DRS Rehabilitation Policy Manual Chapter 6: Physical Restoration Services

6.1 Physical Restoration Services

6.1.1 Overview

*DRS authorizes physical restoration services only when the service is necessary to correct or substantially modify, within a reasonable time, a physical condition that is stable or slowly progressive. Physical restoration services are chosen to substantially improve a consumer’s functional ability to perform the employment goal or support other needed vocational rehabilitation services.*

*Based on 34 CFR Sections 361.48(e) and 361.5(b)(40).

Refer to Chapter 17: Purchasing Goods and Services for Consumers, for information regarding general purchasing processes and procedures that apply to all consumer purchases.

The following section describes

 the kinds of physical restoration services purchased by DRS;  general policies that apply to those purchases; and  specific policies that apply to specific conditions, procedures, and specialized restoration programs.

Physical restoration includes a wide range of services provided in a variety of settings. *DRS provides physical restoration services, when necessary, to correct or substantially modify, within a reasonable time, a physical condition that is stable or slowly progressive.*

*Based on 34 CFR Sections 361.48(e) and 361.5(b)(40)

When planning any physical restoration services, you must

 ensure that the consumer understands the recommended treatment;  document the expected impact of the services on the impediment to employment;  assess and plan for needed posttreatment or procedure follow-up, including medication; and  identify any long-term or ongoing medical needs after DRS involvement ends and discuss with the consumer plans for meeting those needs.

For additional information about the consumer's condition and treatment and the condition's possible impact on employment, consult the Medical Disability Guidelines.

Page 1 of 29 6.1.2 Services Not Authorized

DRS does not authorize payment for some services because the conditions they address

 have no vocational impact, or  are addressed by comparable benefits.

Services not authorized include

 general medical care (that is, medical or surgical services that are not directly related to the vocational objective or do not support other VR services);  maternity care; and  medical or surgical treatment associated with o active tuberculosis, o sexually transmitted diseases, o cancer, o organ transplantation, o AIDS, or o end-stage renal disease.

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6.1.3 Physical Restoration Services Procedures

Use the following procedures when providing physical restoration services:

1. document how the impediments to employment are being addressed by the planned services; 2. obtain a written recommendation for any planned services (for surgery, use DARS3110, Surgery and Treatment Recommendations); 3. when you plan surgical services, have your local medical consultant (LMC) review the DARS3110 or treatment plan before you approve the purchase of services; 4. when you plan certain dental procedures, have your regional dental consultant (RDC) review the treatment plan before you approve the purchase (see Chapter 1: Foundations, Roles, and Responsibilities, 1.4.3 Regional Dental Consultant (RDC) Services, for dental procedures that require review by the RDC); 5. if you plan physical restoration services to be provided in a hospital, ambulatory surgical center, post-acute brain injury facility, or medical school, use a Medical Services Coordinator (MSC) to arrange the services. See Chapter 1: Foundations, Roles, and Responsibilities, 1.3.4 Responsibilities of the Medical Services Coordinator (MSC), which describes the MSC's functions and your responsibilities; 6. for those services requiring the DRS medical director's approval, obtain the approval before providing them;

Page 2 of 29 7. before committing to sponsor medical services not listed in MAPS, you must consult with DRS MAPS Provider Services by emailing [email protected]; 8. if the provider requests payment that exceeds MAPS rates, obtain approval from the DRS medical director; and 9. following the completion of services, obtain information about changes in functional limitations or work capacity from the service provider, either verbally or in writing.

Document how the impediment to employment has changed as a result of the physical restoration service using one of the following:

o the DARS3106, Work Restriction Checklist; o a case note; or o other written means, such as clinic notes or progress notes.

See Tips on Using the DARS3106, Work Restriction Checklist.

Exception: Intercurrent illness and dental treatment do not require assessment of residual functional limitations.

If diagnostic hospitalization exceeds seven days, explain in the case notes.

6.1.4 Actions Contrary to a Consultant's Advice

Your decision to proceed with a physical restoration service requires documented rationale and area manager approval if it is contrary to the advice of the

 LMC,  regional psychological consultant (RPC), or  RDC.

6.1.5 Consumer Changes Physician or Hospital

If a consumer wants to change treating physicians or hospitals after admission, he or she must write a letter regarding the change to the physician or hospital. Place a copy in the case file.

