The following service specification has been revised for

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PART 6-X

PHYSICAL THERAPY

Summary of Changes

Please review the attached service specification carefully for all changes. The following service specification has been revised for clarity, consistency with relevant policy, and conformity with all service specifications. Physical therapy has been updated to reflect current practice as per national physical t herapy guidelines. This service has also been revised to include requirements for compliance with Electronic Visit Verification and with the Department’s Quality Monitoring.

RFQVA DDD-72022 Part 6X, Page 1

2 PART 6-X 3 PHYSICAL THERAPY

4 Service Description H052-KB 5 A service that provides treatment to restore, maintain or improve a physical function.

6 This service provides evaluation, assessment, training, Outcomes, and/or treatment to 7 Division members and is designed to maintain or improve participation and independence in the 8 member’s daily activities. This service shall develop and train members and their caregivers in 9 therapeutic activities in order for the member and caregivers to be able to implement the

10 activities throughout the member’s day (such therapeutic activities are referred to as a “home 11 program”). Evaluation, assessment, training, and treatment are based on outcomes identified in 12 the member’s planning document [e.g., Individual Support Plan (“ISP”)]. Goals 13 Service Requirements and Limitations Description 14 1. This service is intended for members over age of three (3) years and under the age of 15 twenty-one (21) years.

16 2. This service shall be provided with a parent/family member/caregiver present and 17 participating in the therapy session. Qualified Vendors shall refer to the Division’s Provider 18 Manual for guidance regarding participation during therapy sessions.

19 3. This service may be provided in the following settings:

20 3.1 The member’s home;

21 3.2 The member’s community setting;

22 3.3 A group home;

23 3.4 A developmental home (child or adult);

24 3.5 A skilled nursing facility;

25 3.6 An Intermediate Care Facility (“ICF”), including members over the age of twenty-one 26 (21) years; or

27 3.7 The Qualified Vendor’s office/center; or

28 3.8 A Day Treatment and Training location as identified in the member’s planning 29 document under the following circumstances:

30 3.8.1 With the Day Treatment and Training staff present and learning how to 31 implement activities to meet the member’s outcome(s) and in conjunction with 32 the home program, or


33 3.8.2 At the request of the member or member’s representative and with the 34 agreement of the Day Treatment and Training program. A parent/family 35 member/caregivers, other than the Day Treatment and Training staff, must be 36 present and participating. In this circumstance, the Day Treatment and 37 Training program shall not bill the Division for the time in which the therapy is 38 occurring.

39 4. This service shall not be provided when the member is hospitalized.

40 5. This service shall utilize a coaching process and style of interaction to build the capacity of 41 the member/parent/family member/caregivers to meet the member’s planning document 42 outcomes.

43 6. This service require a Primary Care Provider (“PCP”) or attending physician’s order (i.e., 44 prescription). An evaluation does not require a prescription.

45 Service G oals and O bjectives

46 Service Goals 47 1. To address the member’s needs in the following areas:

48 1.1 Gross motor, gait, balance, proprioception, strength, and fine motor,

49 1.2 Muscle tone, neuromuscular, cardiovascular,

50 1.3 Reflex testing (as appropriate), and

51 1.4 Equipment including training, adaptation and/or modifications.

52 To support andThis medically necessary therapeutic service assists the meeting in 53 keeping, learning, or improving physical skills and functioning for daily living. It includes 54 motor function training; therapeutic exercise; manual therapy techniques; assistive 55 technology; functional training in self-care and domestic needs, employment, 56 community, social, and civic life. 57 Physical therapy supports Members to fully engage in their daily lives by planning for 58 and implementing treatment. Members are supported to: 59 ● Develop motor function; 60 ● Use therapeutic exercise; 61 ● Have directly applied manual therapy techniques; 62 ● Use assistive technology; and 63 ● Receive functional training in for physical needs and education/instruction. 64 Outcomes


