CHAPTER 1300 Adult Occupational Therapy Services

CHAPTER 1300
SPECIFIC PROGRAM REQUIREMENT
FOR
ADULT OCCUPATIONAL THERAPY SERVICES
SCOPE OF SERVICES
1301 General
Adult Occupational Therapy Services cover evaluation and therapeutic services that are not otherwise covered by Medicaid State Plan services. These services address the occupational therapy needs of the adult participant that result from his or her developmental disability. Adult Occupational Therapy Services include occupational therapy evaluation, participant/family education, occupational therapy activities to improve functional performance, and sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands.
Adult Occupational Therapy Services are provided by a Georgia licensed occupational therapist and by order of a physician. These services may be provided in a participant’s own or family home, the Occupational Therapist’s office, outpatient clinics, facilities in which Community Access or Prevocational Services are provided, Supported Employment work sites, or other community settings specific to community-based therapy goals specified in the Individual Service Plan. Adult Occupational Therapy Services may not be provided to participants receiving Community Residential Alternative Services in the Comprehensive Supports Waiver.
1302 Special Requirements of Participation
1302.1 Individual Provider
In addition to those conditions of participation in the Medical Assistance Program as outlined in Part I, Policies and Procedures for Medicaid/PeachCare for Kids Manual applicable to all Medicaid providers, Section 106 (General Conditions of Participation), and PART II, Chapter 600 Policies and Procedures for the COMP Program, Adult Occupational Therapy Services providers must meet the following requirements:
1. Service Provision: Adult Occupational Therapy Services are provided by a Georgia licensed occupational therapist and by order of a physician. Physician orders must be on letterhead or as a prescription from the physician and must indicate either the frequency of OT therapy services or an OT evaluation to determine the frequency of OT therapy services.
2. Documentation Requirement: Providers, except for providers of participant-directed services, must document
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the following in the record of each participant receiving Adult Occupational Therapy Services:
a. Specific evaluation, training or therapeutic assistance
provided;
b. Date and the beginning and ending time when the
service was provided;
c. Location where the service was delivered;
d. Verification of service delivery, including first and last
name and title of the person providing the service and
his or her signature;
e. Progress towards moving the participant towards independence by meeting the participant ISP, which includes person-centered goals, desired outcomes in the participant’s action plan, and the amount/type of assistance/support in the Current Service Summary and the Health and Safety sections of the ISP.
f. Adult Occupational Therapy Providers must maintain
documentation for the identified need of therapies,
frequency and duration of therapy, interventions to be
provided, and goals addressing therapies.
3. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for individual providers of participant-directed services are specified in Part II Policies and Procedures for COMP, Chapter 1200.
4. Adult Occupational Therapy Services at Community Access and Prevocational Service Facilities: Providers can provide Adult Occupational Therapy Services at facilities where Community Access and Prevocational Services are rendered; however, the services must be documented and billed separately, and any waiver participant receiving multiple services may not receive these services at the same time of the same day.
1302.2 Provider Agencies
In addition to those conditions of participation in the Medical Assistance Program as outlined in Part I, Policies and Procedures
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for Medicaid/PeachCare for Kids Manual applicable to all Medicaid providers, Section 106 (General Conditions of Participation), and PART II, Chapter 600 Policies and Procedures for the COMP Program, Adult Occupational Therapy Services provider agencies must meet the following requirements:
1. Service Provision: Adult Occupational Therapy Services are provided by a Georgia licensed occupational therapist and by order of a physician. Physician orders must be on letterhead or as a prescription from the physician and must indicate either the frequency of OT therapy services or an OT evaluation to determine the frequency of OT therapy services.
2. Types of Agencies: Agencies that provide Adult Occupational Therapy Services are:
a. Accredited or Certified DD Service Agencies;
b. Home Health Agencies.
3. Staffing Qualifications and Responsibilities:
a. Accredited or Certified DD Service Agencies rendering Adult Occupational Therapy Services must have staffing that meets the following requirements:
1) A designated agency director who must:
 Have either a bachelor’s degree in a human service field (such as social work, psychology, education, nursing, or closely related field) and five years of experience in service delivery to persons with developmental disabilities, with at least two of these years serving in a supervisory capacity; or
 Have an associate degree in nursing, education or a related field and six years of experience in service delivery to persons with developmental disabilities, with at least two of these years serving in a supervisory capacity; or
2) Duties of the Agency Director include, but are not limited to:
 Oversees the day-to-day operation of the agency;
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 Manages the use of agency funds;
 Ensures the development and updating of required policies of the agency;
 Manages the employment of staff and professional contracts for the agency;
 Designates another agency staff member to oversee the agency, in his or her absence.
3) At least one agency employee or professional under contract with the agency must be a Developmental Disability Professional (DDP) (for definition, see Part II Policies and Procedures for COMP, Appendix I);
4) The same individual may serve as both the agency director and the Developmental Disability Professional;
5) Duties of the DDP include, but are not limited to:
 Overseeing the services and supports provided to participants;
 Supervising the formulation of the participant’s plan for delivery of Adult Occupational Therapy Services;
 Conducting functional assessments; and
 Supervising high intensity services.
6) Provider agencies must have available a sufficient number of employees or professionals under contract that are Georgia licensed occupational therapists to provide Adult Occupational Therapy Services as specified in the Individual Service Plans of participants served.
