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Seattle, WA (WorkersCompensation.com) -- Part of getting injured workers healthy -- and back to work -- often involves physical therapy and occupational therapy.
As with other treatments, PT and OT have compliance issues that are addressed by state law.
Below, we take a look at the requirements in Washington.
Occupational Therapy
| Topics | Rules |
| Supplies and materials billing | All supplies and materials must be billed using HCPCS Level II codes. |
| Reimbursement | Occupational therapy treatment will be reimbursed only when ordered by the worker's attending doctor and rendered by a licensed occupational therapist or an occupational therapist assistant serving under the direction of a licensed occupational therapist. Physician assistants may order occupational therapy for the attending doctor. Vocational counselors assigned to injured workers by the department or self-insurer may request an occupational therapy evaluation. However, occupational therapy treatment must be ordered by the worker's attending doctor or by the physician assistant. |
| Progress reports | An occupational therapy progress report must be submitted to the attending doctor and the department or self-insurer following 12 treatment visits or one month, whichever occurs first. Occupational therapy treatment beyond the initial twelve treatments will be authorized only upon substantiation of improvement in the worker's condition. An outline of: 1) the proposed treatment program; 2) the expected restoration goals; and 3) the expected length of treatment will be required. |
| Review | The department or self-insurer will review the quality and medical necessity of occupational therapy services. |
| How much will the department pay for? | The department will pay for a maximum of one occupational therapy visit per day. When multiple treatments (different billing codes) are performed on one day, the department or self-insurer will pay either the sum of the individual fee maximums, the provider's usual and customary charge, or $127.70 whichever is less. The limits do not apply to occupational therapy that is rendered as part of a physical capacities evaluation, work hardening program, or pain management program, provided a qualified representative of the department or self-insurer has authorized the service. |
| Instructions | The department will publish specific billing instructions, utilization review guidelines, and reporting requirements for occupational therapists who render care to workers. |
| Home calls | Occupational therapy services rendered in the worker's home and/or places other than the practitioner's usual and customary office, clinic, or business facility will be allowed only upon prior authorization by the department or self-insurer. |
| Inpatient treatment | No inpatient occupational therapy treatment will be allowed when such treatment constitutes the only or major treatment received by the worker. |
| Discounts | The department may discount maximum fees for treatment performed on a group basis in cases where the treatment provided consists of a non-individualized course of therapy (e.g., pool therapy; group aerobics; and back classes). |
| Codes | Billing codes, reimbursement levels, and supporting policies for occupational therapy services are listed in the fee schedules. |
Physical Therapy
| Topics | Rules |
| Billing | All supplies and materials must be billed using HCPCS Level II codes. |
| Reimbursement | Physical therapy treatment will be reimbursed only when ordered by the worker's attending doctor and rendered by a licensed physical therapist, a physical therapist assistant serving under the direction of a licensed physical therapist, or a licensed athletic trainer serving under the direction of a licensed physical therapist. Physician assistants may order physical therapy for the attending doctor. |
| Review | The department or self-insurer will review the quality and medical necessity of physical therapy services provided to workers. |
| Payment | The department or self-insurer will pay for a maximum of one physical therapy visit per day. When multiple treatments (different billing codes) are performed on one day, the department or self-insurer will pay either the sum of the individual fee maximums, the provider's usual and customary charge, or $143.66, whichever is less. These limits will not apply to physical therapy that is rendered as part of a physical capacities evaluation, work hardening program, or pain management program, provided a qualified representative of the department or self-insurer has authorized the service. |
| Instructions | The department will publish specific billing instructions, utilization review guidelines, and reporting requirements for physical therapists who render care to workers. |
| Diapulse machines | Use of diapulse or similar machines on workers is not authorized. |
| Progress report | A physical therapy progress report must be submitted to the attending doctor and the department or the self-insurer following 12 treatment visits or one month, whichever occurs first. Physical therapy treatment beyond initial 12 treatments will be authorized only upon substantiation of improvement in the worker's condition. An outline of the proposed treatment program, the expected restoration goals, and the expected length of treatment will be required. |
| Home calls | Physical therapy services rendered in the home and/or places other than the practitioner's usual and customary office, clinic, or business facilities will be allowed only upon prior authorization by the department or self-insurer. |
| Inpatient therapy | No inpatient physical therapy treatment will be allowed when such treatment constitutes the only or major treatment received by the worker. |
| Discounts | The department may discount maximum fees for treatment performed on a group basis in cases where the treatment provided consists of a non-individualized course of therapy (e.g., pool therapy; group aerobics; and back classes). |
| Biofeedback | Biofeedback treatment may be rendered on doctor's orders only. The extent of biofeedback treatment is limited to those procedures allowed within the scope of practice of a licensed physical therapist. |
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About The Author
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Frank Ferreri
Frank Ferreri, M.A., J.D. covers workers' compensation legal issues. He has published books, articles, and other material on multiple areas of employment, insurance, and disability law. Frank received his master's degree from the University of South Florida and juris doctor from the University of Florida Levin College of Law. Frank encourages everyone to consider helping out the Kind Souls Foundation and Kids' Chance of America.
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