65 1. Members have optimal physical health and maximal physical independence. 66 2. Members enhance the member’s abilitycapabilities and increase participation in 67 everyday life activities. 68 Goals 69 1. To support the Member, in accordance with their Planning Document and 70 relevant treatment and health plans, to maintain or improve their physical 71 functioning to participate in activities, and routines, and events of everyday life. 72 2. To assist the member and the parent/family member/caregivers in supporting the 73 member’sTo support the Member and their Family, caregivers, or Direct Support 74 Professionals (DSP), in accordance with their Planning Document and relevant 75 treatment and health plans, and their Home Program, to support development 76 and participation to incorporateby incorporating learning opportunities throughout 77 the existing daily routine. 78 Service Objectives 79 The Qualified Vendor shallShall ensure that the following objectives are met: 80 1. The therapist conductsIdentify and respect the Member’s cultural, racial or obtains 81 an ethnic, linguistic, sexual orientation, and spiritual needs. 82 2. Provide services according to Member’s preferences and needs, that recognizes 83 their strengths and promotes independence. 84 3. Offer support that is appropriate for the Member’s age and that addresses typical 85 life experiences such as developing friendships, human sexuality and 86 relationships, exploring recreation activities of interest, using social media and 87 technologies, getting around in the community independently, seeking post-88 secondary education or skill building opportunities, engaging in civic life, finding a 89 career, seeking leadership or advocacy opportunities, moving, finding and 90 developing relationships, parenthood, or transition into retirement. 91 1.4. Evaluate and assess the Member to develop treatment and training that 92 are based on Outcomes identified in the M ember’s Planning Document. The 93 evaluation/assessment of the member’s development.: 94 a. The evaluation/assessment addresses Addresses the concerns and 95 questions of the member’s planning teamMember’s Planning Team as 96 identified in the member’s planning document. Member’s Planning 97 Document; 98 b. The evaluation is Is conducted by a qualified physical therapist who is 99 trained to use appropriate methods and procedures for the

100 memberMember being evaluated. ; 101 1.1 The evaluation/assessment of the member’s development shall include:

102 c. Shall include: 103 i. A review of pertinent recordsRecords related to the


104 member’sMember’s current health status and medical history; 105 ii. An evaluation of the member’sMember’s level of functioning and 106 assessment of the unique needs of the member; Member; 107 iii. An interview with the memberMember and his/hertheir parent/family 108 member/caregivers/DSPs using appropriate questionnaires; 109 iv. Direct observations by the physical therapist; and 110 v. Standardized test and procedures (, as appropriate). . 111 c.d. The evaluation/assessment mustMust result in written evaluation 112 reports. The reports shall: that Shall: 113 i. Address the concerns and questions of the member’s planning 114 team;desired Outcomes of the Member and their Family related to 115 activities of their daily lives; 116 ii. Recommend outcomestherapeutic Outcomes and strategies for the 117 member’s planning document; Member’s Planning Document; 118 iii. Recommend a home programHome Program to be incorporated into 119 the member’sMember’s daily routine; and 120 iv. Document other recommendations, as identified, such as 121 technology or equipment needs. 122 d.e. The physical therapist reviews and discusses 123 evaluation/assessment results with the member/ member’s 124 representativeMember/Responsible Person and other planning team 125 members. Planning Team Members. 126 2. The therapist participatesBased on the member’s planning team by:

127 2.1 Collaborating with the planning team to ensure that all services, supports,needs and 128 strategies are coordinated and focus on assisting the member and his/her caregivers 129 to participateOutcomes identified in desiredthe evaluation assessment, develop a 130 Home Program of therapeutic activities.

131 2.2 Reviewing and synthesizing information from all assessments, evaluations, pertinent 132 records, member and family reports, observations, and other sources of information.

133 2.3 Identifying potential outcomes to be incorporated into the member’s planning 134 document.

135 2.4 Identifying potential strategies/teaming methodologies to meet the therapy outcomes.

136 2.5 Documenting and reporting progress toward therapy outcomes.

137 2.5. The therapist/therapy assistant shall provide intervention, treatment, and training 138 when professional skills are required for the Member, train Members and their


139 Family/caregivers/DSP to implement outcomes of the member’s planning 140 document.the Home Program, and monitor the H ome Program. The Home 141 Program: 142 3. The therapist develops, trains, and monitors a home program for the member that:

143 a. Contains specific activities that the memberMember and his/her 144 parent/family memberFamily/caregivers/DSPs can do each day to help the 145 memberMember to meet his/her outcomes. their Outcomes; 146 b. Is part of the member’sMember’s daily routines; and 147 c. Is reviewed with the Member and Family/caregiver/DSP, and updated by 148 the physical therapist as part of all treatment sessions; and 149 d. Is documented in each quarterly report including progress, oversight, 150 changes, and/or additions. 151 4. When therapy is no longer reasonable and necessary on a regular basis, a therapist shall 152 access and establish a functional maintenance program for the member to achieve the 153 outcomes.