6.1.6 Comparable Services and Benefits for Restoration Services

*Consumers requiring physical restoration services must apply for comparable services when they

 live in an area served by tax-supported hospitals and/or clinics; and  have an income that qualifies the consumer for services at no cost to DRS, or at a reduced rate.*

Page 3 of 29 You must

 assess the availability of comparable services and benefits,  advise the consumer to apply for them, and  help the consumer with the applications, as needed.

*Based on 34 CFR Section 361.53(c)

If comparable services and benefits are available, DRS may participate in the cost of services if the combination of DRS payment and the comparable benefit payment amount does not exceed, as appropriate, the maximum amount allowed by the

 Maximum Affordable Payment Schedule (MAPS),  contracted payment rate, or  retail or negotiated lower price (for non-MAPS, noncontract items).

If the comparable benefit is

 major medical insurance, a health maintenance organization (HMO), or preferred provider organization (PPO), DRS may pay the consumer's portion (co-payment, coinsurance, and any unmet deductible) not to exceed the MAPS rate, contract rate, or retail price, as applicable;  Medicare, DRS may pay the consumer's portion (co-payment, coinsurance, and any unmet deductible) not to exceed the MAPS rate, contract rate, or retail price, as applicable; or  Medicaid, DRS pays nothing. DRS does not supplement a Medicaid payment for a specific service or procedure.

When the consumer is determined eligible for services, use the following and any other available benefits before using DRS funds (See Chapter 4: Assessing and Planning, 4.5 Comparable Services and Benefits, for additional details.):

 Medicaid;  Medicare;  health insurance (including major medical insurance, an HMO, or a PPO);  TRICARE®, formerly the Civilian Health and Medical Program of the Uniformed Services in the United States (CHAMPUS);  workers' compensation medical benefits;  the Children with Special Health Care Needs program (CSHCN);  services at no cost to DRS, or services at a reduced rate, at a tax-supported hospital or clinic;  County Indigent Health Care program;  Veterans Administration (VA) hospitals;  University of Texas Medical Branch at Galveston (UTMB);  M.D. Anderson Cancer Center;

Page 4 of 29  Kidney Health Care program through the Department of State Health Services; and/or  state tuberculosis facilities.

Exceptions to Using Comparable Services and Benefits for Restoration Services

For exceptions to using comparable services and benefits, see Chapter 4: Assessing and Planning, 4.5.2 Exceptions to Using Comparable Services and Benefits.

6.1.2 Key Terms

Anticipated ancillary services—Services typically provided to support the primary service. For example, coordination of orthopedic surgery requires the primary services of a surgeon and hospital, and also requires the additional or ancillary services of anesthesiology, radiology, and laboratory providers.

Courtesy case—Copies of all documents from the consumer case file needed by the medical service coordinator (MSC) to coordinate medical services or for the medical director to approve medical services. The packet that is sent to the MSC must include current medical records, comparable benefit information, a current DARS3110 , Surgery and Treatment Recommendations, the DARS3101 , Consultant Review, and current prescriptions and treatment orders.

Current Procedural Terminology (CPT) codes—Five-digit numerical codes assigned to medical procedures. CPT codes are developed, maintained, and copyrighted by the American Medical Association.

Global service period—The length of time after surgery that the surgeon will provide continued care without charge. The industry standard is 90 days post-surgery; however, the global period should be confirmed with each surgeon.

Healthcare Common Procedure Coding System (HCPCS) Codes—Five-character alpha-numeric codes assigned to durable medical equipment and some medical procedures, such as L codes for prosthetic components.

Intercurrent illness—an acute medical condition that prevents the consumer from participating in planned rehabilitation services.

Local Medical Consultant (LMC)—the medical consultant assigned to the DRS office to review cases and give guidance on the medical aspects of the consumer’s disability to include symptoms, functional limitations, typical treatment and diagnostic tests, prognosis, standards of care, value of second opinion, clarification of medical reports, and the appropriateness of the recommended treatment.

Maximum Affordable Payment Schedule (MAPS) codes—Five-character alpha- numeric codes that DARS uses to identify specific medical procedures, services, and

Page 5 of 29 medical equipment and the payment rate for the specific medical procedure, service, or medical equipment. Most MAPS codes are the same as the CPT code.

Medical complication—an acute or chronic condition that results from the physical restoration service or is inherent in the condition under treatment.

Medical Director—DRS medical consultant with statewide responsibility for approval of specific medical services, medical guidance for individual consumer cases, consultation on development of DRS physical restoration policy, and approval of payments for medical services that exceed MAPS.

