are limited to once per day, for each therapy type (OT and PT):

If procedure code 97750 is billed with an office visit on the same date of service by the same provider, the office visit will be denied.

Procedure code 97150 will be denied if billed on the same date of service by the same provider as procedure code 97750.

Electrical stimulation therapy (procedure code 97032) may be considered with documentation of medical necessity.

2.10.1.3 Prior Authorization and Documentation Requirements

Prior authorization is required for occupational therapy except for therapy provided in the inpatient setting, evaluations or re-evaluations, services provided through the SHARS or Early Childhood Inter- vention (ECI) programs.

Refer to: Section 3, “School Health and Related Services (SHARS)” in this handbook for more infor- mation regarding SHARS.

Note: It is not mandatory for ECI programs to request prior authorization for reimbursement of therapy services; however, in order to expedite claims processing providers should submit the ECI Request for Initial/Renewal Outpatient Therapy form with their claim form. All thera- pists involved with the client must sign and date the ECI Request for Initial/Renewal Outpatient Therapy form. When a physician does not sign the therapy form, a copy of a

Units Number of Minutes

0 units 0 minutes through 7 minutes

1 unit 8 minutes through 22 minutes

2 units 23 minutes through 37 minutes

3 units 38 minutes through 52 minutes

4 units 53 minutes through 67 minutes

5 units 68 minutes through 82 minutes

6 units 83 minutes through 97 minutes

7 units 98 minutes through 112 minutes

8 units 113 minutes through 127 minutes

Procedure Codes

separate prescription for therapies must be included with the physician's original signature, and must be dated on or before the actual beginning date of the therapy. A physician's prescription is required every 180 days.

The following documentation must be submitted to TMHP prior to the start of care for the current episode of therapy for consideration for prior authorization:

• A current written order by a physician based on medical necessity.

• A prescription is considered current when it is signed and dated on or no later than 60 days before the start of therapy.

• A “Request for Initial Outpatient Therapy (Form TP-1)” or “Request for Extension of Outpatient Therapy (2 Pages) (Form TP-2)” must be submitted to TMHP prior to the start of care for the current episode of therapy.

• The most recent evaluation and treatment plan. To establish medical necessity, the written treatment plan must include the following:

• The age of the client at the time of evaluation

• Diagnosis

• Description of specific therapy being prescribed

• Specific treatment goals related to the client's individual needs. Therapy goals may include improving function, maintenance of function, or slowing of the deterioration of function. • For an initial request, anticipated measurable progress toward goals, the prognosis, and the client's

gross motor skills in years or months.

• For a new request for additional therapy, documentation of all progress made from the beginning of the previous treatment period.

• Duration and frequency of therapy • Requested date of service

The number of sessions per week must be supported by documentation supporting the medical necessity for the frequency requested.

A request for OT services may be prior authorized for no longer than 180 days duration. A new request must be submitted if therapy is required for a longer duration.

The GO modifier is required on all prior authorization requests for occupational therapy. When requesting prior authorization for group occupational therapy, the provider must submit documentation supporting the group process as being medically necessary and beneficial to the client. When group therapy is authorized, weekly therapy limits will not be exceeded.

If a provider discontinues therapy with a client and a new provider begins therapy during an existing authorization period, submission of a new plan of care and documentation of the last therapy visit with the previous provider is required along with a letter from the client, or responsible adult, stating the date therapy ended with the previous provider.

2.10.1.4 Claims Information

Providers must submit claims for therapy services in an approved electronic claims format, a CMS-1500, or UB-04 CMS-1450 paper claim form from the vendor of their choice. TMHP does not supply the forms.

Refer to: Section 3: TMHP Electronic Data Interchange (EDI) (Vol. 1, General Information) for information on electronic claims submissions.

Section 6: Claims Filing (Vol. 1, General Information) for general information about claims filing.

Subsection 6.5, “CMS-1500 Paper Claim Filing Instructions” in Section 6, “Claims Filing” (Vol. 1, General Information).

Subsection 6.6, “UB-04 CMS-1450 Paper Claim Filing Instructions” in Section 6, “Claims Filing” (Vol. 1, General Information) for paper claims completion instructions.

2.10.1.5 Reimbursement

OT services are reimbursed in accordance with 1 TAC §355.8441.

See the online fee lookup (OFL) or the applicable fee schedule on the TMHP website at www.tmhp.com for reimbursement rates.