Appendix H: Physical Rehabilitation and/or Therapeutic Treatment

Revision 19-1, Effective March 1, 2019

Qualifications

On occasion, certain medical professionals are needed to direct or support the provision of medical services.

The credentials required and the functions performed may include the following:

  • Advanced practice nurse provides medical evaluation and/or treatment. Licensed by the Texas Board of Nursing.
  • Certified registered nurse anesthetist (CRNA) administers anesthesia. Certified by the American Association of Nurse Anesthetists.
  • Chiropractor provides manipulative treatment of the spine and functional capacity assessments. Licensed by the Texas Board of Chiropractic Examiners.
  • Licensed surgical assistant provides assistant surgeon services. Licensed by the Texas Medical Board.
  • Physician provides medical examinations and/or treatment. Exception: A podiatrist licensed in the state where services are rendered may provide medical or surgical services limited to foot conditions.
  • M.D. (doctor of medicine) or D.O. (doctor of osteopathy) licensed by the Texas State Board of Medical Examiners to practice in the state where services are rendered.
  • Physician assistant provides medical examinations, medication management, and/or treatment. Licensed by the Texas Physician Assistant Board.
  • Podiatrist (doctor of podiatric medicine or DPM) provides medical examinations and treatment for foot conditions. Licensed by the Podiatric Medical Examiners Board.
  • Registered nurse first assistant provides assistant surgeon services. Licensed by the Texas Board of Nursing.
  • Specialist physician performs examinations, treatment, and/or surgery. Certified by an American Medical Specialty Board or the American Osteopathy Specialty Board, or has the training and experience to be eligible for examination by a specialty board.
  • Physician providing surgery must be board certified or eligible for examination by a specialty board in the area of the physician's surgical specialty.
  • Speech and language pathologist provides, with the concurrence of a physician, speech and hearing therapy after surgery or trauma affecting speech. Certified as a speech-language pathologist by the State Board of Examiners for Speech-Language Pathology and Audiology.
  • Speech trainer provides speech training in both expressive (speech language production) and receptive (lip and speech reading) language. May also evaluate and provide training in the use of speech augmentation devices. Certified as a speech-language pathologist by the State Board of Examiners for Speech-Language Pathology and Audiology.

Outpatient Services

Outpatient services may include:

  • physician visits;
  • physical or occupational therapy;
  • speech, language, or hearing therapy; or
  • home health or nursing care.

Provide outpatient services only when prescribed by a physician and only if they are likely, within a reasonable period of time, to correct or modify substantially a stable or slowly progressive physical or mental impairment that constitutes a substantial impediment to independence.

If the service provider requests an extension of treatment beyond his or her initial recommendation, assess the consumer's potential for continued progress. Your assessment may involve reviewing notes on progress of the treatment and/or contacting the physician and/or service provider.

If continuing treatment is appropriate:

  1. clearly document in the case file how continued services are expected to contribute to achieving the independence goal;
  2. approve up to a total of 30 visits or therapy sessions; and
  3. obtain approval from the HHSC to extend treatment beyond 30 visits or therapy sessions.

Physical Therapy

Purchase physical therapy (PT) when required to increase:

  • coordination;
  • strength; or
  • range of motion.

A physician recommends, and later reviews, the provision of PT. A licensed physical therapist provides the service.

Prescription Drugs and Medical Supplies

Provide prescription drugs and medical supplies, as needed, when a consumer cannot buy or obtain them from comparable sources.

When a consumer is discharged from a medical rehabilitation facility or hospital that has an in-house pharmacy, pay for a 30-day take-home supply of the prescription drugs and medical supplies that the consumer received while in the facility or hospital.

If prescription drugs and supplies are needed beyond the 30 days, arrange to purchase them from a pharmacy in the consumer's home area. Buy from the least-expensive available source. When specialized prescription drugs or supplies are not readily available from a local source, buy them from the hospital pharmacy.

Speech Therapy and Speech Training

Speech therapy provides treatment for disorders of:

  • speech;
  • language;
  • voice;
  • communication; and/or
  • auditory processing.

A physician recommends, and later reviews, the provision of speech therapy. A licensed speech-language pathologist provides these services.

The speech-language pathologist may also provide:

  • speech training in both expressive (speech and language production) and receptive (lip or speech reading) systems; and
  • evaluation and training in the use of speech augmentation devices.