Medical Service Coordinator (MSC)—DRS staff person who coordinates consumer medical services that are provided in a hospital, facility or medical school setting. The Home MSC coordinates medical services in the region where the consumer lives and has an active vocational rehabilitation case. The MSC coordinates services when a consumer needs medical treatment outside the region where the consumer normally lives.

Medical Services Required Practice Handbook—The DRS guidance handbook for the coordination and payment of consumer medical services.

Necessary unplanned services—medical service provided due to a medical complication or an additional service ordered by the physician in support of an authorized service. This is also referred to as an ancillary purchase. See Chapter 17: Purchasing Goods and Services for Consumers, 17.5 After-the-Fact Purchases and Revisions to Service Authorizations, 17.5.2 Backdated Ancillary Service Authorizations.

Outdated prescription or physician order—A prescription for medication or therapy that was signed by the physician more than 30 days ago.

Outdated surgery or treatment recommendation—A surgery or treatment recommendation that is more than months from the date the DARS3110, Surgery and Treatment Recommendations, is signed by the physician.

Program specialist for physical disabilities—DRS staff consultant who provides guidance on physical disabilities, vocational rehabilitation implications, and physical restoration services.

Program Specialist for physical restoration—DRS central office staff consultant who provides guidance on medical services purchasing, new medical vendor set-up, vendor qualifications, MAPS code assistance, and rates for medical services.

Regional dental consultant (RDC)—dental consultant that provides guidance to DRS staff on consumer dental issues to include an explanation of report findings, recommended dental restoration services, expected results with treatment and the

Page 6 of 29 value of a second opinion. The RDC review is required for all cast restoration, endodontic procedures, dental implants, and oral surgery.

6.1.3 Restricted Physical Restoration Services

Medical services that are sponsored or supported by DRS must have a direct effect on the consumer’s functional ability to perform the employment goal or the services must support other needed vocational rehabilitation services.

Medical services that are not authorized include:

 on-going general medical care for health maintenance;  emerging technology, temporary, or investigational medical services (T-codes);  maternity care; and  medical or surgical treatment associated with o active tuberculosis, o sexually transmitted diseases, o cancer, o organ transplantation, o human immunodeficiency virus infection (HIV) or acquired immunodeficiency syndrome (AIDS), or o end-stage renal disease.

Management exceptions to this list are not allowed.

For information about information about specific treatments or conditions, refer to 6.4 Physical Restoration Services or Procedures with Special Requirements.

6.1.4 Physical Restoration Services Procedures

The counselor must document how the consumer’s impediments to employment are being addressed by the planned physical restoration services. After getting all required reviews and approvals, these services must be included in the consumer’s individualized plan for employment (IPE). The counselor also provides guidance to ensure that the consumer understands the recommended treatment and status throughout the physical restoration process.

For additional information about the consumer’s medical condition, treatment options, and potential employment impact, consult the Medical Disability Guidelines.

Use the following procedures when authorizing physical restoration services. The counselor must:

1. review the consumer’s medical records related to the reported disability; 2. get a written recommendation for planned medical services; and

Page 7 of 29 3. get the current procedural terminology codes from the surgeon or physician for the recommended procedures.

If the recommendations include DARS sponsored surgeries or invasive procedures requiring general anesthesia:

1. complete a DARS3110, Surgery and Treatment Recommendations; 2. have the local medical consultant (LMC) review the DARS3110; 3. have the LMC complete a DARS3101, Consultant Review, before purchasing medical services; and 4. consult with the DRS program specialist for physical restoration to authorize medical services:

 not listed in the Maximum Affordable Payment Schedule (MAPS);  codes listed as $0; or  codes ending in “99” or the letter “T”.

When dental services are planned, have the regional dental consultant review the treatment plan and complete a DARS3101 before dental services are approved.

If the provider requests authorization for services that exceed the MAPS rates, get approval from the DRS medical director. For services requiring the area manager’s or the DRS medical director's approval, get the approval before authorizing the medical service or before including the service in the consumer’s IPE. Justification of a payment rate that exceeds the MAPS rate must show that the:

 consumer is an established patient of the medical provider;  a limited number of medical providers exist in the geographical area where the consumer resides;  surgery or procedure is complicated and requires the special expertise of the medical provider;  rate is the best value to DRS.

Local field office staff members coordinate consumer medical services that are not provided in a hospital, facility, or medical school. These include a medical evaluation and treatment in a physician office, therapy services, durable medical equipment, and prosthetic or orthotic services.

