N.J. Admin. Code § 10:66-2.13

Current through Register Vol. 56, No. 11, June 3, 2024

Section 10:66-2.13 - Rehabilitative services

(a) Rehabilitative services, as provided in an independent clinic setting, include physical therapy, occupational therapy, speech-language pathology and audiology, including the use of such supplies and equipment as are necessary in the provision of such services. Rehabilitative services are provided for the purpose of attaining maximum reduction of physical or mental disability. Rehabilitative services shall be made available to Medicaid and NJ FamilyCare fee-for-service beneficiaries as an integral part of a comprehensive medical program.

(b) Rehabilitative services shall be provided by or under the direction of a physical therapist, occupational therapist, speech-language pathologist or audiologist employed by or under contract to the clinic. These therapy services are discussed at (c), (d) and (e) below, respectively.

1. All treatments shall be individual and shall consist of a minimum of 30 minutes.

2. A plan of treatment shall be completed during the Medicaid or NJ FamilyCare fee-for-service beneficiary's initial evaluation visit and retained on file.

i. The plan of treatment shall be definitive as to the type, amount, frequency, and duration of the rehabilitative services that are to be furnished and shall include the beneficiary's diagnosis and the anticipated goal(s) of the treatment.

(c) Physical therapy is a service prescribed by a physician or an advanced practice nurse and provided to a Medicaid or NJ FamilyCare fee-for-service beneficiary by or under the direction of a qualified physical therapist. Physical therapy does not include therapy which is purely palliative, such as the application of heat in any form; massage; routine calisthenics; group exercises; assistance in any activity; use of a simple mechanical device; or other services not requiring the special skill of a licensed physical therapist.

1. A physical therapist is an individual who is:

i. Licensed by the New Jersey Department of Law and Public Safety, State Board of Physical Therapy as a physical therapist in accordance with N.J.A.C. 13:39A; and

ii. A graduate of a program of physical therapy accredited by an accrediting agency recognized by the Council on Post-Secondary Accreditation and the United States Department of Education.

2. If treatment or services are provided in a state other than New Jersey, the physical therapist shall meet the requirements of that state, including licensure if applicable, and all applicable Federal requirements.

(d) Occupational therapy is a service prescribed by a physician or an advanced practice nurse and provided to a Medicaid or NJ FamilyCare fee-for-service beneficiary by or under the direction of a qualified occupational therapist.

1. An occupational therapist is an individual who is:

i. Licensed by the New Jersey Occupational Therapy Advisory Council as an occupational therapist in accordance with 13:44K-2.1(a); and

ii. A graduate of a program in occupational therapy accredited by the American Occupational Therapy Association, the World Federation of Occupational Therapy or other nationally-recognized occupational therapist accrediting agency.

2. If treatment or services are provided in a state other than New Jersey, the occupational therapist shall meet the requirements of that state, including licensure if applicable, and all applicable Federal requirements.

(e) Speech-language pathology services and audiology services are diagnostic, screening, preventive, or corrective services prescribed by a physician or an advanced practice nurse and provided to a Medicaid or NJ FamilyCare fee-for-service beneficiary by or under the direction of a speech-language pathologist or audiologist.

1. A speech-language pathologist or audiologist is an individual who is licensed by the State of New Jersey as a speech-language pathologist or audiologist, in accordance with N.J.A.C. 13:44C, and meets all applicable Federal requirements including:

i. A Certificate of Clinical Competence in Speech-Language Pathology or Audiology from the American Speech-Language-Hearing Association;

ii. Completion of the equivalent educational requirements and work experience necessary for the certificate(s); or

iii. Completion of the academic program and in the process of acquiring supervised work experience in order to qualify for the certificate(s).

2. If treatment or services are provided in a state other than New Jersey, the speech-language pathologist or audiologist shall meet the requirements of that state, including licensure if applicable, and all applicable Federal requirements.

(f) Clinic visits billed during the same day shall clearly and separately meet the time and other parameters described in the applicable HCPCS procedure codes, N.J.A.C. 10:66-6.

(g) When the same type of rehabilitative service, regardless of modality, is provided to a Medicaid or NJ FamilyCare fee-for-service beneficiary more than once on the same day, for example, two physical therapy sessions, reimbursement shall be made for one service only. Reimbursement shall be made for a maximum of three units (one unit equals a 30-minute therapy session) per beneficiary per day.

(h) When requesting reimbursement for the following HCPCS procedure codes for rehabilitative services, a separate service line shall be completed for each day that the service is provided. Providers shall not "span bill" for services.

92507

97535

97799

N.J. Admin. Code § 10:66-2.13

Recodified from N.J.A.C. 10:66-2.6 and amended by R.1998 d.577, effective 12/7/1998.
See: 30 N.J.R. 3434(a), 30 N.J.R. 4225(b).
Inserted references to NJ KidCare fee-for-service and substituted references to beneficiaries for references to recipients throughout.
Amended by R.2003 d.69, effective 2/3/2003.
See: 34 N.J.R. 3183(a), 35 N.J.R. 888(a).
Substituted "NJ FamilyCare" for "NJ KidCare" throughout; added (i).
Amended by R.2004 d.208, effective 6/7/2004.
See: 36 N.J.R. 324(a), 36 N.J.R. 2834(a).
Rewrote the section.
Amended by R.2009 d.376, effective 12/21/2009.
See: 41 N.J.R. 2561(a), 41 N.J.R. 4791(a).
In (h), inserted HCPCS procedure code "97535" and deleted HCPCS procedure code "H5300" following code "97799".