OAR 410-131-0040: Physical and Occupational Therapy

(1) The Division's Physical and Occupational Therapy (PT/OT) Services rules are designed to assist licensed physical and occupational therapists deliver health care services and prepare health claims for clients with medical assistance program coverage. 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 30 visits per year of rehabilitative therapy and a total of 30 visits per year of habilitative therapy (physical and occupational therapy) are included on these lines when medically appropriate. Additional visits, not to exceed 30 visits per year of rehabilitative therapy and 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 appropriate, as per guideline note 6 of the Prioritized List of Health Services. (3) OAR 410-131-0040 through 0160: (a) Apply to services delivered by home health agencies and by hospital-based therapists in the outpatient setting. Billing and reimbursement for therapy services delivered by home health agencies and hospital outpatient departments must comply with the rules in their respective provider guides; (b) Do not apply to services provided to hospital inpatients; and (c) May not limit or effect 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 410-141-3830 (Managed Care Entity (MCE) Billing and Payment). (4) The Division shall enroll only the following types of providers as performing providers under the PT/OT program: (a) An individual licensed by the relevant state licensing authority to practice physical therapy; and (b) An individual licensed by the relevant state licensing authority to practice occupational therapy. (5) All Division rules are intended to be used in addition to the General Rules for Health Systems Division programs (OAR 410 division 120) and the Oregon Health Plan (OHP) (OAR 410 division 141). (6) The Oregon Health Evidence Review Commission’s (HERC) Prioritized List of Health Services is found in OAR 410-141-0520 and defines the covered services.