In this chapter, the following terms have the meanings indicated. Terms Defined. “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: Directly related to diagnostic, preventive, curative, palliative, rehabilitative, or ameliorative treatment of an illness, injury, disability, or health condition; Consistent with current accepted standards of good medical practice; The most cost efficient service that can be provided without sacrificing effectiveness or access to care; and Not primarily for the convenience of the participant, family, or provider. “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. To provide services as a physical therapist under this chapter, a physical therapist shall be licensed by the State Board of Physical Therapy Examiners of Maryland to practice physical therapy, as defined in Health Occupations Article, Title 13, Annotated Code of Maryland, or by the appropriate licensing body in the jurisdiction where the physical therapy services are performed. To provide services as a physical therapist assistant under this chapter, a physical therapist assistant shall be licensed by the State Board of Physical Therapy Examiners of Maryland to practice as a physical therapist assistant as defined: 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. To participate in the Program, the provider shall: Comply with all requirements established in COMAR 10.09.36; If delivering services via telehealth, comply with COMAR 10.09.49 and any subregulatory guidance issued by the Department; and Maintain the office and medical equipment so that they are free of hazards to the health and safety of participants. The Physical Therapy Program covers medically necessary physical therapy services ordered in writing by a physician, doctor of dental surgery or of dental medicine, physician assistant, nurse practitioner, nurse midwife, or podiatrist when the services are: 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: Is signed and dated by the prescriber; Specifies the following: Part or parts to be treated; and Expected results of physical therapy treatments; Is kept on file by the therapist as a part of the patient's permanent record, subject to review by the Department or its designee; and Is not altered by the therapist unless: Medically indicated; Signed by the therapist; Necessary changes are made; The prescriber is notified of the change; and The change is noted in the patient's record; and Recorded in the patient's permanent record which includes: The treatment order of the prescriber; The initial evaluation by the therapist and significant past history; All pertinent diagnoses and prognoses; Contraindications, if any; and Progress notes documented in accordance with the requirements listed in COMAR 10.38.03.02-1A(2), C, and D. The Physical Therapy Program covers an initial evaluation, on a one-time-only basis, per condition, when the requirements of §A, of this regulation, are met. If the prescribing order exceeds 30 days, the therapist shall request a new order from the prescriber for continued therapy. The Program does not cover the following: 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. A physical therapist may only supervise two physical therapy assistants at a time. The provider shall submit the request for payment of services rendered according to procedures established by the Department and in the format designated by the Department. The provider shall certify on the invoice that the treatment order is on file and was in effect at the time that services were rendered. The provider shall specify on the invoice the type of treatment provided. A provider shall bill the Program the provider’s customary charge. If the service is free to individuals not covered by Medicaid: The provider: May charge the Program; and Shall be reimbursed in accordance with the rate provisions of §E of this regulation; and The provider’s reimbursement is not limited to the provider’s customary charge. The services covered in this chapter are reimbursed according to COMAR 10.09.23.01-1. The Department will pay for covered services, the lesser of: 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. Supplemental payment on Medicare claims for patients is made subject to the limitations of the State budget and the following provisions: Deductible insurance will be paid in full; Beginning with August 1, 2010 dates of service, coinsurance shall be