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D.C. Municipal Regulations (Last Updated: September 13, 2017) |
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Title 29. PUBLIC WELFARE |
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Chapter 29-19. HOME AND COMMUNITY-BASED SERVICES WAIVER FOR INDIVIDUALS WITH INTELLECTUAL AND DEVELOPMENTAL DISABILITIES |
Section 29-1926. OCCUPATIONAL THERAPY SERVICES
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1926.1 This section shall establish conditions of participation for Medicaid providers enumerated in § 1926.9 (Medicaid Providers) and occupational therapy professionals enumerated in § 1926.8 (professionals) to provide occupational therapy services to persons enrolled in the Home and Community-Based Services Waiver for Individuals with Intellectual and Developmental Disabilities (ID/DD Waiver).
1926.2 Occupational therapy services are services that are designed to maximize independence, prevent further disability, and maintain health.
1926.3In order to be eligible for reimbursement, each Medicaid provider must obtain prior authorization from the Department on Disability Services (DDS) before providing, or allowing any professional to provide, occupational therapy services. In its request for prior authorization, the Medicaid provider shall document the following:
(a) The person’s need for occupational therapy services as demonstrated by a physician’s order; and
(b) The name of the professional who will provide the occupational therapy services.
1926.4In order to be eligible for Medicaid reimbursement, each occupational therapy professional shall conduct a comprehensive assessment of occupational therapy needs within the first four (4) hours of service delivery, and develop a therapy plan to provide services.
1926.5In order to be eligible for Medicaid reimbursement, the therapy plan shall include therapeutic techniques, training goals for the person’s caregiver, and a schedule for ongoing services. The therapy plan shall include:
(a) The anticipated and measurable functional outcomes, based upon what is important to and for the person as reflected in his or her Person-Centered Thinking tools and the goals in his or her ISP;
(b) A schedule of approved occupational therapy services to be provided; and
(c) Shall be submitted by the Medicaid provider to DDS before services are delivered.
1926.6In order to be eligible for Medicaid reimbursement, each Medicaid provider shall document the following in the person’s Individual Support Plan (ISP) and Plan of Care:
(a) The date, amount, and duration of occupational therapy services provided;
(b) The scope of the occupational therapy services provided; and
(c) The name of the professional who provided the occupational therapy services.
1926.7Medicaid reimbursable occupational therapy services shall consist of the following activities:
(a) Consulting with the person, their family, caregivers and support team to develop the therapy plan;
(b) Implementing therapies described under the therapy plan;
(c) Recording progress notes and quarterly reports during each visit. Progress notes shall contain the following:
(1) Progress in meeting each goal in the ISP;
(2) Any unusual health or behavioral events or changes in status;
(3) The start and end time of any services received by the person; and
(4) Any matter requiring follow-up on the part of the service provider or DDS;
(d) Routinely assessing (at least annually and more frequently as needed) the appropriateness, quality and functioning of adaptive equipment to ensure it addresses the person’s needs;
(e) Completing documentation required to obtain or repair adaptive equipment in accordance with insurance guidelines and Medicare and Medicaid guidelines, including required timelines for submission;
(f) Participating in ISP and Support Team meetings to provide consultative services and recommendations specific to the expert content with a focus on how the person is doing in achieving the functional goals that are important to him or her; and
(g) Conducting periodic examinations and modified treatments for the person, as needed.
1926.8Medicaid reimbursable occupational therapy services shall be provided by a licensed occupational therapist.
1926.9 Occupational therapy service providers, without regard to their employer of record, shall be selected by and be acceptable to the person receiving services, their guardian, or legal representative.
1926.10In order to be eligible for Medicaid reimbursement, an occupational therapist shall be employed by the following providers:
(a) An ID/DD Waiver provider enrolled by DDS; and
(b) A Home Health Agency as defined in Section 1999 of Title 29 DCMR.
1926.11Each Medicaid provider shall comply with Section 1904 (Provider Qualifications) and Section 1905 (Provider Enrollment Process) of Chapter 19 of Title 29 DCMR.
1926.12Each Medicaid provider shall maintain the following documents for monitoring and audit reviews:
(a) The physician’s order;
(b) A copy of the occupational therapy assessment and therapy plan in accordance with the requirements of Subsections 1926.4 and 1926.5; and
(c) Any documents required to be maintained under Section 1909 (Records and Confidentiality of Information) of Chapter 19 or Title 29 DCMR, that are applicable to this service.
1926.13If the person enrolled in the ID/DD Waiver is between the ages of eighteen (18) and twenty-one (21) years, the DDS Service Coordinator shall ensure that Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefits under the Medicaid State Plan are fully utilized and the ID/DD Waiver service is neither replacing nor duplicating EPSDT services.
1926.14Medicaid reimbursable occupational therapy services shall be limited to four (4) hours per day and one-hundred (100) hours per year. Requests for additional hours may be approved when accompanied by a physician’s order documenting the need for additional occupational therapy services and approved by a DDS staff member designated to provide clinical oversight.
1926.15The Medicaid reimbursement rate for occupational therapy services shall be one hundred dollars and thirty-two cents ($100.32) per hour. The billable unit of service shall be fifteen (15) minutes.