Ala. Admin. Code r. 560-X-7-.12

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-7-.12 - Physical Therapy

(1) Physical therapy is a covered service based on medical necessity. Physical therapy services that do not require the professional skills of a qualified physical therapist to perform or supervise are not considered medically necessary. Physical therapy is covered:

(a) in a hospital outpatient setting, and

(b) for acute conditions.

(2) Rehabilitative services are not covered. Rehabilitative services are defined as the restoration to useful activity of people with chronic physical or disabling conditions.

(3) Physical therapy services are limited to those CPT codes listed in the Hospital Billing Manual. Maximum units for daily and annual limits are noted for each covered service.

(4) Physical therapy records will be reviewed retrospectively as part of the Provider Review Program. The following medical criteria must be met and the treatment plan must be stated in the recipient's medical record. If the medical criteria are not met and/or documentation of the treatment plan is not stated in the medical record relevant claims will be recouped. The medical criteria are:

(a) Physical therapy is covered for acute conditions only. An acute condition is a new diagnosis which has been made within three months of the beginning date of the physical therapy treatments.

(b) Chronic conditions are not covered except for acute exacerbations or as a result of an EPSDT screening. A chronic condition is a condition where the diagnosis is made more than three months before the beginning date of the physical therapy treatments.

(c) An acute exacerbation is defined as the sudden worsening of the patient's clinical condition, both objectively and subjectively, where physical therapy is expected to improve the patient's clinical condition.

(5) In addition to the recipient meeting the above stated medical criteria, the provider of service is responsible for developing a plan of treatment. This plan of treatment must be readily available at all times for review in the recipient's medical record. The plan of treatment should contain but is not limited to, the following information:

(a) Recipient's name

(b) Recipient's current Medicaid number

(c) Diagnosis(es)

(d) Date of onset or the date of the acute exacerbation, if applicable

(e) Type of surgery performed, if applicable

(f) Date of surgery, if applicable

(g) Functional status prior to and after physical therapy is completed

(h) Frequency and duration of treatment

(i) Modalities

(j) For ulcers, the location, size, and depth should be documented.

(6) The plan of treatment must be signed by the physician who ordered the physical therapy and the therapist who administered the treatments. The information contained in the treatment plan must be documented in the recipient's medical record.

Ala. Admin. Code r. 560-X-7-.12

Emergency rule effective July 1, 1991. Permanent rule effective October 12, 1991.

Amended by Alabama Administrative Monthly Volume XXXIII, Issue No. 09, June 30, 2015, eff. 7/16/2015.

Previous rule 560-X-7-.12 entitled "Preoperative Hospitalization" effective October 1, 1982. Repealed effective May 11, 1987. Amended: Filed March 7, 1997; effective April 11, 1997. Amended: filed August 6, 1999; effective September 10, 1999. Amended: Filed June 11, 2015; effective July 16, 2015.

Author: Solomon Williams, Associate Director, Institutional Services

Statutory Authority: State Plan, Attachment 3.1-A; Title XIX, Social Security Act; 42 C.F.R. §§440.10, 440.20, 440.50.