A physician's recommendation and review are not required for speech training.

Other Durable Medical Goods and Services

Required Procedures

After an initial prescription is received, obtain the specifications for the prescription (that is, the type, size, and special features needed) by arranging for the consumer to be evaluated by:

  • a physiatrist;
  • a physical or occupational therapist; or
  • another qualified service provider.

Definitions

The following are definitions for different types of durable medical equipment.

Power wheelchairs: A power wheelchair is battery-operated. It has a base with four wheels and adjustable seat with armrests. It also has a controller (joystick or touch pad) attached to one armrest that allows the rider to control the movement of the chair. The chair can be disassembled for transport and usually comes with an on-board battery charger. The braking system is either automatic or electric. Powered wheelchairs can be customized with advanced technology and with several options, including seat size (width and depth), seat-to-floor height, foot rests, and leg rests.

Manual wheelchairs: A standard manual wheelchair may have a cross-brace frame that folds easily for transport or storage, or may be nonfolding, with a rigid frame. The chair may have built-in or removable armrests or footrests (optional) for ease of transfer, a mid- to high-level back, and push handles to allow a person outside of the car to propel the chair. The seat sizes may be customized for the user. The standard tire used for the rear wheels on most wheelchairs is a pneumatic tire, with a standard size of 24 inches. Pneumatic tires have wheel locks, sometimes called brakes, which can be applied by pushing a lever located on the sides, allowing the user to control the speed or come to complete stop.

Scooters: A scooter is a power-operated vehicle that has a seat on a long platform, moves on either three or four wheels, is controlled by a steering handle, and can be independently driven by a user. It has rear drive, uses a 24-volt system and an electronic or dynamic braking system, has high-to-low speed settings, and has tires designed for indoor and outdoor use.

Power units and controllers: A power unit and controller is a computer peripheral or general control device consisting of a hand-held stick that pivots about one end and transmits its angle in two or three dimensions to a computer, or to a touch pad that serves the same purpose. A power unit and controller is used to propel, brake, steer, negotiate, and maneuver a powered wheelchair or scooter around obstacles.

Seating or positioning systems: A wheelchair seating system is designed for the individual needs of the consumer to:

  • provide postural support, thereby enabling the consumer to sit when the consumer does not have sufficient strength or control to do so unaided;
  • provide correction to encourage normal postural development and to reduce the tendency to develop orthopedic deformities;
  • enhance functionality, enabling the consumer to perform everyday tasks in the home or social setting in which the consumer would not otherwise be able to perform those tasks;
  • manage the distribution of pressure to reduce the risk of tissue damage resulting from inappropriate loads being applied to the skin; and
  • accommodate established orthopedic deformities.

The actual components and complexity of any particular wheelchair seating system depend on the problems that the system addresses. This definition includes parts (for example, cushions), as well as the complete system.

Patient lifts: Patient lifts are assistive devices used to help caregivers transfer a person safely back and forth from a bed to a chair when the person cannot transfer without assistance. Lifts fall into four broad categories: mobile lifts, sit-to-stand lifts, ceiling lifts, and wall-mounted lifts. The lifts can be operated hydraulically or electronically.

The definition of patient lifts does not include:

  • lifts that require structural modification of a building; or
  • lift chair recliners, sometimes referred to as easy chairs, with seats that raise an occupant to a standing position.

Hospital beds: A hospital bed consists of special features (a modified catch-spring assembly and bed ends with casters and manually operated foot-end cranks or an electric motor) that permit independent adjustment of the elevation of the head and knee sections. The bed can accommodate a standard trapeze bar when attached to the head end and other accessories. The bed should be equipped to accommodate side rails. This definition does not include special or customized mattresses.

Fabricated good: A fabricated good is a device constructed to meet a specific need.

Functional unit: A functional unit is the fully constructed or fabricated durable medical equipment that can be immediately used by the consumer for whom it was specified. For example, a wheelchair would include the frame, seating system, controls, batteries, or other parts necessary to make it immediately usable by the consumer.

Manufacturer's suggested retail price (MSRP): The MSRP is the published price that a manufacturer of a product suggests that retailers charge for the product.

Other medical goods and supplies: Other medical goods and supplies are all of the medical goods and supplies that are not defined as durable medical equipment.

Contractor-provided specification: A contractor-provided specification is a written detailed description of the exact product to be provided, including the cost of the product and the date by which the product will be delivered.