paid: In full for the following: Mental health services; CPT codes that are priced by report; Claims for anesthesia services; Claims from a federally qualified health center; and HCPCS codes beginning with A through W; and For all other claims, at the lesser of: 100 percent of the coinsurance amount; or The balance remaining after the Medicare payment is subtracted from the Medicaid rate; and Services not covered by Medicare, but covered by the Program, according to §F, in this regulation. Payments on Medicare claims are authorized if: 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. The provider may not bill the Department for: Services rendered by mail or telephone; Completion of forms and reports; or Broken or missed appointments. Billing time limitations for claims submitted pursuant to this chapter are set forth in COMAR 10.09.36. The Department may return to the provider, before payment, all invoices not properly signed, completed, and accompanied by properly completed forms required by the Department. Recovery and reimbursement for this chapter are as set forth in COMAR 10.09.36.07. Cause for suspension or removal and imposition of sanctions for this chapter are as set forth in COMAR 10.09.36.08. The Department may consult with a peer review committee approved by a local chapter of the American Physical Therapy Association. The Department will give consideration to the findings and recommendations of this group. Appeal procedures for this chapter are set forth in COMAR 10.09.36.09. The interpretive regulation for this chapter is set forth in COMAR 10.09.36.10. Health-General Article, §§2-104(b), 15-103, 15-105, and 15-141.2, Annotated Code of Maryland Effective date: July 11, 1980 (7:14 Md. R. 1349) Regulation .03A amended effective January 6, 1983 (9:26 Md. R. 2572); January 30, 1984 (11:2 Md. R. 113) Regulation .07F amended effective October 1, 1982 (9:19 Md. R. 1895) Regulation .07F amended as an emergency provision effective July 1, 1982 (9:17 Md. R. 1698); emergency status expired September 30, 1982 Regulation .07F amended as an emergency provision effective July 1, 1984 (11:13 Md. R. 1171); adopted permanently effective October 29, 1984 (11:21 Md. R. 1813) Regulation .07F amended as an emergency provision effective October 1, 1986 (13:22 Md. R. 2393); adopted permanently effective February 9, 1987 (14:2 Md. R. 129) Regulation .07F amended as an emergency provision effective July 1, 1990 (17:14 Md. R. 1755); amended permanently effective November 1, 1990 (17:20 Md. R. 2427) Regulation .07G amended effective April 9, 1984 (11:7 Md. R. 625) Regulation .07L amended effective January 30, 1984 (11:2 Md. R. 113); September 10, 1984 (11:18 Md. R. 1584) Regulation .07L amended as an emergency provision effective January 28, 1991 (18:3 Md. R. 301); emergency status expired April 8, 1991 (18:9 Md. R. 1004) Regulation .07L amended as an emergency provision effective April 9, 1991 (18:9 Md. R. 1005); amended permanently effective October 7, 1991 (18:18 Md. R. 2004) Regulation .08A amended effective May 12, 1986 (13:9 Md. R. 1029) Regulation .09A, B amended effective August 17, 1981 (8:16 Md. R. 1365) Regulation .10 amended effective June 6, 1983 (10:11 Md. R. 974) Regulation .11 adopted effective October 25, 1982 (9:21 Md. R. 2106) Regulations .01—.05 and .07—.11 amended as an emergency provision effective December 2, 1992 (19:26 Md. R. 2282); amended permanently effective June 1, 1993 (20:10 Md. R. 851) Regulations .01, .04, and .05 amended as an emergency provision effective February 8, 1995 (22:5 Md. R. 364); emergency status expired May 31, 1995; amended permanently effective June 5, 1995 (22:11 Md. R. 821) Chapter revised effective October 24, 2005 (32:21 Md. R. 1708) Regulation .01B amended effective August 27, 2018 (45:17 Md. R. 803) Regulation .02 amended effective August 27, 2018 (45:17 Md. R. 803) Regulation .03 amended effective August 27, 2018 (45:17 Md. R. 803); August 7, 2023 (50:15 Md. R. 681) Regulation .04 amended effective August 27, 2018 (45:17 Md. R. 803) Regulation .04 amended effective August 7, 2023 (50:15 Md. R. 681) Regulation .06D, F, I amended effective July 4, 2016 (43:13 Md. R. 712) Regulation .06E amended effective November 14, 2011 (38:23 Md. R. 1421); February 27, 2017 (44:4 Md. R. 253) Regulation .06G amended effective April 4, 2011 (38:7 Md. R. 430) Regulation .06H amended effective August 27, 2018 (45:17 Md. R. 803)