4243 SPECIFIC PROVIDER REQUIREMENTS: PHYSICAL THERAPY

4243.1 Physical Therapy services shall only be reimbursed by Medicaid if they are provided by the following Medicaid-enrolled providers:

1. (a) A home care agency licensed pursuant to Health-Care and Community Residence Facility, Hospice and Home Care Licensure Act of 1983, effective February 24, 1984 (D.C. Law 5-48; D.C. Official Code, §§ 44-501 et seq.), and implementing rules; or
2. (b) An independent licensed physical therapist.

4243.2 Physical therapy services shall be reimbursed by Medicaid if they are provided by a physical therapist or a physical therapy assistant working under the direct supervision of a physical therapist.

4243.3 In order to receive Medicaid reimbursement, all practitioners shall meet the following requirements:

1. (a) Be licensed to practice physical therapy in accordance with the District of Columbia Health Occupations Revisions Act of 1985, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code §§ 3-1201.01 et seq. (2016 Repl.)), and implementing rules, Chapter 67 (Physical Therapy) of Title 17 DCMR; or
2. (b) Be a physical therapy assistant who is licensed to practice as a physical therapy assistant in accordance with the District of Columbia Health Occupations Revisions Act of 1985, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code §§ 3-1201.01 et seq. (2016 Repl.)), and implementing rules, Chapter 82 (Physical Therapy Assistants) of Title 17 DCMR.

4243.4 In order to be eligible for reimbursement, each Medicaid provider must obtain prior authorization from DHCF or its designee prior to providing, or allowing any professional to provide physical therapy services. In its request for prior authorization, the Medicaid provider shall document the following:

1. (a) The EPD Waiver beneficiary's need for physical therapy services as demonstrated by a physician's order; and
2. (b) The name of the professional or home care agency that will provide the physical therapy services.

4243.5 In order to be eligible for Medicaid reimbursement, each individual providing physical therapy services shall participate in PCSP and interdisciplinary team meetings to provide consultative services and recommendations to focus on how the beneficiary is doing in achieving the functional goals that are important to him or her;

4243.6 Each Medicaid provider shall maintain the following documents for monitoring and audit reviews:

(a) The physician's order;

(b) A copy of the physical therapy assessment and therapy plan developed in accordance with the requirements of this Section; and

(c) Any documents required to be maintained by DHCF as specified in Section 4255 (Audits and Monitoring/Oversight Reviews).

SOURCE: Final Rulemaking published at 64 DCR 6784 (July 21, 2017).