154 4.1 The therapist shall reassess and revise the maintenance program as needed.

155 5. Discharge planning is assessed throughout service delivery.

156 Service Utilization Information 157 1. The member’s planning document identifies the need for evaluation and assessment.

158 2. The outcomes identified in the member’s planning document support the model of service 159 delivery.

160 3. The member’s planning team determines who will assist the member in attaining the 161 outcomes.

162 4. All planning team members contribute to the discussion and documentation for types and 163 frequency of services for the member and are not unilateral decision-makers.

164 5. The therapist follows a physician’s order (i.e., prescription) for the frequency and duration of 165 services for the member.

166 6. Services for the member are time-limited and are revised consistent with ongoing 167 assessment and attainment of anticipated outcomes.

168 7. Service delivery methods, times, days, and locations are flexible and meet the requirements 169 of the member, the member’s representative, and his/her caregivers.


170 6. TheThe Home Program Should support the Member with therapeutic activities 171 that are medically necessary and that are documented in their Planning 172 Document, such as: 173 a. Gross motor, gait, balance, proprioception, strength, and fine motor; 174 b. Muscle tone, neuromuscular, cardiovascular; 175 c. Reflex testing (as appropriate); 176 d. Equipment including training, adaptation and/or modifications; and 177 e. Activities to support and enhance the Member’s ability to participate in 178 activities, routines, and events of everyday life. 179 3.7. The physical therapist makes recommendations for needed equipment, 180 possible adaptations, and repairs and supports the memberMember and 181 his/hertheir parent/family member/caregiver/DSP in its use. 182 8. 8.1 The physical therapist/physical therapist assistants Shall provide 183 intervention, treatment, and training when professional skills are required to 184 implement Outcomes of the M ember’s Planning Document. 185 9. When the Member no longer demonstrates clinical progress, and has attained 186 maximal potential, or the therapy is no longer medically necessary, the physical 187 therapist Shall formulate and implement a functional maintenance program for 188 the Member to achieve the Outcomes and generalize skills across environments. 189 a. The therapist Shall reassess and revise the maintenance program, as 190 needed. 191 10. Evaluate the need for discharge planning throughout service delivery. 192 11. The physical therapist participates on the M ember’s Planning Team by: 193 a. Collaborating with the P lanning Team to ensure that all services, supports, 194 Outcomes, and strategies are coordinated and focus on assisting the 195 Member and their caregivers to participate in desired activities; 196 b. Reviewing and synthesizing information from all assessments, 197 evaluations, pertinent Records, Member and Family reports, observations, 198 and other sources of information; 199 c. Identifying potential Outcomes to be incorporated into the Member’s 200 Planning Document that align with the Members/Responsible Person’s 201 desired Outcomes; 202 d. Identifying potential strategies/teaching methodologies to meet the therapy 203 Outcomes; and 204 e. Documenting and reporting progress toward therapy Outcomes. 205 Service Requirements and Limitations 206 1. The Member’s Planning Document Must identify the need for evaluation, 207 assessment, and continued services.


208 2. This service requires a primary care provider (PCP) or physician’s order, or 209 prescription, for the assessment/evaluation and a certified plan of care for 210 ongoing physical therapy services. 211 3. Frequency and duration of occupational therapy services are based on the 212 qualified provider/PCP's certified Plan of Care (POC). 213 4. The Occupational Therapist develops a POC utilizing the objective findings of the 214 OT evaluation. The POC must: 215 a. Include, at a minimum, the Member’s treatment diagnosis, long-term 216 treatment goals as well as the type, duration, and frequency of therapy 217 services as well as the discharge criteria; 218 b. Include the signature and professional identity of the occupational 219 therapist who established the POC and the date it was established; 220 c. Be sent to the Member’s PCP for certification as soon as possible; 221 d. Include a dated signature on the POC by the physician or PCP for the 222 Member as well as the PCP’s NPI number; and 223 e. Be provided to the Member’s Support Coordinator with a copy of the 224 certified POC prior to authorization of services. 225 5. The support coordinator Must receive the certified POC within three (3) weeks of 226 the completion of the evaluation. The certified POC will serve as the medical 227 prescription/ referral for continued/ongoing therapy services. Please be aware 228 that a face-to-face visit with the Member May be required by the PCP. 229 6. In accordance with the Members and their Family Members desired Outcomes, 230 decisions for the type and frequency of services are made by all Planning Team 231 Members. 232 7. Service delivery methods, times, Days, and locations are flexible and meet the 233 requirements of the Member, the Member’s Responsible Person, and their 234 caregivers. 235 8. Outpatient occupational services are covered for ALTCS Members, acute 236 Members, and Members over the age of twenty-one (21) when medically 237 necessary. 238 9. This service Shall only be provided in: 239 a. The Member’s home; 240 b. The Member’s community; 241 c. A group home, nursing supported group home, enhanced behavioral 242 group home; 243 d. A developmental home; 244 e. A skilled nursing facility; 245 f. An Intermediate Care Facility (ICF), including Members over the age of


