La. Admin. Code tit. 40 § I-5127

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-5127 - Physical Medicine

A. Practicing Physical and Occupational Therapists

1. To bill for physical therapist and/or occupational therapist services under workers' compensation, a practicing therapist must be:

a. currently licensed in the state of Louisiana as a physical therapist or as an occupational therapist;

b. if billing for physical or occupational therapy procedures, you must provide your physical therapist or occupational therapist license number. These procedures will not be reimbursed unless a current Louisiana license number is provided;

c. services must be billed using the appropriate national CPT codes as listed in this manual.

2. The following criteria must be met for therapy to qualify for reimbursement:

a. the patient's condition must have the potential for restoration of function;

b. the therapy must be specific for the improvement of the patient's condition;

c. the therapy must be provided under a current, written plan of care which is approved by a physician and substantiated in the office notes.

3. Upon request, physicians must submit to carriers documentation substantiating the medical necessity of therapies ordered.

B. Plan of Care

1. On the initial visit, a therapist must evaluate the patient's therapy needs and develop a written plan of care based upon the assessment of the patient's level of function and the physician's orders.

2. Plan of Care Content. At a minimum, the plan of care should contain:

a. the potential degree of restoration and measurable goals;

b. the specific therapies to be provided including the frequency of each treatment;

c. the estimated duration for the therapeutic regimen.

3. Plan of Care Review

a. The therapist must review each plan of care at least every 30 days and make necessary revisions.

b. Physical and occupational therapy services required in excess of 45 days from onset of evaluation for treatment shall require evidence in writing as to the necessity for continued therapy. Thereafter, evidence in writing to the necessity for continued physical therapy shall be required every 30 days.

C. Assessment

1. Billing. The initial, written assessment developed by the therapist must be reported to the carrier using procedure code, 97001 or 97003.

2. Reimbursement

a. Only one initial assessment per injury may be reimbursed. Reimbursement for the use of additional initial assessment time is not allowed.

b. Reimbursement for reassessment shall be recommended only once in a seven day period. Reassessment for established patients shall be billed under 97002 or 97004.

c. Assessment of the patient's status includes assessment of the neuromuscular system. Therefore, reimbursement must not be made for neuromuscular testing codes, extremity testing codes and/or range of motion codes except for those testing procedures identified by the following code: 97535 or 97755.

D. Modalities and Procedures

1. Body Areas. Under workers' compensation, the following two body areas, or any portions thereof, are recognized for the provision of modalities and procedures:

a. the trunk-the entire body including the spine, excluding the head and limbs (syn: torso);

b. any two extremities:

i. an upper extremity is an upper limb, including the shoulder, upper arm, elbow, forearm, wrist and hand;

ii. a lower extremity is a lower limb, including the hip, thigh, knee, leg, ankle and foot.

2. Reimbursement

a. No more than one visit per day for the purpose of therapy may be reimbursed.

b. The carrier should compare the billing with the plan of care to ensure that only the services that are itemized in the plan of care are reimbursed.

c. Since the Hubbard Tank or Therapeutic Pool is designed for full body immersion, unless full body immersion is medically necessary and prescribed, Procedure Codes 97036 must not be reimbursed.

d. Prior written authorization must be obtained when billing for more than eight modalities, procedures or combination in one physical and occupational therapy session.

e. Therapeutic exercises and procedures codes 97150, 97110, 97530 are to utilized by physical therapists when billing for therapeutic exercise and procedures such as, but not limited to, joint mobilization, gait training, muscle re-education, activities of daily living, patient education, etc.

E. Transcutaneous Electrical Nerve Stimulation (TENS)

1. TENS may be provided by the therapist when ordered by the physician, itemized in the plan of care and authorized by the carrier.

2. Reimbursement for TENS testing and training is limited to four sessions per injury.

3. Billing for TENS Equipment. When the physician recommends TENS for long-term therapy, authorization must be obtained from the carrier for rental or purchase of equipment prior to providing the equipment to the patient. For reimbursement and billing instructions, please refer to the Durable Medical Equipment Manual.