7) Duties of the occupational therapists include all
covered services in Section 1306.
b. Home Health Agencies rendering Adult Occupational Therapy Services must have staffing that meets the conditions of participation in the Medical Assistance
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Program as outlined in PART II, Chapter 600 Policies and Procedures for Home Health Services.
4. Agency Policies and Procedures: Each provider agency must develop written policies and procedures to govern the operations of Adult Occupational Therapy services, which follow the Standards for the Georgia Department of Behavioral Health and Developmental Disabilities refer to Part II Policies and Procedures for COMP.
5. Documentation Requirement: Providers, except for providers of participant-directed services, must document the following in the record of each participant receiving Adult Occupational Therapy Services:
a. Specific evaluation, training or therapeutic assistance provided;
b. Date and the beginning and ending time when the service was provided;
c. Location where the service was delivered;
d. Verification of service delivery, including first and last name and title of the person providing the service and his or her signature;
e. Progress towards moving the participant towards independence by meeting the participant ISP, which includes person-centered goals, desired outcomes in the participant’s action plan and the amount/type of assistance/support in the Current Services Summary and the Health and Safety sections of the ISP.
f. Adult Occupational Therapy Providers must maintain documentation for the identified need of therapies, frequency and duration of therapy, interventions to be provided, and goals addressing therapies.
6. Participant-Directed Services Documentation and other Requirements: Documentation and other requirements for providers of participant-directed services are specified in Part II Policies and Procedures for COMP, Chapter 1200.
7. Adult Occupational Therapy Services at Community Access and Prevocational Service Facilities: Providers can provide Adult Occupational Therapy Services at facilities where Community Access and Prevocational Services are
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rendered; however, the services must be documented and billed separately, and any waiver participant receiving multiple waiver services may not receive these services at the same time of the same day.
8. DBHDD Contract/LOA and DBHDD Community Service Standards: Providers must adhere to DBHDD Contract/LOA, DBHDD Community Service Standards and all other applicable DBHDD Standards, including accreditation by a national organization (CARF, JCAHO, The Council, Council on Accreditation) or certification by the Department of Behavioral Health and Developmental Disabilities (see Part II Policies and Procedures for COMP, Chapter 603).
1303 Licensure
A. Adult Occupational Therapy Services are provided by a licensed Occupational Therapist in accordance with the applicable Georgia license as required under OCGA Title 43-28-1.
B. Home Health Agencies providing Adult Occupational Therapy services must have a Home Health Agency License (State of Georgia Rules and Regulations 290-5-38)
1304 Special Eligibility Conditions
A. Adult Occupational Therapy Services are not available until the waiver participant’s 21st birthday.
B. The need for Adult Occupational Therapy Services must be reflected in the Intake and Evaluation Team approved Individual Service Plan (ISP).
C. There is a reasonable expectation by the licensed occupational therapist that the participant can achieve the goals in the necessary time frame.
D. All services must be ordered by a physician.
1305 Prior Approval
Adult Occupational Therapy Services must be authorized prior to service delivery by the operating agency at least annually in conjunction with the Individual Service Plan development and with any ISP revisions. The need for Adult Occupational Therapy must be an identifiable assessed need in the ISP and directly related to the disability.
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1306 Covered Services
Reimbursable Adult Occupational Therapy Services include the following based on the assessed need of the participant and as specified in the approved ISP:
1. Occupational therapy evaluation.
2. Therapeutic activities to improve functional performance.
3. Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands.
4. Participant/family education.
1307 Non-Covered Services
1. Adult Occupational Therapy Services do not include in-home therapeutic services for the treatment of an illness or injury that are covered in Home Health Services under the regular Medicaid State Plan.
2. Participants cannot receive Adult Occupational Therapy Services if receiving Community Residential Alternative Services.
3. Adult Occupational Therapy Services may not be provided at Community Residential Alternative Services sites.
4. Transportation to and from these services is not included in the rate.
5. Group Therapy Activities.
6. Not covered for conditions not related to DD diagnosis.
7. Services that have not been ordered by a physician.
8. Services in a hospital.
9. Payment is not made for those goods and services covered by the State Medicaid Plan except where a participant’s need exceeds State Plan coverage limits and exceptions to the coverage limits are not available.
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1308 Basis for Reimbursement
The reimbursement rates for Adult Occupational Therapy Services are found in Appendix A.
The rate cannot exceed the established Medicaid rates for the Children Intervention Services Program.
1. Unit of service for OT evaluation is one (1) evaluation and for OT Therapeutic Activities and OT Sensory Integrative Techniques is fifteen (15) minutes.
2. The annual maximum of units for OT Evaluation (97003 and 97003 UC) is one (1) unit.
3. The daily maximum number of units for OT Therapeutic Activities (97530-GO and 97530-GO/UC) and for OT Sensory Integrative Techniques (97553-GO and 97553-GO/UC) is four (4) units.
4. $1,800.00 annual maximum for all adult therapy waiver services (including PT, OT, and SLT).
1309 Participant-Direction Options
A. Participants can choose the self-direction option with Adult Occupational Therapy Services.
B. An individual serving as a representative for a waiver participant in self-directed services is not eligible to be a participant-directed provider of Adult Occupational Therapy Services.
C. For details on participant-direction, see Part II Policies and Procedures for COMP, Chapter 1200.

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