13.1 Overview

Post-acute rehabilitation services (PARS) for traumatic brain injury (TBI) and traumatic spinal cord injury (TSCI) are advanced rehabilitation services provided through an interdisciplinary team approach. For residential services, the participant must have a TBI or have a TBI with a TSCI and for a non-residential setting, the participant may have a TBI or TSCI. For outpatient therapy services, the participant must have a TBI or a TSCI.

Services that are provided are based on an assessment of the individual's deficits. The goal is to achieve independence in the home and community and establish new patterns of cognitive activity or compensatory mechanisms. HHSC Rate Analysis sets PARS rates and can be located here.

13.2 Required Documentation

For a participant receiving PARS, the provider uses the Mayo Portland Adaptability Inventory (MPAI-4) or Functional Inventory Measure (FIM), as applicable, based on service:

  • on admission;
  • on discharge; and
  • when the six-month follow-up is provided, after discharge.

The Individualized Program Plan (IPP) must document the progress or lack of progress that the participant is making toward reaching the measurable goals and objectives.

Activity schedules must facilitate participation and provide opportunities for the participant to be independent. Schedules must indicate the participant’s general activities for the day, including meals, therapeutic activities, recreation and leisure activities. The activity schedule must address the goals in the IPP and be made available to each participant. Copies of schedules for each participant must be made available to CRS counselors for review. The activity schedule directs the intensity of the daily work that the participant must do to implement the IPP, about both informal and formal training.

The provider must submit and maintain all documentation pertaining to billing. Providers for residential and non-residential services are required to submit service record details into the CRS Data Reporting System. The service record details must be submitted by the 10th working day of the month following service delivery (for example, services delivered in September must be uploaded by the tenth of October). Providers are supplied with an Excel file format or layout and with access to the web-based system to upload the service record details. The details required are outlined in Appendix D, Service Record for CRS Data Reporting System. (See Chapter 4, General Provider Responsibilities for additional documentation requirements.) For technical assistance related to issues with the CRS Data Reporting System contact CRS_Program@hhsc.state.tx.us.

13.3 Assessment, Planning and Interdisciplinary 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 may request additional supporting documentation as needed. All planned and needed services for the participant must be documented. This must be reviewed to preauthorize services.

The IDT reviews the IPP at each monthly meeting to determine whether to continue and possibly modify the services. The IDT may also meet as frequently as is prudent and necessary to maintain an effective treatment program. Adjustments to the IPP, including discharge planning, are made as necessary.

13.4 Outcome Measures

Providers of PARS residential and non-residential services for traumatic brain injury must administer the Mayo-Portland Adaptability Inventory (MPAI-4) to all CRS participants. For non-residential services for traumatic spinal cord injury, providers must administer the Functional Independence Measure (FIM) to all CRS participants.  MPAI must be completed and signed by a licensed professional.

The MPAI-4 or FIM scores must be administered at:

  • Admission
  • Discharge
  • Six months after discharge (when possible) with documented effort to obtain it.

Providers must report all outcome measures and send the report to the CRS Program. Below are the state fiscal year quarters and due dates:

Table 1, State Fiscal Year Quarters and Due Dates

MonthsDue Dates
  • September
  • October
  • November
Quarterly progression measures due Dec. 10
  • December
  • January
  • February
Quarterly progression measures due Mar. 10
  • March
  • April
  • May
Quarterly progression measures due Jun. 10
  • June
  • July
  • August
Quarterly progression measures due Sept. 10

If the due date falls on a weekend or state holiday, the report is due the following business day.

13.5 Customer Satisfaction

All providers who provide PARS in a residential setting must include participation satisfaction measures based on input from participants about benefits received from the services.

Each provider may develop its own survey instrument and procedure. However, at a minimum, the survey instrument must include the following prompt:

Using the Likert scale in the table below, rate the following statements:

  1. I was treated in a friendly, caring, and respectful manner by the staff of [insert provider’s name].
  2. Services were provided in a timely manner.
  3. The services met my needs.
  4. I was satisfied with the services provided.

Likert Scale

Rate NumberDefinition
1Strongly disagree
2Disagree
3Neither agree nor disagree
4Agree
5Strongly agree

Providers must give all participants, both successful and unsuccessful, an opportunity to respond upon discharge from the CRS program. Providers must keep in the participant's file all attempts to obtain participant response to the participant satisfaction survey. The CRS program may request the responses from the provider every six months.

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.

13.6.2 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.

13.7 Non-residential

Post-acute rehabilitation non-residential services for traumatic brain injury and traumatic spinal cord injury offer the same core therapy as residential services. Also included are case management, community independence supports, medical team conferences, and a standard facility or community base fee for non-residential services which covers dietary and nutritional services, medical (nursing and physician) services, and administrative or operational costs. Staff qualifications for providing core services remains unchanged. See Appendix B for Post-Acute Rehabilitation Core Services – Modality and Staff Qualifications.

13.8 Outpatient Therapy

Outpatient therapy services are to be utilized as a continuum of services and do not include residential or non-residential base services. In order to provide outpatient therapy services, it must be outlined in the provider contract. Staff qualifications for providing core services remain unchanged. See Appendix B, Post-Acute Rehabilitation Core Services Modality and Staff Qualifications. See Chapter 12, Traumatic Brain Injury and Traumatic Spinal Cord Injury – Outpatient Therapy Services, for additional guidelines on outpatient services.