OAR 410-131-0120: Limitations of Coverage and Payment

(1) The provision of PT/OT evaluations and therapy services require a prescribing practitioner referral, and services shall be supported by a therapy plan of care signed and dated by the prescribing practitioner as specified in 42 CFR 440.110. (2) PT/OT initial evaluations and re-evaluations do not require PA and are not subject to prepayment review (PPR), but are limited to the following: (a) Up to two initial evaluations in any 12-month period; and (b) Up to four re-evaluation services in any 12-month period. (3) Reimbursement is limited to the initial evaluation when both the initial evaluation and a re-evaluation are provided on the same day. (4) School-sponsored therapy services are considered supplemental to other plan-covered therapy services that the student receives. School-based therapy services may not apply toward the client’s maximum therapy allowances. (See OAR chapter 410, division 133 SBHS rules.) (5) All other occupational and physical therapy treatments are subject to PPR and require PA following 30 visits in a calendar year. See OAR 410-131-0160. (6) A licensed occupational or physical therapist or a licensed occupational or physical therapy assistant under the supervision of a therapist shall be in constant attendance while therapy treatments are performed: (a) Rehabilitative and habilitative therapy treatments may not exceed one hour per day each for occupational and physical therapy; (b) Modalities: (A) Are subject to PPR and require PA following 30 habilitative and 30 rehabilitative visits in a calendar year; (B) Up to two modalities may be authorized on the day of treatment; (C) Need to be billed in conjunction with a therapeutic procedure code, excluding procedure code S8940; and (D) Each individual supervised modality code may be reported only once for each client encounter. (c) Massage therapy is limited to two units per day of treatment and shall be authorized only in conjunction with another therapeutic procedure or modality. (7) Supplies and materials for the fabrication of splints shall be billed at the acquisition cost, and reimbursement may not exceed the Division’s maximum allowable in accordance with the physician fee schedule. Acquisition cost is purchase price plus shipping. Off-the-shelf splints, even when modified, are not included in this service. (8) The following services are not covered under this rule: (a) Services not medically appropriate; (b) Services that are not paired with a funded diagnosis on the HERC‘s Prioritized List pursuant to OARs 410-141-3820 and 410-141-3830; (c) Work hardening; (d) Back school and back education classes; (e) Services included in OAR 410-120-1200 (Excluded Services Limitations); (f) Durable medical equipment and medical supplies other than the following splint supplies: (A) Application of splints: (i) 29105 Application of long arm splint (shoulder to hand); (ii) 29125 Application of non-moveable, short arm splint (forearm to hand); (iii) 29126 Application of moveable, hinged short arm splint (forearm to hand); (iv) 29130 Application of non-moveable, hinged finger splint; (v) 29131 Application of moveable, hinged finger splint. (B) Supplies to create splints: (i) Q4017 Cast supplies, long arm splint, adult (11 years +), plaster; (ii) Q4018 Cast supplies, long arm splint, adult (11 years +), fiberglass; (iii) Q4019 Cast supplies, long arm splint, pediatric (0-10 years), plaster; (iv) Q4020 Cast supplies, long arm splint, pediatric (0-10 years), fiberglass; (v)Q4021 Cast supplies, short arm splint, adult (11 years +), plaster; (vi) Q4022 Cast supplies, short arm splint, adult (11 years +), fiberglass; (vii) Q4023 Cast supplies, short arm splint, pediatric (0-10 years), plaster; (viii) Q4024 Cast supplies, short arm splint, pediatric (0-10 years), fiberglass; (ix) Q4049 Finger splint, static; (x) Q4051 Splint supplies, miscellaneous (includes thermoplastics, strapping, fasteners, padding and other supplies). (9) Physical capacity examinations are not a part of the PT/OT program but may be reimbursed as administrative examinations when ordered by the local branch office. See OAR chapter 410, division 150 for information on administrative examinations and report billing.