016.06.05 Ark. Code R. 046
Current through Register Vol. 49, No. 10, October, 2024
Rule 016.06.05-046 - Section II: Occupational, Physical, Speech Therapy Services - Provider Manual Update Transmittal No. 41Section IIOccupational, Physical, Speech Therapy Services201.000Arkansas Medicaid Participation Requirements Individual and group providers of occupational therapy, physical therapy and speech-language pathology services must meet the following criteria to be eligible to participate in the Arkansas Medicaid Program.
A. A provider of therapy services must meet the enrollment criteria for the type of therapy to be provided as established and outlined in section 202.000 of this manual.B. A provider of therapy services has the option of enrolling in the Title XVIII (Medicare) Program. When a beneficiary is dually eligible for Medicare and Medicaid, Medicare must be billed prior to billing Medicaid. The beneficiary may not be billed for the charges. Providers enrolled to participate in the Title XVIII (Medicare) Program must notify the Arkansas Medicaid Program of their Medicare provider number. Claims filed by Medicare "nonparticipating" providers do not automatically cross over to Medicaid for payment of deductibles and coinsurance.C. The provider must complete and submit to the Provider Enrollment Unit a provider application (form DMS-652), a Medicaid contract (form DMS-653) and a Request for Taxpayer Identification Number and Certification (Form W-9). View or print a provider application (form DMS-652), Medicaid contract (form DMS-653) and Request for Taxpayer Identification Number and Certification (Form W-9).D. The following documents must accompany the provider application and the Medicaid contract.1. A copy of all certifications and licenses verifying compliance with enrollment criteria for the therapy discipline to be practiced. (See section 202.000 of this manual.)2. If enrolled in the Title XVIII (Medicare) Program, an out-of-state provider must submit a copy of verification that reflects current enrollment in that program.E. The Arkansas Medicaid Program must approve the provider application and the Medicaid contract as a condition of participation in the Medicaid Program. Persons and entities that are excluded or debarred under any state or federal law, regulation or rule are not eligible to enroll, or to remain enrolled, as Medicaid providers.F. A copy of subsequent state license renewal must be forwarded to Provider Enrollment within 30 days of issuance. If the renewal document(s) have not been received within this timeframe, the provider will have an additional and final 30 days to comply.G. Failure to timely submit verification of license renewal will result in termination of enrollment in the Arkansas Medicaid Program.201.100Group Providers of Therapy Services Group providers of therapy services must meet the following criteria to be eligible for participation in the Arkansas Medicaid Program.
A. In situations where a therapist, a therapy assistant, a speech-language pathologist or a speech-language pathology assistant is a member of a group of therapy service providers, each individual therapist, speech-language pathologist, or assistant and the group must both enroll.1. Each individual in the group must enroll following the participation requirements in section 201.000 and by meeting the enrollment criteria established in section 202.000 for the applicable therapy disciplines.2. The group must also enroll in the Arkansas Medicaid Program by completing and submitting to the Medicaid Provider Enrollment Unit a provider application (form DMS-652), a Medicaid contract (form DMS-653) and a Request for Taxpayer Identification Number and Certification (Form W-9). View or print a provider application (form DMS-652), Medicaid contract (form DMS-653) and Request for Taxpayer Identification Number and Certification (Form W-9).The Arkansas Medicaid Program must approve the provider application and the Medicaid contract as a condition of participation in the Medicaid Program. Persons and entities that are excluded or debarred under any state or federal law, regulation or rule are not eligible to enroll, or to remain enrolled, as Medicaid providers.
3. The group has the option of enrolling in the Title XVIII (Medicare) program. (See subpart B of section 201.000 of this manual.)4. The group must also comply with subsequent certifications and license renewals as outlined in section 201.000, subparts F and G.B. Group providers are "pay to" providers only. The service must be performed and billed by the performing licensed and Medicaid-enrolled therapist, speech-language pathologist, therapy assistant or speech-language pathology assistant with the group.201.110School Districts and Education Service Cooperatives If a school district or an education service cooperative contracts with an individual qualified therapist or speech-language pathologist, the criteria for group providers of therapy services apply. The qualified individual is considered the provider of therapy services and must complete an application and contract with the Division of Medical Services. (Refer to section 201.100.)
