DMA Clinical Coverage Policy No: 10A (amended 6/1/2017)
Medicaid patients who are over 20 have visit limits that are listed below. All visit limits refer to combined PT, OT, and ST visits from all therapy providers in any outpatient setting, including hospital outpatient, home health, orthopaedic outpatient and any other outpatient setting. If multiple disciplines treat on the same date of service, each count separately toward the total visit limit.
One Eval for All Patients. All patients may have one therapy evaluation per calendar year.
One Eval + Three Treatment Visits. Patients over 20 may have one evaluation visit and a total of three therapy treatment visits per calendar year, if the patient:
- has a neurological or lymphedema diagnosis listed in Attachment A of DMA Policy 10A (“Attachment A”) Link to Policy 10A-Attachment A;
- if all of the visits are within 60 days following a neurosurgical or musculoskeletal surgical procedure listed on Attachment A; or
- if all of the visits are within 30 days of cast removal, hardware removal (or both) or elimination of weight bearing restrictions or immobilization post musculoskeletal surgical procedure listed in Attachment A.
A new neurosurgical or musculoskeletal surgical procedure allows for a new episode of one evaluation and three therapy treatment visits.
Two Evals + Eight Treatment Visits. Patients over 20 may have up to two therapy evaluations and a total of eight therapy treatment visits, if all of these visits are completed:
- within three calendar months of the patient’s discharge from an inpatient joint replacement or hip fracture surgery listed in Attachment A;
- within 30 calendar days of cast removal, hardware removal (or both) or elimination of weight bearing restriction or immobilization post musculoskeletal surgical procedure listed in Attachment A; or
- within three calendar months of receipt of upper extremity or lower extremity prosthesis.
A new joint replacement, hip fracture surgical procedure or receipt of new prosthesis allows for a new episode of two therapy evaluations and eight therapy treatment visits.
Three Evals + 24 Treatment Visits. Patients over 20 may have up to three therapy evaluations, and a total of 24 therapy treatment visits when the patient is within six calendar months of discharge from inpatient services for a cerebrovascular accident (CVA), traumatic brain injury (TBI) or spinal cord injury (SCI) diagnosis listed in Attachment A of this policy. A documented occurrence of a new CVA, TBI or SCI with a corresponding inpatient stay allows for a new episode of up to three (3) therapy evaluations and a total of 24 therapy treatment visits.
