Rehabilitation Services

Eligible Providers

Audiologists
Comprehensive Outpatient Rehabilitation Facilities (CORFs)*
Indian Health Services (IHS)
Long-term care (LTC) facilities
Medicare-certified rehabilitation agencies
Occupational therapists
Occupational therapy assistants**
Outpatient hospitals
Physical therapists
Physical therapist assistants**
Rehab billing entities
Rural Health Clinics (RHCs)
Speech-language pathologists
Speech-language pathology assistants**

* A CORF is a nonresidential facility that is established and operated exclusively to provide diagnostic, therapeutic, and restorative services to outpatients for the rehabilitation of injured, disabled, or sick people. Services are provided at a single, fixed location, by or under the direction of a physician in a facility that meets Federal conditions of participation. In addition, a facility that qualifies as a CORF may enroll to provide mental health services.

** These practitioners do not directly enroll with Minnesota Health Care Programs (MHCP).

Plan of Care

Rehabilitative, therapeutic, and specialized maintenance therapy and audiology services must be provided under a written treatment plan that states with specificity the member’s condition, functional level, treatment objectives, and the physician’s order, plans for continuing care, modifications to the plan, and the plans for discharge from treatment.

The plan of care must be reviewed and revised as medically necessary by the member’s physician or other licensed practitioner of the healing arts within the practitioner’s scope of practice under State law at least once every 90 days. If the service is a Medicare-covered service and is provided to a member who is eligible for Medicare, the plan of care must be reviewed at the intervals required by Medicare.

The following must be documented in the member’s plan of care:

The medical diagnosis and any contraindications to treatment
A description of the member’s functional status/limitations
Treatment plan including interventions to be provided
Outcomes of the rehabilitative and therapeutic services, including treatment goals that are functional, measurable, and time-specific
Projected frequency and duration of treatment
Plans for discharge from treatment
A description of the member’s progress toward the outcomes for subsequent plan of care: Home program teaching, collaboration with other professionals and services, progress toward goals with updates as indicated, modification to the initial plan of care, plans for continuing care

Member’s Record of Services

Providers must document all evaluations, services provided, member progress, attendance records, and discharge plans. Documentation must be kept in member’s records. The record of services must contain the following:

The date, type, length, and scope of each rehabilitative and therapeutic service provided to the member
The name or names and titles of the people providing or supervising each rehabilitative and therapeutic service
A statement every 30 days by the therapist providing or supervising the services provided to a long-term care member that the therapy’s nature, scope, duration, and intensity are appropriate to the medical condition of the member in accordance with Minnesota Statutes (not required for an initial evaluation)

Therapy Students Providing Care

When appropriate supervision is provided, qualified therapists may bill and be paid for services provided by students of the following: physical therapists (PTs), physical therapist assistants, occupational therapists (OTs), occupational therapy assistants, and speech language pathologists (SLPs) if the service would have otherwise been eligible for payment if performed directly by the supervising therapist.

Qualified therapists must follow State licensure requirements for student supervision in addition to Minnesota Health Care Programs (MHCP) guidelines. They must use their professional judgement to determine whether a service is billable.

A student is defined as a person in a professional educational program (approved by the appropriate accrediting body) who is satisfying supervised clinical education requirements.

Supervision must be on-site. On-site supervision means the supervising therapist is immediately available in the same building or campus for student instruction. Telecommunication, except within the facility, does not meet the requirement of on-site supervision.

The supervising therapist is responsible for delegating specific duties to the student to establish competency and ensure patient safety. The supervising therapist determines the decision to delegate after establishing proficiency in functions performed by the student and is supported by sufficient academic and clinical preparation.

The supervising therapist is responsible for all functions performed by the student, including completing the documentation or co-signing the student’s documentation. In signing the documentation, the therapist indicates he/she has read it and is responsible for its contents. Documentation must clearly indicate the student provided the services under the therapist’s direction. The student may also sign the documentation, but it is not required for payment.

Rehabilitation Therapy Assistants

Physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) are not eligible to enroll with PrimeWest Health. However, PrimeWest Health reimburses providers for the supervised services provided by these assistants when delivered under the direction of a qualified enrolled therapist in the respective therapy discipline.

