Chapter 12, Traumatic Brain Injury and Traumatic Spinal Cord Injury – Outpatient Therapy Services

12.1 Overview

Outpatient therapy services refer to any core service identified in Appendix B, Post-Acute Rehabilitation Core Services – Modality and Staff Qualifications including, but not limited to: occupational therapy, physical therapy, speech therapy, mental health counseling, and substance abuse services. Outpatient therapy services are provided on a one-on-one basis by licensed therapists to participants who have a traumatic brain injury, a traumatic spinal cord injury, or both.

A physician must prescribe outpatient therapy services (as applicable) and are provided without admittance to a hospital. The goal is to correct or modify a stable or slowly progressive physical or mental impairment that constitutes a substantial impediment to independence.

Goods and services that are not considered outpatient therapy services are considered ancillary. See Chapter 14, Traumatic Brain Injury and Traumatic Spinal Cord Injury – Ancillary Goods and Services for billing guidelines and reimbursement of ancillary services.

12.2 Required Documentation

Assessments for outpatient therapy services must be completed by a qualified, licensed professional, as defined in Appendix B, Post-Acute Rehabilitation Core Services – Modality and Staff Qualifications
Before providing outpatient therapy services, the provider must recommend to the CRS program the specific type of service, frequency, and duration necessary for the participant to reach the outcomes noted in the treatment plan. The assessment and treatment plan can be contained in the same document, if all the essential elements of both are included.

The treatment plan must be developed with the participant or the participant’s family, guardian or representative and licensed professional before outpatient therapy services are provided. The treatment plan must contain clearly defined, measurable objectives and be sent by the provider to a CRS program staff member.

To justify continuing outpatient therapy services, the licensed professional must provide data at least monthly. The data provided must support the need to provide services to the participant. If the participant’s progress is inadequate or the participant regresses, additional documentation is necessary to revise the treatment plan and continue the outpatient therapy services. Providers must keep on file documentation showing that the services were preauthorized by the CRS program. The provider must respond to CRS program staff member inquiries pertaining to billing within two business days after receiving the request. The provider must submit documentation within five business days after receiving the request. See Chapter 4, General Provider Responsibilities for additional documentation requirements.

12.3 Assessment, Planning and Interdisciplinary Team Meetings

An assessment (see Chapter 10.1) and Individualized Program Plan (IPP) (see Chapter 10.2) must be completed to address participant’s deficits. The CRS counselor or CRS program staff member must receive an update or participate in a team meeting to discuss the participant’s status. The update should include the individual’s condition, course of treatment, progress, or lack of progress made toward reaching the treatment goals, with supporting data. The CRS counselor may request additional supporting documentation as needed. This must be reviewed to preauthorize additional services based on the following schedule:

  • if the participant is receiving 2-4 hours of service per week, the provider must submit an update every 60 days;
  • if the participant is receiving 5 or more hours of service per week, the provider must submit an update monthly.

*Note: outpatient services differ from post-acute rehabilitation services (PARS) non-residential which requires a full interdisciplinary team meeting. Outpatient therapy should be reserved for individualized services with a lower level of care while PARS non-residential require more intensive level of care for services.

12.4 Billing Guidelines

The provider must submit a prescription (as applicable) or physician’s recommendation for requested outpatient therapy services for the CRS program staff member to issue a service authorization. Following the evaluation, if the provider determines that it is necessary for the participant to receive therapy, the provider submits a written report and recommendations identifying the type of therapy needed, the duration and the frequency. If the CRS program staff member approves the therapy, a service authorization will be issued.

If the provider provides services without a service authorization or provides services outside of the originally proposed or approved dates, payment for the services is not guaranteed.

Invoices must be submitted at least monthly, and no later than the fifteenth of each month following the service. Data supporting the service must accompany each invoice. Outpatient therapy services are delivered per the contract or the terms and conditions set forth in the service authorization. These services are authorized by CRS counselors and are reimbursed according to the reimbursement methodology described in 1 TAC §355.9040.

Ancillary goods and services must be identified on the Individualized Program Plan and preauthorized by a CRS program staff member and are reimbursed based on fee for service in accordance with 1 TAC §355.9040. See Chapter 6, General Billing Guidelines for general billing guidelines.

12.5 Exceptions and Limitations

Outpatient therapy services are approved only when no more than two years have elapsed between the date of injury and the date of initial contact. CRS participants may receive up to 120 hours of outpatient services if medical necessity is determined.