246 twenty-one (21) years; 247 g. The Qualified Vendor’s office/center; 248 h. Day Treatment and Training location as identified in the Member’s 249 Planning Document under the following circumstances: 250 i. With the Day Treatment and Training staff present and learning 251 how to implement activities to meet the Member’s outcome(s) and 252 in conjunction with the Home Program; or 253 ii. At the request of the Member or Member’s Responsible Person and 254 with the agreement of the Day Treatment and Training program: A 255 parent/family member/caregiver, other than the Day Treatment and 256 Training staff, Must be present and participating. In this 257 circumstance, the Day Treatment and Training program Shall not 258 bill the Department for the time in which the therapy is occurring. 259 10. This service Shall use a coaching process and style of interaction to build the 260 capacity of the Member/Family Member/caregivers/DSPs to meet the Outcomes 261 identified in the Member’s Planning Document, and the Outcomes identified in 262 the Member’s Planning Document support the model of service delivery (e.g., 263 coaching). 264 11. Co-treatment May be appropriate in a single therapy session when: 265 a. Therapists have substantiated the medical necessity for both therapists to 266 be working concurrently on similar goals; 267 b. Documentation to the Department, clearly indicates the rational for co-268 treatment and is aligned with Outcomes in the Planning Document; 269 c. Each therapist independently documents progress; 270 d. Coordination between therapists is for the sole benefit of the Member, not 271 simply for scheduling convenience; and 272 e. Continued co-treatment is determined at each planning meeting. 273 12. The Member’s Planning Team determines who will complete the Home Program 274 to assist the Member in attaining the Outcomes. 275 1.13. The therapist monitors any equipment that supports the member’s outcomes 276 related to their discipline. Member’s physical therapeutic Outcomes.

277 Rate Basis 278 1. Published. The published rate is based on one (1) hour of direct service.

279 2. Throughout the term of the contract, the appropriate billing codes, billing units, and 280 associated billing rules are subject to change. All billing codes and billing units, and 281 associated billing rules will be included in the Division’s Policies and Procedures Manual, 282 Billing Manual, RateBook, and/or other provider resources made available by the Division.


283 14. Direct Service Qualified Vendors Shall comply with AHCCCS’s requirements for 284 Electronic Visit Verification (EVV) to track and monitor timely service delivery and 285 access to care for Members. 286 15. Qualified Vendors Must cooperate and collaborate with the Department’s quality 287 monitoring. 288 Staff or Qualified Vendor Training and Qualifications 289 1. The Qualified Vendor shallShall comply with all minimal training requirements 290 specified in the Quality Vendor Agreement (QVA) and applicable administrative 291 rules including: 292 a. Cardiopulmonary Resuscitation (CPR) and First Aid provided or 293 sponsored by a nationally recognized organization, with in-person skills 294 demonstration, such as chest compressions and first aid. CPR and first 295 aid certification Must be maintained; 296 b. Article 9, Managing Inappropriate Behaviors by instructors certified by the 297 Department and following the Department’s training and testing 298 guidelines; 299 c. Specific training indicated in the Member’s Planning Document or as 300 requested by the Member/Responsible Person, and/or the Department; 301 d. Prevention and Support Training by an instructor certified by the 302 Department; 303 e. Training on the needs of the specific Member served and the operations of 304 the Qualified Vendor’s program; and 305 f. Additional skills needed to address the special or extraordinary needs of 306 the Member as required by the M ember’s Planning Document. 307 1.2. The Qualified Vendor Shall ensure that all direct service providers (therapists 308 and therapyphysical therapist and physical therapist assistants) meet all 309 applicable licensure requirements in or der to provide therapy services, including: 310 a. Physical Therapy services mustMust be provided by a personPerson 311 licensed by the Arizona Board of Physical Therapy Examiners pursuant to 312 Arizona Revised Statutes (“: 313 1.1 A.R.S.”), Title 32, Chapter 19.

