Chapter 17. Physical Therapy Services

“Department” means the Maryland Department of Health, which is the single State agency designated to administer the Maryland Medical Assistance Program pursuant to Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq.

“Direct supervision” means that a licensed physical therapist is personally present and immediately available within the same treatment area as the physical therapy assistant to give aid, direction, and instruction when physical therapy procedures or activities are performed.

“Initial evaluation” means the determination of the participant's condition by taking a case history and the administration of appropriate tests on the first visit. Treatment provided at this visit is considered to be part of the initial evaluation.

“Medical Assistance Program” means the program of comprehensive medical and other health related care for indigent and medically indigent individuals, jointly financed by the federal and state governments and administered by states under Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq., as amended.

“Medically necessary” means that the service or benefit is:

“Medicare” means the insurance program administered by the federal government under Title XVIII of the Social Security Act, 42 U.S.C. §§1395—1395ccc.

“Participant” means an individual who is certified as eligible for, and is receiving, Medical Assistance benefits.

“Patient” means a person awaiting or undergoing health care or treatment.

“Physical therapist” means an individual licensed by the Maryland Board of Physical Therapy Examiners or similarly licensed or certified by the appropriate licensing body in the state or jurisdiction in which the service is provided and within the scope of Health Occupations Article, Title 13, Annotated Code of Maryland, or within the scope established by the jurisdiction of the provided service.

“Physical therapist assistant” means an individual licensed as a physical therapy assistant, working under the direct supervision of a licensed physical therapist, and performing limited physical therapy procedures that are assigned by a licensed physical therapist within the scope of Health Occupations Article, Title 13, Annotated Code of Maryland, or who is otherwise similarly licensed or certified by the appropriate licensing body in the state or jurisdiction where the service is provided and performing therapy procedures within the scope established by the state or jurisdiction of license or certification.

“Physical therapy aide” means a nonlicensed person in the employ of a physical therapist.

“Physician” means an individual licensed to practice medicine by the state in which the physician's practice is located.

“Plan of care” means the plan of treatment aimed at achieving the anticipated functional goals.

“Prescriber” means a physician, doctor of dental surgery or of dental medicine, physician assistant, nurse practitioner, nurse midwife, or podiatrist licensed to prescribe physical therapy.

“Program” means the Medical Assistance Program.

“Progress” means the measurable improvement as related to goals.

“Provider” means an individual, association, partnership, corporation, or unincorporated group licensed or similarly licensed or certified to provide health care services for participants and who, through appropriate agreement with the Department, has been identified as a Program provider by the issuance of an individual account number.

“Treatment order” means a written prescription for physical therapy signed by a physician, doctor of dental surgery or of dental medicine, physician assistant, nurse practitioner, nurse midwife, or podiatrist.

In Health Occupations Article, Title 13, Annotated Code of Maryland; or

By the appropriate licensing body in the jurisdiction where the physical therapy assistant services are performed.

Provided by a licensed physical therapist or by a licensed physical therapist assistant under a licensed physical therapist's direct supervision;

Provided in the provider’s office, the patient’s home, a domiciliary level facility, or via telehealth in accordance with COMAR 10.09.49 or other subregulatory guidance issued by the Department;

Diagnostic, rehabilitative, or therapeutic, and directly related to the written treatment order;

Of sufficient complexity and sophistication, or the condition of the patient is such, that the services of a physical therapist are required;

Rendered pursuant to a written treatment order which:

Recorded in the patient's permanent record which includes:

Services provided in a facility or by a group where reimbursement for physical therapy is covered by another segment of the Program;

Services performed by physical therapist assistants when not under the direct supervision of a physical therapist;

Services performed by physical therapy aides; or

Experimental treatment.

The provider:

The provider’s reimbursement is not limited to the provider’s customary charge.

The provider’s customary charge to the general public unless the service is free to individuals not covered by Medicaid; or

The Department's fee schedule.

Deductible insurance will be paid in full;

Beginning with August 1, 2010 dates of service, coinsurance shall be paid:

Services not covered by Medicare, but covered by the Program, according to §F, in this regulation.

The provider accepts Medicare assignment;

Medicare makes direct payment to the provider;

Medicare has determined that services were medically justified;

Services are covered by the Program; and

Initial billing is made directly to Medicare according to Medicare guidelines.

Services rendered by mail or telephone;

Completion of forms and reports; or

Broken or missed appointments.