Or. Admin. Code § 410-129-0020

Current through Register Vol. 63, No. 12, December 1, 2024

Section 410-129-0020 - Therapy Plan of Care, Goals, Outcomes, and Record Requirements

(1) Therapy shall be based on a prescribing practitioner's written order and therapy treatment plan with goals and objectives developed from an evaluation or re-evaluation. The limits, authorization, and plan of treatment criteria apply to both rehabilitative and habilitative therapy. The definition for both is the following:

(a) "Rehabilitative Services" means health care services that help an individual re-establish, restore, or improve skills and functioning for daily living that have been lost or impaired due to illness, injury, or disability;

(b) "Habilitative Services" means health care services that help an individual keep, learn, or improve skills and functioning for daily living, designed to establish skills that have not yet been acquired at an age-appropriate level. Examples include therapy for a child who is not walking or talking at the expected age.

(2) A total of thirty (30) visits per year of rehabilitative therapy and a total of thirty (30) visits per year of habilitative therapy (speech therapy) are included when medically appropriate. Additional visits, not to exceed thirty (30) visits per year of rehabilitative therapy and thirty (30) visits per year of habilitative therapy, may be authorized in cases of a new acute injury, surgery, or other significant change in functional status. Children under age 21 may have additional visits authorized beyond these limits if medically necessary and medically appropriate, pursuant to 42 CFR § 441 Subpart B.

(3) The therapist shall teach the therapy regimen to individuals, including the client, family members, foster parents, and caregivers who can assist in the achievement of the goals and objectives. The client must be present when the therapy is appropriately demonstrated at the time of teaching to assure that the therapy regimen is performed safely and correctly. The Division may not authorize extra treatments for teaching.

(4) All Speech-Language Pathology (SLP) treatment services require a therapy plan of care that is required for claims subject to prepayment review (PPR) or requiring Prior Authorization (PA) for payment.

(5) The Division shall provide authorization for the level of care or type of service that meets the client's medical need consistent with the Health Evidence Review Commission's (HERC) Prioritized List of Health Services (Prioritized List) and the American Hippotherapy Association's (AHA) position on coding and billing for equine related modalities.

(6) These rules do not limit or affect any obligations of a school district or education entity eligible for reimbursement for covered, health-related services provided in support of a child with a disability education program required by state and federal law. School-sponsored services are supplemental to other health plan therapy services and are not considered duplicative. See OAR chapter 410, division 133 SBHS rules for services provided by public education providers and OAR 410-141-3565 (Managed Care Entity (MCE) Billing).

(7) The SLP therapy plan must adhere to the licensing board requirements of care and shall include:

(a) Client's name and ICD diagnosis code;

(b) The type, amount, frequency, and duration of the proposed rehabilitative or habilitative therapy;

(c) Individualized, measurably objective, short-term and long-term functional goals;

(d) Dated signature of the therapist or the prescribing practitioner establishing the therapy plan of care; and

(e) Evidence of certification of the therapy plan of care by the prescribing practitioner.

(8) SLP therapy records must be compliant with applicable record and documentation requirements (see Oregon Administrative Rules in chapter 335, division 010).

(9) Documentation of clinical activities may be supplemented using flowsheets or checklists; however, these may not substitute for or replace detailed documentation of assessments and interventions.

Or. Admin. Code § 410-129-0020

HR 5-1991, f. 1-18-91, cert. ef. 2-1-91; HR 27-1993, f. & cert. ef. 10-1-93; HR 36-1994, f. 12-30-94, cert. ef. 1-1-95; OMAP 36-1999, f. & cert. ef. 10-1-99; DMAP 22-2014, f. & cert. ef. 4-2-14; DMAP 49-2016, f. 7-26-16, cert. ef. 8/1/2016; DMAP 19-2017, f. & cert. ef. 6/9/2017; DMAP 56-2017, amend filed 12/26/2017, effective 1/1/2018; DMAP 100-2018, amend filed 11/06/2018, effective 11/06/2018; DMAP 102-2018, amend filed 12/13/2018, effective 12/13/2018; DMAP 18-2019, temporary amend filed 06/18/2019, effective 7/1/2019 through 12/27/2019; DMAP 44-2019, amend filed 11/06/2019, effective 11/14/2019; DMAP 93-2023, amend filed 12/21/2023, effective 1/1/2024

Statutory/Other Authority: ORS 413.042

Statutes/Other Implemented: ORS 414.025 & ORS 414.065