13.6 Residential

PARS for participants who have a traumatic brain injury (TBI), or who have both a TBI and a traumatic spinal cord injury (TSCI), are provided in a residential setting and are based on a tiered billing system. Each tier is a preauthorized level of service.

The tiers are:

  • Tier Base;
  • Tier Base Plus; and
  • Core Therapy services.

13.6.1 Licensure and Accreditation

All providers who provide PARS in a residential setting that do business with the CRS program must be licensed by at least one of the following regulatory agencies, as appropriate:

The providers must maintain accreditation from:

  • the Commission on Accreditation of Rehabilitation Facilities;
  • the Joint Commission on Accreditation of Healthcare Organizations; or
  • the Disease-Specific Care Certification in Brain Injury Rehabilitation Program.

New facility-based providers doing business with CRS that do not already meet this requirement are granted up to two years from the date of their CRS contract for post-acute brain injury or post-acute spinal cord injury services to obtain the accreditation.

13.6.2 Billing Guidelines-Tiers

HHSC negotiates contracts with providers to provide post-acute rehabilitation, which is reimbursed in accordance with 1 TAC §355.9040. Residential services for traumatic brain injury are authorized based on a tiered rate structure. Each tier represents a preauthorized number of hours allotted for providing core therapy services. A week is defined as Sunday through Saturday. To determine the appropriate tier, use the clinical recommendation for services, frequency, and duration. For example, if the interdisciplinary team (IDT) recommends the following core therapy service—PT 2 times per week for 1 hour, OT recommended 3 times a week for 1 hour and Art Therapy 1 times a week for 1 hour—the appropriate tier would be Tier 1.

Based on the participant’s need determined during the initial pre-admission assessment, the provider may request an admission tier of level 2 through level 8. This request is to be submitted in writing using Form 3149, Comprehensive Rehabilitation Services Request for Tier Change, or included in the pre-admission evaluation, which identifies services needed, frequency, duration and requested tier. With prior authorization, the tier may be changed to reflect the level recommended on a weekly basis by the IDT.  Justification must include information related to the participant's needs, goals, and recommended core therapy services.

Note: Additional supporting documentation (i.e., daily therapy notes, etc.) may be requested during utilization review activities.

All post-acute rehabilitation residential services providers must submit billing for services within 30 days of the last date of services. Participants should receive core therapy services at the authorized tier.

The invoice submitted by the provider indicates the tier level and the core therapy services provided to the participant each day of service. The CRS counselor or CRS program staff member then confirms the data in the CRS Data Reporting System to ensure that the total hours for the week do not exceed the approved tier.  For example, a participant is authorized for Tier 4 services, the number of hours of core therapy services provided cannot exceed 28 hours within the week. Payment will be based on the services provided within the authorized tier.

When submitting an invoice, Post-Acute Rehabilitation providers are required to submit a monthly summary that includes a descriptive breakdown of services provided including frequency, duration, progress, or lack of progress made towards the participant's goals, actions to be taken, and preliminary discharge information. Providers are also required to upload service record details of daily services provided in the CRS Data Reporting System, per Chapter 13.2, Required Documentation. Providers will only be required to submit daily therapy documentation if a participant’s file is randomly selected for utilization review. The provider will receive a written request with a time frame outlining when documentation is to be returned to the CRS requestor.

Participant needs are the foundation of the CRS program and as such, minor fluctuations in the delivery of core therapy services is expected to accommodate a participant’s medical needs. If a participant is unable or unwilling to participate in core therapy services for a day or two, the provider must provide appropriate clinical documentation for increasing core therapy service hours on a subsequent day. Core therapy service hours must not be increased for the purposes of maximizing billing. For example, a participant is authorized for Tier 4 services, the participant is ill for three of the seven days that week. Upon recovery, the participant must not be asked to participate in increased hours of core therapy services that could potentially be harmful to the participant simply to ensure that maximum billing occurs for the assigned tier.

Patterns where Base or Base Plus Tier services are provided, followed by days with increased hours of therapy services above the recommended number of hours of core therapy services per day, must be supported by written clinical justification from assigned therapists.

The CRS counselor or other CRS program staff member compares the submitted invoice and the supporting documentation (which includes the approved tier) to what has been submitted in the CRS Data Reporting System. Disparity between the submitted documentation and invoice will be addressed by CRS program staff members and resolution obtained before payment is issued.

13.6.3 Co-Pay and Co-Insurance

Co-pay and co-insurance is covered when a participant has third-party insurance that is being billed for services. All other pay sources must be exhausted before the CRS program is billed for services.

13.6.4 Tier Base and Tier Base-Plus

Tier Base services include administrative costs, room and board, paraprofessional services, medical services (that is, physician and nursing services), dietary and nutritional services, and case management. These services may not be billed separately to the CRS program.

Tier Base-Plus services include the base services plus one-quarter to three-quarter hours of core therapy services.

13.6.5 Core Therapy Services

See Appendix B for a complete list of core therapy services and provider qualifications. Core therapy services for PARS residential services including, but not limited to physical therapy, occupational therapy, speech therapy, cognitive therapy and neuropsychological services.