The designated medical services coordinator (MSC) coordinates all consumer physical restoration services that will be provided in a hospital, ambulatory surgical center, post- acute brain injury facility, or medical school (See Key Terms Courtesy case). Send a complete courtesy case to the MSC to assist with coordination of the services.

Exception: The local field office staff member may coordinate a laboratory or radiology diagnostic test at a hospital or facility if the diagnostic test is ordered by a physician in conjunction with a medical evaluation and the laboratory or radiology order does not

Page 8 of 29 allow time for MSC coordination of the requested diagnostic test. In that case, the local field office staff member should seek guidance from the MSC before issuing the service authorization.

The counselor contacts the consumer at the time of hospital discharge to ensure that the consumer understands post-operative instructions and is aware that he or she must notify the physician and the counselor if there are signs and symptoms of a potential medical complication. The counselor provides continued monitoring and support to the consumer during rehabilitative treatment to assess progress and compliance with the treatment regimen.

Following the completion of services, obtain information about changes in functional limitations or work capacity from the service provider, either verbally or in writing. Document how the impediment to employment has changed as a result of the physical restoration service using one of the following:

 DARS3106, Work Restriction Checklist;  Clinic or progress notes; or  ReHabWorks case note.

Exception: Intercurrent illness and dental treatment do not require assessment of residual functional limitations.

Identify the consumer’s long-term and ongoing medical needs after DRS sponsorship of physical restoration services ends and discuss plans for meeting those needs.

6.1.5 Actions Contrary to a Consultant's Advice

A decision to proceed with a physical restoration service contrary to the advice of the local medical consultant (LMC) or the regional dental consultant (RDC) requires a documented rationale and approval of both the area manager and the DRS medical director.

6.1.6 Role of the Medical Services Coordinator (MSC)

The medical services coordinator (MSC) must coordinate

 all hospital in-patient and outpatient medical services;  ambulatory surgical center services;  residential and non-residential post-acute brain injury (PABI) services; and  treatment at medical schools.

The MSC coordinates all needed discharge medications and durable medical equipment for the first two weeks following discharge for in-region cases and the first 30 days for out-of-region cases.

Page 9 of 29 For MSC-coordinated services, the counselor must send a complete courtesy case of required information to the designated MSC. For out-of-region consumer medical services, the counselor must send the courtesy case to the designated in-region MSC (Home MSC) who will forward the courtesy case to the appropriate out-of-region MSC (Service MSC) for coordination of the service and notify the counselor of the case assignment. When out-of-region services are completed, the Service MSC notifies both the Home MSC and the counselor that the services have been completed and transfers the medical services coordination of the case back to the Home MSC for additional services that must be provided in the home region.

When coordinating medical services, the MSC must

 serve as the DRS point of contact with the medical provider to coordinate the service(s);  verify comparable benefits;  get a cost estimate for medical services and notify counselor;  request Budget Buster funds as applicable to case on behalf of the counselor;  issue service authorizations for service and all anticipated ancillary services;  get admission or start dates for services and notify consumer as directed by the counselor. Verify consumer admission, discharge and completion of service;  notify the counselor of any case coordination issues or medical complications requiring authorization of additional services;  coordinate discharge medication and durable medical equipment needs for the consumer;  pay medical provider bills and send paid bills to counselor;  get consumer treatment records and send records to the counselor; and  document in the electronic case management system pertinent MSC case actions related to the coordination of medical services, including o comparable benefit verification information with contact name and date; o estimated cost of medical services and Budget Buster request if applicable; o specific medical service coordinated to include the provider name, admission or start date of service, and number of units or days authorized; o for surgery cases, document the name of the surgery, surgeon, hospital or facility and admission and surgery date; o verification of discharge date, end date of service, and consumer completion of service; o a list of ancillary providers required for coordination of the primary medical service; o consumer medical complications and requests for additional services or an extension of services; o the reason for delay in the coordination of medical services; o the counselor contact to discuss medical coordination case issues; and o the medical provider contacts to coordinate and pay for medical services.

Page 10 of 29 6.1.7 Necessary Unplanned Medical Services

The counselor should not pay for any medical service that has not been pre-approved with a service authorization. If additional medical services are deemed necessary, the provider should notify the counselor or the medical services coordinator (MSC) to request a service authorization before providing the additional service(s).

