Original Notice.

Preproposal statement of inquiry was filed as WSR 99-11-084.

Title of Rule: Repealing WAC 388-86-090 Physical therapy and 388-87-090 Payment--Physical therapy and related services; and new section WAC 388-545-500 Physical therapy.

Purpose: The department is establishing new chapter 388-545 WAC to combine all medical therapy rules. Therefore, WAC 388-86-090 Physical therapy and 388-87-090 Payment--Physical therapy and related services, are being repealed and WAC 388-545-500 Physical therapy is being established. The new chapter reorganizes rule sections and updates the language to comply with the Governor's Executive Order 97-02.

Statutory Authority for Adoption: RCW 74.08.090 and 74.09.520.

Statute Being Implemented: RCW 74.08.090 and 74.09.520.

Summary: The department is establishing new chapter 388-545 WAC to combine all medical therapy rules. Therefore, WAC 388-86-090 Physical therapy and 388-87-090 Payment--Physical therapy and related services, are being repealed and WAC 388-545-500 Physical therapy is being established. The new chapter reorganizes rule sections and updates the language to comply with the Governor's Executive Order 97-02.

Reasons Supporting Proposal: To comply with the Governor's Executive Order 97-02. To combine all medical therapies into one chapter.

Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Patty Balestra, DOSS, 623 8th Avenue S.E., Olympia, WA 98501, (360) 586-3745.

Name of Proponent: Department of Social and Health Services, Medical Assistance Administration, governmental.

Rule is not necessitated by federal law, federal or state court decision.

Explanation of Rule, its Purpose, and Anticipated Effects: New chapter 388-545 WAC is being established to combine all medical therapies into one chapter, necessitating the repeal of WAC 388-86-090 and 388-87-090. The new rule reorganizes sections and uses clear writing standards to clarify program requirements.

Proposal Changes the Following Existing Rules: The proposed rule combines physical therapy rules with other therapies (occupational therapy and speech/audiology services) into one new chapter, and repeals duplicative chapter sections.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has analyzed the proposed rule amendments and concludes that no new costs will be imposed on the small businesses that are affected by them.

RCW 34.05.328 does not apply to this rule adoption. The rule does not fit the definition of a significant legislative rule.

Hearing Location: Lacey Government Center (behind Tokyo Bento Restaurant), 1009 College Street S.E., Room 104-B, Lacey, WA 98503, on November 9, 1999, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Paige Wall by October 26, 1999, phone (360) 664-6094, TTY (360) 664-6178, e-mail wallpg@dshs.wa.gov.

Submit Written Comments to: Identify WAC Numbers, Paige Wall, Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, by November 9, 1999.

Date of Intended Adoption: November 10, 1999.

September 30, 1999

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

(1) The following providers are eligible to enroll with the medical assistance administration (MAA) to provide physical therapy services:

(a) A licensed physical therapist or physiatrist;

(b) A physical therapy assistant supervised by a licensed physical therapist; or

(c) A physical therapy aide, in schools, trained and supervised by a licensed physical therapist.

(2) Clients in the following MAA programs are eligible to receive physical therapy services described in this chapter:

(a) Categorically needy (CN);

(b) Children's health;

(c) General assistance-unemployable (GA-U) (within Washington state or border areas only);

(d) Alcoholism and drug addiction treatment and support act (ADATSA) (within Washington state or border areas only);

(e) Medically indigent program (MIP) for emergency hospital-based services only; or

(f) Medically needy program (MNP) only when the client is either:

(i) Twenty years of age or younger and referred under the early and periodic screening, diagnosis and treatment program (EPSDT/healthy kids program) as described in WAC 388-86-027; or

(ii) Receiving home health care services as described in chapter 388-551 WAC.

(3) Physical therapy services that MAA eligible clients receive must be provided as part of an outpatient treatment program:

(a) In an office, home, or outpatient hospital setting;

(b) By a home health agency as described in chapter 388-551 WAC;

(c) As part of the acute physical medicine and rehabilitation (acute PM&R) program as described in the acute PM&R subchapter under chapter 388-550 WAC;

(d) By a neurodevelopmental center; or

(e) By a school district or educational service district as part of an individual education or individualized family service plan as described in WAC 388-86-022.