Speech-language pathology assistants (SLPAs) are not eligible to enroll with PrimeWest Health and their services are not eligible for reimbursement, even when supervised.

Physical Therapist Assistants (PTAs)

In order to qualify for reimbursement for supervised services provided, a PTA must meet the following requirements:

Have successfully completed all academic and field work requirements of a PTA program accredited by the Commission on Accreditation in Physical Therapy Education
Maintain state licensure requirements or be in compliance with state regulatory requirements in states that do not license PTAs

Supervision of a PTA

A qualified physical therapist must provide on-site observation of the treatment and must document appropriateness of the treatment at least every sixth session when services are provided by a PTA. A therapist may delegate patient treatment procedures only to a PTA who has sufficient didactic and clinical preparation. The physical therapist may not delegate the following activities to the PTA or to other supportive personnel: patient evaluation or reevaluation, treatment planning, initial treatment, change of treatment, and initial or final documentation. A licensed physical therapist may supervise no more than two PTAs at any time.

Occupational Therapy Assistants (OTAs)

In order to qualify for reimbursement for supervised services provided, an OTA must meet the following requirements:

Be certified by the National Board for Certification of Occupational Therapy as an OTA
Maintain applicable state licensure requirements or be in compliance with state regulatory requirements in states that do not license OTAs

Supervision of an OTA

A qualified occupational therapist must determine the frequency and manner of supervision of an OTA performing intervention procedures based on the condition of the patient or member, the complexity of the intervention procedure, and the service competency of the OTA.

Face-to-face collaboration between the occupational therapist and the OTA must occur every 10 intervention days or every 30 days, whichever comes first, during which time the occupational therapist is responsible for:

Planning and documenting an initial intervention plan and discharge from interventions
Reviewing intervention goals, therapy programs and member progress
Supervising changes in the intervention plan
Conducting or observing intervention procedures for selected members and documenting appropriateness of intervention procedures. Members must be selected based on the occupational therapy services provided to the member and the role of the occupational therapist and the OTA in those services
Ensuring the service competency of the occupational therapy assistant in performing delegated intervention procedures

Face-to-face collaboration must occur more frequently if necessary to meet these requirements.

PrimeWest Health will not reimburse for evaluations and reevaluations if provided by OTAs.

The occupational therapist must document supervision in the member’s file or chart.

Speech-Language Pathology Assistants (SLPAs)

A Speech-Language Pathology Assistant (SLPA) is a person who meets the requirements under MN Stat. secs. 148.511 – 148.5198 and is licensed by the Minnesota Department of Health (MDH). SLPAs must follow the requirements under MN Stat. sec. 148.5192 for allowed and prohibited duties.

Supervision of an SLPA

A supervising speech-language pathologist authorizes and accepts full responsibility for the performance, practice, and activity of an SLPA. A minimum of one hour every 30 days of consultative supervision time must be documented for each SLPA.

A supervising speech-language pathologist must meet the following criteria:
Be licensed under sections 148.511 to 148.5198 or 122A.184;
Hold a certificate of clinical competence from the American Speech-Language-Hearing Association or its equivalent as approved by the commissioner; and
Have completed at least 10 hours of continuing education in supervision
Provide direct supervision. Direct supervision means observation and guidance by the supervising speech-language pathologist during the performance of a delegated duty that occurs either on-site and in-view or through the use of real-time, two-way interactive audio and visual communication.
Be available to communicate with an SLPA at any time the assistant is in direct contact with a member.
Document activities performed by the assistant that are directly supervised by the supervising speech-language pathologist. At a minimum, the documentation must include the following:
- Information regarding the quality of the SLPA's performance of the delegated duties; and
- Verification that any delegated clinical activity was limited to duties authorized to be performed by the SLPA under this section
Review and cosign all informal treatment notes signed or initialed by the SLPA.

Once every 60 days, the supervising speech-language pathologist must treat or cotreat, with the SLPA, each member on the SLPA's caseload.