Invoices for medical services provided without DRS pre-approval should be infrequent and must be immediate services required for the safety and welfare of a consumer. These invoices must be submitted to the area manager for counselor coordinated medical services or the operations director for programs for MSC coordinated medical services for review and approval of a back-dated service authorization for payment. The area manager or operations director for programs must document the review of the invoice and the decision regarding payment in the electronic case management system.

Refer to Chapter 17: Purchasing, for more information about processing ancillary, after- the-fact, and back-dated service authorizations.

6.1.8 Treatment of Medical Complications

*A medical complication, either acute or chronic, that results from the physical restoration services or is inherent in the condition under treatment is considered a part of the physical restoration service.*

*Based on 34 CFR Section 361.5(b)(40)(xiv)

The medical services coordinator (MSC) is responsible for confirming that the consumer is discharged from the hospital or facility as planned and in accordance with the number of days documented on the service authorization. If the consumer is not discharged as planned due to medical complications, the MSC and the counselor should follow the procedures identified in the Medical Services Required Practices Handbook.

The MSC is the point of contact with the hospital or facility concerning the authorization of additional hospital days and medical treatment. The counselor assesses the prognosis for recovery that will permit the consumer to participate in vocational rehabilitation (VR) services leading to employment.

If the consumer does not make sufficient recovery from medical complications, and the counselor concludes that the consumer is no longer able to participate in VR services, the counselor refers the consumer to other comparable benefits for additional services and support.

After reviewing and documenting the circumstances of the consumer’s closure with the manager and the MSC, the counselor must notify the following persons in writing if the decision is made to close the consumer’s case:  Consumer

Page 11 of 29  Consumer's family  Hospital representative  Attending physician

If the closure reason is “disability too severe,” refer to Chapter 16: Closure, 16.3.2 Reasons and Procedures for Unsuccessful Closures, for required closure procedures for all closure reasons.

6.1.9 Comparable Services and Benefits for Restoration Services

When a consumer is determined eligible for services, use all available comparable services and benefits for planned physical restoration before using DRS funds.

*A consumer determined eligible for services with planned physical restoration must apply for comparable services and benefits if the consumer

 lives in an area served by tax-supported hospitals and or clinics; and  has an income that qualifies the consumer for services at no cost to DRS, or at a reduced rate.*

*Based on 34 CFR 361.53(a-c)

The counselor must

 assess the availability of comparable services and benefits; and  advise the consumer to apply for them, and assist the consumer with the applications, as needed.

Use an identified comparable service or benefit unless

 the use of the comparable service or benefit would result in an interruption or delay in the provision of vocational rehabilitation services to a consumer who is determine to be at medical risk, based on medical evidence provided by an appropriate qualified medical professional; and  the treating physician who has an established relationship with the consumer does not have privileges to perform the service at the hospital or facility where the comparable benefit is available.

If comparable benefits are verified, DRS may pay the consumer’s portion, to include the consumer’s deductible, co-insurance, and or co-pay amount, provided that the consumer’s portion does not exceed the maximum amount allowed by the

 Maximum Affordable Payment Schedule (MAPS),  contracted payment rate, or  retail or negotiated lower price (for non-MAPS, noncontract items).

Page 12 of 29 If the comparable benefit is

 major medical insurance, a health maintenance organization (HMO), or preferred provider organization (PPO), DRS may pay the consumer's portion (co-payment, coinsurance, and any unmet deductible) not to exceed the MAPS rate, contract rate, or retail price, as applicable;  Medicare, DRS may pay the consumer's portion (co-payment, coinsurance, and any unmet deductible) not to exceed the MAPS rate, contract rate, or retail price, as applicable; or  Medicaid, DRS pays nothing. DRS does not supplement a Medicaid payment for a specific service or procedure.

Explanation of Benefits (EOB)

When a consumer has health insurance, Medicare, or Medicaid, the provider must first submit a timely claim to these entities, as applicable, for payment of the provided medical services. An Explanation of Benefits (EOB) is sent to the medical provider to document the payment made per benefit coverage and the patient’s payment responsibility (consumer portion). The medical provider must submit to DRS a copy of the EOB with the provider’s invoice so that the DRS payment responsibility can be determined.

If the comparable benefit denies the service, review the EOB to determine the reason for the denial. Contact the medical provider if the service was denied for insufficient documentation and request that the provider re-submit the claim with proper documentation. DRS is not responsible for payment of services when a medical provider fails to timely file the claim with the comparable benefit.