Core therapy services are based on the recommended tier and must be provided by a licensed or certified professional. If an identified core therapy service is provided by a non-licensed or certified professional, the service is not billable as part of the core therapy service for the tier.

For example, nursing services are considered part of base services and therefore are not billable as part of core therapy services. Goods and services that are not considered base or core therapy services are defined as ancillary and must be authorized by the CRS counselor.

See Chapter 14 for details.

13.6.6 Preauthorization for Changing Tiers

Changes in the approved tier require preauthorization from a CRS program staff member. The provider must document in the participant’s record why a participant received less than the preauthorized or approved tier or why it is clinically recommended to increase the tier.

When a provider requests a change in Tier for a participant, the provider must complete the Form 3149, Comprehensive Rehabilitation Services Request for Tier Change. The form will include the requested Tier change and the justification of need detailing goals, progress or lack of progress and the type, frequency and duration of therapy services. The Request for Tier Change Form must be faxed or sent via secure email to the CRS Counselor. The CRS Counselor will review, make a determination and return to the requesting provider within five business days. Unauthorized services may not be reimbursed by the CRS program. The CRS program staff member may request documentation supporting the provider’s request. If requested, the documentation must be submitted before delivering services at the newly requested tier or the change in tier is considered unauthorized.

13.6.7 Exceptions and Limitations

PARS that are provided in a residential setting are limited to 180 days from the first day of services and are sponsored by the CRS program. All services must be preauthorized.

Tier Base: A participant does not receive any core therapy services on a given day. The provider bills Tier Base for that day to indicate that the provider is being reimbursed only for the base services and that no core therapy services were provided. The CRS program does not expect that participants will be approved for Tier Base. The tier is provided to account for days of service that fall below the authorized tier.

Tier Base Plus: A participant receives a limited core therapy service of one- to three-quarter hours per day. The CRS program does not expect that participants will be approved for Tier Base Plus. The tier is provided to account for days of service that fall below the authorized tier.

Core Individual and Group Therapy: One hour of individual therapy or two hours of group therapy count as one hour toward a tier. The total number of hours applied to a tier equals the sum of the individual and group hours. For example, one hour of individual and one hour of group equals 1.5 hours total and is billed as Tier 1. One hour of individual and four hours of group equals three hours total and is billed as Tier 3. For group therapy, group size is limited to ten participants.

Billing Core Therapy Services: Two therapists cannot bill for the same period. Divide therapy units and time by the number of therapists delivering the service to determine the number of hours attributed to each. For example, if a physical therapist and an occupational therapist deliver one hour of individual therapy to a participant together, the therapy counts as one hour toward the tier. On the supporting documentation, the therapy is shown as .5 hours of physical therapy and .5 hours of occupational therapy. (The providers may split the hour differently, such as three-quarter hours of physical therapy and one-quarter hours of occupational therapy, if the sum does not exceed one hour. For staff qualifications, see Appendix B Post-Acute Rehabilitation Core Services – Modality and Staff Qualifications.

Billing for a partial week: If billing for fewer than seven calendar days, the billing guidelines for the maximum number of hours provided at the approved tier apply. For example, if a participant is approved for Tier 4, the sum must not exceed 28 hours, regardless of the number of days involved.

Copays: Providers bill a third party or the participant ’s insurance company for services. The CRS program pays the consumer’s required copay or coinsurance for the service. Tiered rates do not apply. However, the provider must still submit detailed billing information on the services delivered to the participant.

Day of Admission or Discharge: Admission and discharge days are handled the same as any other service day. If no core therapy services are delivered, the provider bills for Tier Base services. If core therapy services are delivered, the provider bills for the appropriate tier for the number of hours delivered, in accordance the prior authorization.

Therapeutic Passes: A therapeutic pass allows a participant to leave a residential facility unaccompanied by facility staff. Therapeutic passes are reviewed and incorporated into the participant’s plan of care by the treatment team. The purpose of the therapeutic pass is to facilitate a participant’s transition from a residential facility to their own home and the community. For example, a participant may go home for the weekend to practice skills learned and apply them to the home environment, go shopping with family members, or practice taking the bus or public transportation. While a participant is on therapeutic pass, staff members from the residential facility must be available to provide the participant, the participant’s family, or others who are supporting the participant with guidance and instruction, usually by phone as needed.

Within one day of the participant’s return to the facility, the facility team must review and address with the participant all of the issues identified while on the therapeutic pass. If the facility team determines that changes in the participant’s therapy services or ancillary services are required, a team member must notify the CRS counselor and schedule a follow up interdisciplinary team meeting. If the counselor and the interdisciplinary team approve, the facility team incorporates techniques into the participant’s therapy or ancillary services to address the issues.

Providers must document services provided and may bill for services rendered while the participant is at the residential facility on the same day as a therapeutic pass. For example, a participant has a pass scheduled to leave the facility from 11 a.m. to 5 p.m., but requires assistance for ADL’s, medications, and meals before and after the pass so, the provider may bill for this date. If the participant will be out of the facility for a 24-hour period with no services provided, the provider cannot bill for that time.