F. Medical Supplies. Medical supplies used in the course of physical and occupational therapy including dressings, splinting and orthotic materials, educational materials, lumbar and cervical rolls, etc., may be billed and reimbursed using Procedure Code 99070.

G. Fabrications of Orthotics

1. Evaluation of orthotics shall be billed according to §5127. C

2. Fabrication and fitting of orthotics shall be billed under 97530 or 97760 as a PT/OT procedure.

3. Supplies shall be billed according to §5127. F

H. Test and Measurements

1. Reimbursement for extremity testing, muscle testing and range of motion measurements shall be billed according to §5127. C

2. Procedure codes 97755 shall be used when testing is performed by means of mechanical equipment. These procedure codes shall include print out of test results with report.

a. Prior authorization is required to bill 97755 if testing exceeds 30 minutes for single joint, single plane; or, 45 minutes for single joint multiple plane; or, 45 minutes for multiple joint, multiple plane for noninvolved side.

b. Prior authorization is required to bill 97755 if re-testing exceeds 15 minutes for single joint, single plane; or 30 minutes for single joint multiple plane; or, 30 minutes for multiple joint, multiple plaine for noninvolved side.

I. Programs in Industrial Rehabilitation; Work Hardening and Work Conditioning

1. Operational Definitions

a.Work Conditioning. Work conditioning is a work-related, intensive, goal-oriented treatment program specifically designed to restore an individual's systemic, neuro-musculo-skeletal (strength, endurance, movement, flexibility and motor control) and cardiopulmonary functions. The objective of the work conditioning program is to restore the claimant's physical capacity and function so the claimant can return to work.

b.Work Conditioning Assessment. Work conditioning assessment is defined as evaluation(s), test(s), and procedure(s) required to identify and quantify the claimant's individual work-related, systemic, neuro-musculo-skeletal restoration needs. The results of this assessment shall be used to identify eligibility, design a plan of care, monitor progress and plan for discharge and return to work.

c.Work Conditioner Provider. A licensed physical therapist, a licensed occupational therapist.

d.Work Hardening. Work hardening is a highly structured, goal-oriented, individualized treatment program designed to return the person to work. Work hardening programs, which are interdisciplinary in nature, use real or simulated work activities designed to restore physical, behavioral, and vocational functions. Work hardening addresses the issues of productivity, safety, physical tolerances, and worker behaviors.

e.Direct Supervision. Direct supervision means supervision of personnel by a licensed provider who is physically available on site.

f.Work Hardening Assessment. Work hardening assessment is defined as interdisciplinary evaluation(s), test(s), and procedure(s) required to identify and quantify the claimant's individual restoration needs related to physical, functional, behavioral, and vocational status. The initial interdisciplinary assessment is used to identify claimant's eligibility, design a plan of care, monitor process, plan for discharge and return to work.

g.Work Hardening Providers. Work hardening providers include the following professionals:

i. physical therapist;

ii. occupational therapist;

iii. psychologist;

iv. vocational specialist.

2. Program Comparison

Work Conditioning Program	Work Hardening Program
Addresses physical and functional needs which may be provided by one discipline (single discipline model).	Addresses physical, functional, behavioral vocational needs within an interdisciplinary model.
Requires work conditioning assessment.	Requires work hardening assessment.
Utilizes physical conditioning and functional activities related to work.	Utilizes real or simulated work activities.
Provided in multi-hour sessions up to: 2-4 hours/day, 5 days/week, up to 6 weeks (need additional approval after this length of stay)	Provided in multi-hour sessions up to: 4-8 hours/day, 5 days/week, up to 8 weeks

3. Work Conditioning Guidelines

a. Claimant Eligibility

i. To be eligible for work conditioning, a claimant must:

(a). have a job goal;