6.2 Professional Medical ServicesProviders

Medical treatment may include the services of a

 attending physicians,  surgeons,  anesthesiologists,  assistant surgeons,  consultants,  radiologists,  pathologists,  physician assistants, and  advanced practice nurses.

 physician,  surgeon,  anesthesiologist,

Page 13 of 29  assistant surgeon,  chiropractor,  radiologist,  pathologist,  physician’s assistant,  nurse practitioner,  physical therapist,  occupational therapist,  speech therapist, and/or  certified registered nurse anesthetist

A physician’s assistant (PA) and a nurse practitioner (NP) provide medical services under the licensure and supervision of a physician; however, they may evaluate and treat a consumer, as well as issue a report, without a physician’s co-signature.

For additional information about required qualifications of health care providers, refer to Chapter 17: Purchasing Goods and Services for Consumers, 17.23 Health Care Professionals—Required Qualifications.

6.2.1 Medical Reports

The medical provider must send documentation that the medical service was provided along with the invoice for payment. Examples of acceptable documentation include

 medical report or office notes;  operative report;  therapy progress notes; and  diagnostic test report

If a medical evaluation is purchased, the evaluation report must address the following:

 Medical history  Reported symptoms  Review of body systems  Clinical examination findings  Diagnoses of medical condition(s)  Recommended treatment

6.2.21 Payment to Medical ProfessionalsProviders

The following conditions apply to payment for professional medical services:

 Payment for medical treatment must be the professional's usual fees and may not exceed the MAPS maximum.

Page 14 of 29  Before providing the recommended medical services, the professional performing the procedure must agree to accept the DRS allowance in MAPS as payment in full.  For additional payment for unusually difficult or complicated cases to be considered, you must consult the DRS Central Office program specialist for physical restoration (by emailing [email protected]) to obtain the medical director's approval.  Before you commit to providing medical services not listed in MAPS, consult the DRS Central Office program specialist for physical restoration by emailing [email protected].  When DRS is participating in the cost of physical restoration services, the combined total contribution by DRS, the consumer, and/or a third party may not exceed the MAPS maximum. Exception: If the third party is an HMO or PPO, DRS may pay the consumer's co-payment amount for professional medical services, as defined in MAPS, if the co-payment amount does not exceed the established MAPS rate.

Payment for medical treatment must be the professional's usual fees or the Maximum Affordable Payment Schedule (MAPS) maximum payment rate for the medical service, whichever is less.

If the medical professional’s usual fee exceeds the MAPS maximum payment rate, verify that the medical professional providing the service will agree to accept the DRS allowance in MAPS as payment in full.

If the medical provider requests payment that exceeds the MAPS rate for the medical service, get approval from the DRS medical director.

If the medical provider requests payment for travel costs, send the request to a central office program director for approval.

Consult with the DRS program specialist for physical restoration if requested to authorize medical services not listed in MAPS.

Medical providers are not paid maintenance or a per diem.

6.2.2 Treatment of Medical Complications

*A medical complication, either acute or chronic, that results from the physical restoration services or is inherent in the condition under treatment is considered a part of the physical restoration service.*

*Based on 34 CFR Section 361.5(b)(40)(xiv)

Page 15 of 29 When severe complications arise and the consumer is no longer eligible for VR services, actively try to refer the consumer to other resources. Terminate services after arrangements have been made with the

 consumer,  consumer's family,  hospital, and  attending physician.

6.2.3 Postoperative Care

Plan for postoperative care when you arrange for surgery. Postoperative care in the hospital ordinarily is included in the surgery fee. When postoperative care occurs after the consumer is discharged from the hospital and is not included in the surgery fee, you may authorize an additional payment.

Some types of surgery require the services of other physicians (for example, cardiologist, internist). Fees for these services are not part of the surgery fee. Plan to pay for these costs over and above the surgical fee.

6.2.4 Unanticipated Charges

*DRS pays for unanticipated professional services ordered during the physical restoration process. The attending physician usually orders these services "on-the- spot." Prior authorization could jeopardize the timely provision of needed services. Typical unanticipated services include, for example,

 charges for interpretations of electrocardiograms (ECG or EKG),  X-rays,  laboratory tests,  consultations, or  treatment for medical complications (either acute or chronic).*

*Based on 34 CFR Section 361.50(a)

6.2.3 Professional Surgical Services

The surgeon’s fee usually includes post-operative office visits for a period of time (See Key Terms, Global service period). The global period should be verified for each consumer and surgery.

