Section 16.03.09.732 - THERAPY SERVICES: COVERAGE AND LIMITATIONSTherapy services are covered under these rules when delivered by a therapy professional and provided by one (1) of the following providers: outpatient hospitals, outpatient rehabilitation facilities, comprehensive outpatient rehabilitative facilities, nursing facilities, school-based services, independent practitioners, and home health agencies. Therapy services provided by a home health agency under a home health plan of care must meet the requirements under Sections 730 through 739 of these rules, and the requirements under Sections 720 through 729 of these rules.
01.Service Description: Occupational Therapy and Physical Therapy. Modalities, therapeutic procedures, tests, and measurements as described in the Idaho Medicaid Provider Handbook are covered with the following limitations: a. Any evaluation or re-evaluation may only be performed by the therapist. Any changes in the participant's condition not consistent with planned progress or treatment goals necessitate a documented re-evaluation by the therapist before further treatment is carried out.b. Any CPT procedure code that falls under the heading of either, "Active Wound Care Management," or "Tests and Measurements," requires the therapist to have direct, one-to-one (1:1) patient contact.c. The therapist may be reimbursed for the technical component of muscle testing, joint range of motion, electromyography, or nerve velocity determinations as described in the CPT Manual when ordered by a physician, nurse practitioner, or PA.d. Any assessment provided under the heading "Orthotic Management and Prosthetic Management" must be completed by the therapist.e. The services of occupational or physical therapy assistants used when providing covered therapy benefits are included as part of the covered service. These services are billed by the supervising therapist. Therapy assistants may not provide evaluation services, or take responsibility for the service. The therapist has full responsibility for the service provided.02.Service Description: Speech-Language Pathology. Speech-language pathology services must be provided as defined in Section 730 of these rules. Services provided by speech-language pathology aides and assistants are considered unskilled services, and will be denied as not medically necessary if they are billed as speech-language pathology services.03.Non-Covered Services: Occupational Therapy, Physical Therapy, and Speech-Language Pathology. a. Continuing services for participants who do not exhibit the capability to achieve measurable improvement and who do not meet the criteria for a maintenance program.b. Services that address developmentally acceptable error patterns.c. Services that do not require the skills of a therapy professional.d. Massage, work hardening, and conditioning.e. Services not medically necessary, under Section 011 of these rules.f. Duplicate services, under Section 730 of these rules.g. Acupuncture (with or without electrical stimulation).h. Biofeedback, unless provided to treat urinary incontinence.i. Services that are experimental or investigational.04.Service Limitations. a. Physical therapy (PT) and speech-language pathology (SLP) services are limited to a combined annual dollar amount for all PT and SLP services. The Department will set the total amount based on the annual Medicare caps. The Department may allow additional therapy services, when the services are determined to be medically necessary and supporting documentation is provided upon request of the Department.b. Occupational therapy services are limited to an annual dollar amount set by the Department based on the annual Medicare caps. The Department may allow additional therapy services, when the services are determined to be medically necessary and supporting documentation is provided upon request of the Department.c. Exceptions to service limitations. i. Therapy provided by home health agencies is subject to the limitations on home health services under Section 722 of these rules.ii. Therapy provided through school-based services or the Idaho Infant Toddler Program is not included in the service limitations under Subsection 732.04 of this rule.iii. Therapy provided to EPSDT participants under the age of twenty-one (21) under the EPSDT requirements in Sections 881 through 883 of these rules, and Section 1905(r) of the Social Security Act, will be authorized by the Department when additional therapy services are medically necessary.d. Feeding therapy services are covered for children with a diagnosed feeding disorder that results in a clinically significant deviation from normal childhood development. The provider of feeding therapy is an occupational therapist or speech therapist with training specific to feeding therapy.e. Maintenance therapy is covered when an individualized assessment of the participant's condition demonstrates that skilled care is required to carry out a safe and effective maintenance program.f. Virtual care modalities are covered to the extent they are allowed under the rules of the applicable board of licensing. The Department will define limitations on virtual care in the provider handbook to promote quality services and program integrity.Idaho Admin. Code r. 16.03.09.732