(b). have stated or demonstrated willingness to participate;

(c). have identified systemic neuro-musculo-skeletal physical and functional deficits that interfere with work;

(d). be at a point of resolution of the initial or principal injury that participation in the work conditioning program would not be prohibited.

ii. Work conditioning generally follows acute medical care or may begin when the claimant meets the eligibility criteria.

b. Provider Responsibility

i. The carrier/SIE should be notified prior to initiation of the program.

ii. The need for a program shall be established by a work conditioning provider based on the results of a work conditioning assessment.

iii. The program shall be provided by or under the direct supervision of a work conditioning provider.

iv. The work conditioning provider shall document all evaluations, services provided, claimant progress, and discharge plans. Information shall be available to the claimant, C/SIE, other providers, and any referral source.

v. The work conditioning provider shall develop and utilize an outcome assessment system designed to evaluate, at a minimum, patient care results, program effectiveness, and efficiency.

vi. The work conditioning providers should be appropriately familiar with job expectations, work environments, and skills required of the claimant through means such as site visitation, videotapes, and functional job descriptions.

c. Program Content:

i. development of program goals in relation to job skills and job requirements;

ii. techniques to improve strength, endurance, movement, flexibility, motor control and cardiopulmonary capacity related to the performance of work tasks;

iii. practice, modification, and instruction in work related activities;

iv. education related to safe job performance and injury prevention;

v. promotion of claimant responsibility and self management;

vi. work conditioning programs are provided in multi-hour sessions available up to five days a week for a duration of up to eight weeks.

d. Program Termination

i. The claimant shall be discharged from the work conditioning program when the goals for the claimant have been met.

ii. Work conditioning shall be discontinued when any of the following occur.

(a). The claimant has or develops behavioral or vocational problems which are not being addressed and which interfere with return to work.

(b). There are medical contraindications.

(c). The claimant fails to comply with the requirements of participation.

(d). The claimant's progress has reached a plateau prior to meeting goals.

(e). Services are discontinued by the referral source.

iii. When the claimant is discharged or discontinued for the work conditioning program, the work conditioning provider shall notify the C/SIE, and/or any referral source, and include the following information:

(a). reasons for program termination;

(b). clinical and functional status;

(c). recommendations regarding return to work;

(d). recommendations for follow-up services.

4. Work Hardening Guidelines

a. Client Eligibility

i. To be eligible for work hardening a claimant must:

(a). have a job goal for return to work at the time of discharge;

(b). have stated or demonstrated willingness to participate;

(c). have identified physical (systemic neuro-muscular-skeletal), functional, behavioral and vocational deficits that interfere with work;

(d). be at the point of resolution of the initial or principal injury that participation in the work hardening program would not be prohibited.

ii. Work hardening may begin only after the completion of the work hardening assessment.

b. Provider Responsibility

i. The C/SIE should be notified prior to initiation of the program.

ii. The need for a program shall be based on the results from a work hardening assessment performed by all of the work hardening providers.

iii. The program components shall be provided by or under the direct supervision of the appropriate work hardening providers.

iv. The treating work hardening providers shall meet on a regular basis to discuss, coordinate and document program progress and outcome achievement.

v. The work hardening providers shall document all evaluations, services provided, claimant progress, and discharge plans. Information shall be available to the claimant, C/SIE, other professional providers, and any referral source.

vi. The work hardening providers shall develop and utilize an outcome assessment system designed to assess, at a minimum, patient care results, program effectiveness, and efficiency.

vii. The work hardening providers should be familiar with job expectations, work environments, and skills required of the claimant through means as site visitation, videotape, functional job descriptions, interview of claimant, or interview of employer.

viii. There should be an area that is designed, arranged and equipped for the specific purpose of providing work hardening programs.

