Wiki PT, OT, Speech and Pediatric Therapy

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dshull81401

dshull81401

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Montrose, CO
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Needing help, I work at a hospital that has inpatient and outpatient therapy and I have been Coding the outpatient PT, OT SPEECH and Pediatric Therapy for over 9 years. and over the last couple of weeks, I am getting push back that the Therapist now so not think they need an order, and if they do have an order that they do not necessarily have to see the patient for what the DX is on the order, that they can diagnose the patient them self's and I was told I am not qualified to ask for clarification. I have looked everywhere I can think for guild lines on Therapy documentation and querying the therapists. Thank You for any help.
 
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It's the state practice act and scope of practice. Internal policy of a facility can also dictate this. In addition, some payers may have regulations regarding requiring a "written order" or referral from the referring provider. WC probably won't allow it without auth for example.
However, most states (if not all) now have direct access. The therapists can most certainly see a patient for an Initial Evaluation without an order, but the payer may not want to pay for it. Depends.

This is a question for your supervisor, manager, or internal compliance department. As a staff coder, you should not be determining or making a decision on this (my opinion). You are questioning their clinical practice and scope of practice. This is what they do on the initial eval or re-eval. If it is outside of their scope, they would refer the patient to an appropriate provider. For example, I can make an appointment independently, walk into my local outpatient PT for my eval and they can either create my plan of care and set up my treatment, or refer me to another provider. Maybe I need an MRI, CT, X-Ray, etc. There are practices that do not accept patients without a referral or order from their PCP or MD, DO, PA, NP, etc. but that is an internal policy or maybe they are heavy WC or Medicare. An HMO may require a patient to have a referral/order.

Here is an example UHC policy (not CO though): https://www.uhcprovider.com/content...p/rehabilitation-services-pt-ot-st-common.pdf
"Services must relate directly and specifically to a written treatment plan established by a physician after consulting with the qualified therapist (Physical and/or Occupational) and/or speech pathologist or audiologist.

You can also check CMS/Medicare regulations.
 
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amyjph said:
It's the state practice act and scope of practice. Internal policy of a facility can also dictate this. In addition, some payers may have regulations regarding requiring a "written order" or referral from the referring provider. WC probably won't allow it without auth for example.
However, most states (if not all) now have direct access. The therapists can most certainly see a patient for an Initial Evaluation without an order, but the payer may not want to pay for it. Depends.

This is a question for your supervisor, manager, or internal compliance department. As a staff coder, you should not be determining or making a decision on this (my opinion). You are questioning their clinical practice and scope of practice. This is what they do on the initial eval or re-eval. If it is outside of their scope, they would refer the patient to an appropriate provider. For example, I can make an appointment independently, walk into my local outpatient PT for my eval and they can either create my plan of care and set up my treatment, or refer me to another provider. Maybe I need an MRI, CT, X-Ray, etc. There are practices that do not accept patients without a referral or order from their PCP or MD, DO, PA, NP, etc. but that is an internal policy or maybe they are heavy WC or Medicare. An HMO may require a patient to have a referral/order.

Here is an example UHC policy (not CO though): https://www.uhcprovider.com/content...p/rehabilitation-services-pt-ot-st-common.pdf
"Services must relate directly and specifically to a written treatment plan established by a physician after consulting with the qualified therapist (Physical and/or Occupational) and/or speech pathologist or audiologist.

You can also check CMS/Medicare regulations.
Click to expand...
Thank You, My Director is new and asked me to get the information myself and then present it to her. as far as making any decisions on my own that does not happen. We are just trying to find guidelines as to how and why things have suddenly changed. but again, Thank you for help and information.
 
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dshull81401 said:
Thank You, My Director is new and asked me to get the information myself and then present it to her. as far as making any decisions on my own that does not happen. We are just trying to find guidelines as to how and why things have suddenly changed. but again, Thank you for help and information.
Click to expand...
YW. If you are part of a larger facility the compliance department/legal should be weighing in on this. Probably the RCM manager and or director too (anyone at the C level) because, while they may be able to see patients for direct access, getting payment could be impacted depending on the payer. In all the large outpatient PT clinics I have worked, an order or referral was made mandatory because of this problem. (That's just my experience).

If you are seeing peds patients for example, and they have CO MCD (HCPF), look at the provider manual. They have to have an order/referral.

Some snips from the manual:

Documentation Requirements​

Rendering providers must document all evaluations, re-evaluations, services provided, member progress, attendance records and discharge plans. All documentation must be kept in the member's records along with a copy of the referral or prescribing provider's order. Documentation must support both the medical necessity of services and the need for the level of skill provided. Rendering providers must copy the member's primary care provider (PCP), prescribing provider and/or medical home on all relevant records.

Initial Evaluation​

Written documentation of the initial evaluation must include the following:
  1. Referral Information: Reason for referral and referral source.

Covered Services​

Physical and Occupational Therapy services are covered if they are medically necessary as defined in 10 CCR 2505-10 Section 8.076.1.8 and meet the following criteria:

  1. Treatment services must be ordered by an eligible prescribing provider (Physician, Physician Assistant, or Advanced Practice Nurse) and be started within 28 days of the date ordered.
 
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