A medical complication that results from the surgery or is inherent in the condition under treatment is considered to be a part of the physical restoration service.

Page 16 of 29 DRS uses a multiple surgical procedure discount when calculating the surgeon’s fee per MAPS. Refer to the Medical Services Required Practice Handbook for the payment methodology.

Co-Surgeons

Two surgeons may not be paid as co-surgeons on the same case at the same time except when the surgery requires the collaboration of two or more surgical specialties.

For approval of co-surgeons:

 get DARS3110, Surgery and Treatment Recommendations, from both surgeons;  verify that the identified surgeons have different specialties required by the proposed surgery;  verify that the CPT codes identifying the surgical procedures are different for each surgeon; and  get approval from the DRS medical director to pay for co-surgeons.

Surgical Assistant

A licensed physician, licensed physician’s assistant (PA), licensed surgical assistant (LSA), or registered nurse first assistant (RNFA) may be paid as a surgical assistant. Refer to the Medical Services Required Practices Handbook for the payment methodology.

Anesthesiology Services

A fee for the administration of anesthesia during a surgical procedure is paid to an anesthesiologist or a certified registered nurse anesthetist (CRNA). When a CRNA administers anesthesia under the supervision of an anesthesiologist, the supervising anesthesiologist may be paid for supervising the CRNA. Refer to the Medical Services Required Practices Handbook for the payment methodology.

A fee for anesthesia may not be paid to a physician or surgeon who administers a local anesthetic agent when performing an office procedure.

6.3 Hospital and Ambulatory Surgery Center (ASC) Services

Both hospitals and ambulatory surgical centers (ASC) provide medical services; however, procedures performed in an ASC do not require an overnight stay and are usually less complicated than those requiring hospitalization. This section covers such considerations for medical services as

 contracts with hospitals,  selecting the appropriate facility,  paying for hospital services by contract,

Page 17 of 29  paying for ASC services by MAPS codes,  exceptions to payment limits,  limits on the duration of hospitalization, and

 additional services.

6.3.1 Hospital Contracts

Hospital contracts define the business relationship between DARS and those hospitals from which DARS purchases consumer services. The contract specifies allowable payment methods for all services purchased from the hospital, which may include

 inpatient or outpatient services,  post-acute brain injury services,  psychological services,  community rehabilitation program services, and  medical records.

If a consumer needs a medical service at a hospital that does not have a DARS contract, the assigned medical service coordinator (MSC) must contact the DRS regional program specialist for quality assurance (RPS-QA) to negotiate a payment rate for the medical service. A DARS3423, Exception to Contracted Hospital Purchase must be completed and submitted through the regional director for final approval by the DRS assistant commissioner. If you need to purchase medical services from a hospital that does not currently have a contract with DARS, see Chapter 17: Purchasing, 17.4.8 Exceptions to Contracts.

6.3 Clinical Settings

Physical restoration services include, a wide range of medical services provided in a variety of clinical settings such as hospitals, outpatient facilities, and doctors’ offices.

Refer to Chapter 17: Purchasing Goods and Services for Consumers, 17.24 Health Care Facilities—Required Qualifications for additional information about required qualifications of health care facilities.

6.3.1 Ambulatory Surgery Center (ASC) Services

Medical procedures performed in an Ambulatory Surgery Center (ASC) are usually less complicated than procedures performed in a hospital and do not require an overnight stay. The Maximum Affordable Payment Schedule codes to pay the surgeon and the ASC are the same, except the code for the facility is preceded by “ASC.” Get a copy of the operative report and or the discharge summary before authorizing payment.

Page 18 of 29 6.3.2 Hospital or Medical Facility Services

Hospitals or medical facilities must have a written contract with DARS in order to receive payment for provided services. The DARS Contract Management Unit (CMU) maintains all hospital and medical facility contracts. The hospital or medical facility contract defines the business relationship with DARS, as well as the rate of payment for services, which may include

 inpatient hospital services;  outpatient hospital services;  residential post-acute brain injury services (PABI);  non-residential PABI; and  medical records.

When hospital or medical facility services are necessary, select a hospital or facility that has a DARS contract whenever possible. If a physician selects a hospital or facility for a medical service that does not have a DARS contract, the medical services coordinator must contact the physician’s office to determine if the physician has hospital and facility privileges at a DARS contracted hospital and if the surgery or procedure can be moved to the DARS contracted hospital.