c. Program Content:

i. development of program goals in relationship to specific job requirement or specific functional goals;

ii. techniques to develop strength, endurance, movement, flexibility, motor control and cardiopulmonary capacity related to the performance of work tasks;

iii. practice, modification, and instruction in simulated or real work activities;

iv. education related to safe job performance and injury prevention;

v. provision of behavioral and vocational services as determined by the respective work hardening provider;

vi. promotion of claimant responsibility and self-management;

vii. provision in multi-hour sessions with a minimum of four hours and up to eight hours, five days a week, for duration up to eight weeks;

viii. assist the claimant to obtain as appropriate:

(a). alcohol and other drug dependency counseling;

(b). engineering and ergonomic services;

(c). medical services;

(d). nutritional and weight control services;

(e). orthotic and prosthetic services;

(f). smoking cessation counseling.

d. Program Termination

i. The claimant shall be discharged from the work hardening program when the goals for the claimant have been met.

ii. Work hardening shall be discontinued when any of the following occur.

(a). The claimant has or develops problems which cannot be addressed within the program.

(b). There are medical contraindications.

(c). The claimant demonstrates a lack of willingness to participate.

(d). The claimant fails to comply with the requirements of participation.

(e). The claimant's progress has reached a plateau prior to meeting goals.

(f). Services are discontinued by the referring source.

iii. When the claimant is discharged or discontinued from the work hardening program, the work hardening provider(s) shall notify the C/SIE and/or any referral source, and include the following information:

(a). reasons for program termination;

(b). clinical and functional status;

(c). recommendations regarding return to work;

(d). recommendations for follow-up services.

e. Work Hardening/Work Conditioning Checklist

Work Hardening/Work Conditioning Checklist
This checklist is intended only to be used as an outline. Please refer to billing instructions in reference to Work Hardening/Work Conditioning Guidelines for details.
Checklist for Bill
Work Hardening
___ 1.	No additional modality charge should be added to a work hardening charge
___ 2.	Services rendered by a licensed Physical Therapist or Occupational Therapist
___ 3.	Maximum length of stay for work hardening is eight weeks
___ 4.	Program should be daily after first week of evaluation
___ 5.	Claimant should not have frequent unexcused absences
___ 6.	Preauthorization obtained

Work Conditioning
___ 1.	No additional modality charge should be added to a work conditioning charge
___ 2.	Services rendered by a licensed Physical Therapist or Occupational Therapist
___ 3.	Maximum length of stay for work conditioning is six weeks
___ 4.	Program should be three to five weeks
___ 5.	Claimant should not have frequent unexcused absences
___ 6.	Preauthorization obtained

Checklist for Medical Records
Work Hardening
___ 1.	Thorough initial evaluation to include history, musculo-skeletal assessment, functional testing and job description or job evaluation
___ 2.	Treatment plan
___ 3.	Documentation of claimant staffings
___ 4.	Claimant's progress documented in progress notes
___ 5.	Discharge evaluation and discharge report
___ 6.	Documentation of claimant education
___ 7.	Documentation of work simulation tasks
___ 8.	Documentation of therapeutic exercise task
___ 9.	Documentation of aerobic conditioning tasks
___10.	Documentation of four to eight hour daily program

Work Conditioning
___ 1.	Thorough initial evaluation to include history, musculo-skeletal assessment, functional testing and job description or job evaluation
___ 2.	Treatment plan
___ 3.	Claimant's progress documented in progress notes
___ 4.	Discharge evaluations and discharge reports
___ 5.	Documentation of claimant education
___ 6.	Documentation of work simulation tasks
___ 7.	Documentation of therapeutic exercise tasks
___ 8.	Documentation of aerobic conditioning tasks
___ 9.	Documentation of two to four hour daily program

La. Admin. Code tit. 40, § I-5127

Promulgated by the Department of Labor, Office of Workers' Compensation, LR 19:54 (January 1993), repromulgated LR 19:212 (February 1993), amended LR 20:1299 (November 1994), amended by the Workforce Commission, Office of Workers' Compensation, LR 40:376 (February 2014).

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1034.2.