The following requirements apply only to Arkansas school districts and education service cooperatives that employ (via a form W-4 relationship) qualified therapists or qualified speech-language pathologists to provide therapy services.
A. The Arkansas Department of Education must certify a school district or education service cooperative.1. The Arkansas Department of Education must provide a list, updated on a regular basis, of all school districts and education service cooperatives certified by the Arkansas Department of Education to the Medicaid Provider Enrollment Unit of the Division of Medical Services.2. The Local Education Agency (LEA) number must be used as the license number for the school district or education service cooperative.B. The school district or education service cooperative must enroll as a provider of therapy services. Refer to section 201.100 for the process to enroll as a provider and for information regarding applicable restrictions to enrollment.211.000Introduction The Arkansas Medicaid Occupational, Physical and Speech Therapy Program reimburses therapy services for Medicaid-eligible individuals under the age of 21 in the Child Health Services (EPSDT) Program.
Therapy services for individuals aged 21 and older are only covered when provided through the following Medicaid Programs: Developmental Day Treatment Clinic Services (DDTCS), Hospital/Critical Access Hospital (CAH)/End-Stage Renal Disease (ESRD), Home Health, Hospice and Physician/Independent Lab/CRNA/Radiation Therapy Center. Refer to these Medicaid provider manuals for conditions of coverage and benefit limits.
Medicaid reimbursement is conditional upon providers' compliance with Medicaid policy as stated in this provider manual, manual update transmittals and official program correspondence.
All Medicaid benefits are based on medical necessity. Refer to the Glossary for a definition of medical necessity.
262.110Occupational, Physical, Speech Therapy Procedures CodesThe following occupational, physical and speech-language pathology procedure codes are payable when billed using type of service (TOS) B.
A.OCCUPATIONAL THERAPYProcedure Code | Required Modifiers | Description |
97003 | - | Evaluation for Occupational Therapy (30-minute unit; maximum of 4 units per state fiscal year, July 1 through June 30) |
97530 | - | Individual Occupational Therapy (15-minute unit; maximum of 4 units per day) |
97150 | U2 | Group Occupational Therapy (15-minute unit; maximum of 4 units per day, maximum of 4 clients per group) |
97530 | UB | Individual Occupational Therapy by Occupational Therapy Assistant (15-minute unit; maximum of 4 units per day) |
97150 | UB, U1 | Group Occupational Therapy by Occupational Therapy Assistant (15-minute unit; maximum of 4 units per day, maximum of 4 clients per group) |
B.PHYSICAL THERAPYProcedure Code | Required Modifier | Description |
97001 | - | Evaluation for Physical Therapy (30-minute unit; maximum of 4 units per state fiscal year, July 1 through June 30) |
97110 | - | Individual Physical Therapy (15-minute unit; maximum of 4 units per day) |
97150 | - | Group Physical Therapy (15-minute unit; maximum of 4 units per day, maximum of 4 clients per group) |
97110 | UB | Individual Physical Therapy by Physical Therapy Assistant (15-minute unit; maximum of 4 units per day) |
97150 | UB | Group Physical Therapy by Physical Therapy Assistant (15-minute unit; maximum of 4 units per day, maximum of 4 clients per group) |
C.SPEECH-LANGUAGE PATHOLOGYProcedure Code | Required Modifier | Description |
92506 | - | Evaluation for Speech Therapy (30-minute unit; maximum of 4 units per state fiscal year, July 1 through June 30) |
92507 | - | Individual Speech Session (15-minute unit; maximum of 4 units per day) |
92508 | - | Group Speech Session (15-minute unit; maximum of 4 units per day, maximum of 4 clients per group) |
92507 | UB | Individual Speech Therapy by Speech-Language Pathology Assistant (15-minute unit; maximum of 4 units per day) |
92508 | UB | Group Speech Therapy by Speech-Language Pathology Assistant (15-minute unit; maximum of 4 units per day, maximum of 4 clients per group) |
262.120Augmentative Communication Device (ACD) EvaluationProcedure Code | Description |
92607 | Augmentative Communication Device Evaluation |
262.400Special Billing ProceduresServices may be billed according to the care provided and to the extent each procedure is provided. Occupational, physical and speech therapy services do not require prior authorization. ACD evaluations do require prior authorization.
016.06.05 Ark. Code R. 046