(4) MAA pays only for covered physical therapy services listed in this section when they are:

(a) Within the scope of an eligible client's medical care program;

(b) Medically necessary and prescribed by a physician, physician's assistant (PA), or an advanced registered nurse practitioner (ARNP);

(c) Begun within thirty days of the date prescribed;

(d) For conditions which are the result of injuries and/or medically recognized diseases and defects; and

(e) Within accepted medical physical therapy standards.

(5) Physical therapy for clients age twenty-one and older when prescribed by a physician, PA, or an ARNP must:

(i) Prevent the need for hospitalization or nursing home care;

(ii) Assist a client in becoming employable;

(iii) Assist a client who suffers from severe motor disabilities to obtain a greater degree of self-care or independence; or

(iv) Be a part of a treatment program intended to restore normal function of a body part following injury, surgery, or prolonged immobilization.

(6) MAA determines physical therapy program units as follows:

(a) Each fifteen minutes of timed procedure code equals one unit; and

(b) Each nontimed procedure code equals one unit, regardless of how long the procedure takes.

(7) MAA does not limit coverage for physical therapy services listed in subsections (8) through (10) of this section if the client is twenty years of age or younger.

(8) MAA covers, without requiring prior authorization, the following prescribed physical therapy services per client, per diagnosis, per calendar year, for clients twenty-one years of age and older:

(a) One physical therapy evaluation. The evaluation is in addition to the forty-eight program units allowed per year;

(b) Forty-eight physical therapy program units;

(c) Ninety-six additional outpatient physical therapy program units when the diagnosis is any of the following:

(i) A medically necessary condition for developmentally delayed clients;

(ii) Surgeries involving extremities, including:

(A) Fractures; or

(B) Open wounds with tendon involvement.

(iii) Intracranial injuries;

(iv) Burns;

(v) Traumatic injuries;

(vi) Meningomyelocele;

(vii) Down's syndrome;

(viii) Cerebral palsy; or

(ix) Symptoms involving nervous and musculoskeletal systems and lack of coordination;

(d) Two durable medical equipment (DME) needs assessments. The assessments are in addition to the forty-eight physical therapy program units allowed per year. Two program units are allowed per DME needs assessment; and

(e) One wheelchair needs assessment in addition to the two durable medical needs assessments. The assessment is in addition to the forty-eight physical therapy program units allowed per year. Four program units are allowed per wheelchair needs assessment.

(f) The following services are allowed, per day, in addition to the forty-eight physical therapy program units allowed per year:

(i) Two program units for orthotics fitting and training of upper and/or lower extremities.

(ii) Two program units for checkout for orthotic/prosthetic use.

(iii) One muscle testing procedure. Muscle testing procedures cannot be billed in combination with each other.

(g) Ninety-six additional physical therapy program units are allowed following a completed and approved inpatient acute PM&R program. In this case, the client no longer needs nursing services but continues to require specialized outpatient physical therapy for any of the following:

(i) Traumatic brain injury (TBI);

(ii) Spinal cord injury (paraplegia and quadriplegia);

(iii) Recent or recurrent stroke;

(iv) Restoration of the levels of functions due to secondary illness or loss from multiple sclerosis (MS);

(v) Amyotrophic lateral sclerosis (ALS);

(vi) Cerebral palsy (CP);

(vii) Extensive severe burns;

(viii) Skin flaps for sacral decubitus for quadriplegics only;

(ix) Bilateral limb loss;

(x) Open wound of lower limb; or

(xi) Acute, infective polyneuritis (Guillain-Barre'syndrome).

(9) Additional medically necessary physical therapy services, regardless of the diagnosis, require prior authorization for clients twenty-one years of age and older.

(10) MAA will pay for one visit to instruct in the application of transcutaneous neurostimulator (TENS) per client, per lifetime.

(11) Duplicate services for occupational therapy and physical therapy are not allowed for the same client when both providers are performing the same or similar procedure(s).

(12) MAA does not cover physical therapy services that are included as part of the reimbursement for other treatment programs. This includes, but is not limited to, hospital inpatient and nursing facility services.

(13) MAA does not cover physical therapy services performed by a physical therapist in an outpatient hospital setting when the physical therapist is not employed by the hospital. Reimbursement for services must be billed by the hospital.

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     The following sections of the Washington Administrative Code are repealed:

WAC 388-86-090	Physical therapy.
WAC 388-87-090	Payment--Physical therapy and related services.

© Washington State Code Reviser's Office