314 i. 1.1.1 A Physical Therapist physical therapist using a Physical 315 Therapy Assistant mustphysical therapist assistant Must adhere to 316 the supervision requirements from the Arizona Board of Physical 317 Therapy Examiners pursuant to A.R.S., Title 32, Chapter 19.; 318 b. Physical Therapy Technicianstherapy technicians or other personsPersons 319 who are not Physical Therapistsphysical therapists or Physical Therapy 320 Assistants shallphysical therapist assistants Shall not be used to provide 321 this service. ; and


322 c. Each Physical Therapist shallphysical therapist and physical therapist 323 assistant Shall have a National Provider Identifier (“(NPI”). ). 324 2.3. The Qualified Vendor and/or appropriate staff will attend administrative 325 meetings, orientation, and various trainings required by the DivisionDepartment.

326 Recordkeeping and Reporting R equirements 327 1. The Qualified Vendor shall submit an evaluation report to the member’s Support

328 3.4. Coordinator, the member/member’s representative,Shall maintain Records 329 documenting training for all therapists and therapy assistants and the PCP within 330 three (3) weeks of the evaluationmake training and Records available upon request 331 by the Department. 332 1.1 The content of the evaluation report shall include, at a minimum, the Division’s therapy 333 reporting requirements as identified on the Therapy Assessment/Evaluation report 334 form.

335 Rate Basis 336 1. The Qualified Vendor shall ensure that the therapist maintains contact notes for each 337 therapy session and submits the noteswill bill according to the Division as 338 requestedDivision’s Policies and Procedures Manual, Billing Manual, Rate Book. 339 2. The Qualified Vendor shall submit quarterly individualized progress reports on the member 340 to the Division and the member/member’s representative unless the member/member’s 341 representative has requested not to receive them. The quarter is based on the calendar 342 year and the reports are due no later than the fifteenth (15) day following the end of the 343 quarter. The Qualified Vendor shall refer to the Division’s Provider Manual for guidance on 344 report due dates and minimum content of the reports.

345 3. The Qualified Vendor shall submit a discharge summary report to the member’s Support 346 Coordinator, the member/member’s representative, and the PCP no later than the tenth 347 (10th) business day after closure of services or a change of a Qualified Vendor.

348 3.1 The content of the report shall include, at a minimum, the Division’s discharge 349 summary reporting requirements as identified on the Division’s Quarterly Therapy 350 Progress/Discharge Report form.

351 4. The Qualified Vendor shall maintain daily records on file as proof of the number of hours 352 worked by each direct service staff (therapists/therapy assistants) providing direct service to 353 members.

354 4.1 Each time sheet, equivalent document, or data system must contain the original 355 signature or other independent verification (that complies with A.R.S. § 41-132) of the 356 member/member’s representative confirming the hours worked. Proof of hours worked 357 must be signed or verified by the member/member’s representative prior to the 358 Qualified Vendor submitting the claim for payment.


359 5. The Qualified Vendor shall maintain a copy of the member’s current physician’s order (i.e., 360 prescription) for therapy services in the member’s record.

361 6. Upon initiation of service for the member and each month thereafter, the Qualified Vendor 362 shall verify and update current information from the member/parent/family 363 member/caregivers about the member’s insurance coverage, Third Party Liability (“TPL”). 364 Updated information shall be provided to the member’s Support Coordinator in the method 365 requested by the Division.

366 7. The Qualified Vendor shall provide and maintain updated information regarding availability, 367 capacity, and contact information in the Division’s Therapy Directory as directed by the 368 Division.

369 2. The Qualified Vendor shall maintain data that demonstrates full compliance with all 370 programmatic and contractual requirements of the Department and the Division.The 371 Qualified Vendor Shall bill the Department this modified rate. This modified rate 372 Must receive prior approval by the Department.


Documents

The following service specification has been revised for