A full-time, speech-language pathologist may supervise no more than two full-time, SLPAs or the equivalent of two full-time assistants.

Note: Any agency or clinic that intends to utilize the services of a SLPA must provide written notification to the member or, if the member is under age 18, to the member's parent or guardian before a SLPA may perform any of the duties described in this section.

Covered Services

To be covered as a rehabilitative and therapeutic service:

Physical therapy and occupational therapy must be prescribed by a physician or other licensed practitioner of the healing arts within the practitioner’s scope of practice under state law.
Speech-language pathology and audiology services must be provided:
1. Upon written referral by a physician or other licensed practitioner of the healing arts within the practitioner’s scope of practice under state law, or in the case of a LTCF resident, on the written order of a physician; and
2. By an SLP, audiologist, or a person completing the clinical fellowship year required for certification as an SLP or audiologist under the supervision of an SLP or audiologist as specified in MN Stat. sec. 148.515, subd. 4.
Occupational therapy and physical therapy must require the skills of a PT, OT, or therapy assistant that is under the direction of a PT or an OT. The PT or OT must provide on-site observation of the treatment and documentation of its appropriateness at least every sixth treatment session when the therapy assistant provides services.
Treatment must be specified in a plan of care that is reviewed and revised as medically necessary by the member’s attending physician, or other licensed practitioner of the healing arts within the practitioner’s scope of practice under state law at least once every 90 days. The member’s functional status must be expected by the physician or other licensed practitioner of the healing arts within the practitioner’s scope of practice under state law to progress toward or achieve the objectives in the member’s plan of care within a 90-day period.

Members who are eligible for both PrimeWest Health and Medicare may not receive services from SLPs in private practice because these providers may not enroll as a provider with Medicare. Private practice SLPs must refer dually eligible members to Medicare-eligible providers.

Services provided by rehabilitation agencies must be provided at a site surveyed by MDH and certified according to Medicare standards, or at a site that meets State Fire Marshall standards, as documented in the providers’ records, or at the member’s residence. However, if services are provided to Medicare-eligible members, providers must comply with Medicare’s site requirements.

Eligible Ordering and Referring Providers

PrimeWest Health recognizes only the following MHCP-enrolled providers as valid ordering or referring providers for outpatient OT, PT, or SLP services:

Physicians
Dentists
Podiatrists
Physician assistants
Specific advanced practice nurses:
1. Nurse practitioner
2. Clinical nurse specialist
3. Certified nurse midwife
Optometrists (only allowed to refer for PT and OT services for low-vision rehabilitation)

Speech language pathologist assistants are not eligible for MHCP or PrimeWest Health enrollment or payment.

Specialized Maintenance Therapy

Specialized maintenance therapy coverage is limited to PrimeWest Health members ages 20 and under. Specialized maintenance therapy is covered only when it is provided by a PT, OT, therapy assistant, or SLP, specified in a plan of care that meets the requirements of this chapter, and provided to members whose condition cannot be maintained or treated only through rehabilitative nursing services, as defined in MN Rules part 4658.0525, or services of other care providers, or by the member because the member’s physical, cognitive or psychological deficits result in:

Spasticity or severe contracture that interferes with the activities of daily living (ADL) or the completion of routine nursing care, or decreased functional ability compared to the member’s previous level of function; or
A chronic condition that results in physiological deterioration and that requires specialized maintenance therapy services or equipment to maintain strength, range of motion, endurance movement patterns, ADLs, cardiovascular function, integumentary status, or positioning necessary for completion of the member’s ADLs, or decreased abilities relevant to the member’s current environmental demands.

Specialized maintenance therapy must have expected outcomes that are:

Functional
Realistic
Relevant
Transferable to the member’s current or anticipated environment, such as home, school, community, work
Consistent with community standards

Specialized maintenance therapy must meet at least one of the following characteristics:

Prevent deterioration and sustain function;
Provide interventions, in the case of a chronic or progressive disability, that enable the member to live at his/her highest level of independence; or
Provide treatment interventions for members who are progressing but not at a rate comparable to the expectations of restorative care.