6.3.3 Necessary Medical Services at a DARS Non-Contract Hospital or Medical Facility

If a consumer needs a medical service at a hospital or medical facility that does not have a DARS contract, the assigned medical service coordinator must contact the Contract Management Unit (CMU) to develop a single consumer contract with a negotiated payment rate for the medical service. A DARS3423, Exception to Contracted Hospital Purchase, must be completed to initiate the approval process.

Refer to Chapter 17: Purchasing Goods and Services for Consumers, 17.13.3 Process for Exceptions to Hospital Contracts for a list of required processes and procedures.

6.3.24 Selecting the Appropriate Facility

The consumer's treating physician can provide guidance to help you decide whether a hospital or ASC will best meet your consumer's needs. In either case, consider the

 consumer's informed choice,  availability of comparable services and benefits to pay for all or part of costs,  proximity of the facility to the consumer's home and family, and  best value.

If hospitalization is necessary, use a hospital with which DARS has a contract. When selecting a hospital, you and the consumer should consider

Page 19 of 29  specialized services available (for example, for traumatic brain or spinal cord injuries, ear, heart, brain, or orthopedic surgery);  the composition of the patient population (for example, a comprehensive medical rehabilitation program primarily serving elderly stroke patients may not be appropriate for treating a young consumer with a spinal cord injury);  the availability of additional services (for example, driver's evaluation and training, vocational evaluation, specialized orthotics, rehabilitation engineering); and  the availability and/or access to follow-up and aftercare.

6.3.3 Payment

Hospitals must have a written contract with DARS in order to receive payment. Payment may not exceed the hospital's current payment rate under the contract. Consult the hospital contract comments in ReHabWorks to obtain the hospital's current payment rate. Obtain a copy of the operative report or discharge summary before authorizing payment.

Use MAPS codes to pay for services provided at ASCs. The MAPS codes for paying a physician and for paying an ASC facility are identical except that the code for an ASC facility is preceded by "ASC." Refer to Procedure for Purchasing Services from Ambulatory Surgical Centers and ASC Fees for further information. Obtain a copy of the operative report or discharge summary before authorizing payment.

6.3.4 Exceptions to the Payment Rate Limits

Hospital contracts allow payments by comparable benefits in lieu of the contracted rate when the consumer's circumstances warrant. (See 6.1.6 Comparable Services and Benefits for Restoration Services for the correct payment procedures when using specific comparable benefits).

A special agreement with the hospital may be executed under the terms of the hospital contract. Before providing services by special agreement, complete DARS3422, Reduced Payment Agreement. The DARS3422 must be signed by authorized hospital representatives and DARS, and placed in the consumer's case file. See Circumstances Resulting in Reduced Payment Agreements for examples.

6.3.5 Limits on the Duration of Hospitalization

If the treating physician expects the recommended hospitalization to exceed 30 days, you must assess the case and staff it with the

 receiving counselor, if one is involved;  area manager; and  LMC.

Page 20 of 29 When the consumer requires hospitalization beyond what DARS originally agreed to and DARS payment will not continue, you must make other arrangements to pay for the excess hospitalization. Give written notification to

 the consumer,  the hospital,  the attending physicians, and  all other parties concerned.

6.3.6 Other Services

Blood

If a consumer needs blood, arrange for replacement, if the physician has not done so. Purchase blood when replacement is impossible.

Personal Items

DARS does not pay for personal items such as

 television rental,  telephone calls,  gourmet meals,  cots, and  guest trays.

Private Room

DARS does not pay for a private room unless

 the physician orders it as medically necessary, and/or  no other room is available.

Social Work Charges

DARS pays for hospital charges for social work services at the hospital contract rate when they are prescribed by attending physicians.

6.3.5 Hospital or Medical Facility Payments

Hospital and medical facility services are paid according to the current payment rate as established by the DARS contract and may not exceed the contract rate. Hospital services are paid on the basis of a percentage of the hospital’s usual and customary billing. Consult the hospital contract comments in the ReHabWorks to get the hospital’s current payment rate. Get appropriate documentation that a medical service was provided before authorizing payment.

Page 21 of 29 Refer to 6.5 Specialized Physical Restoration Programs for additional requirements for specialized physical restoration programs.

Documentation Required for Payment of a Hospital or Medical Facility Bill

Provider Service Documentation for Payment Hospital Inpatient surgery or Discharge summary and/or treatment operative report Hospital Inpatient diagnostic tests Discharge summary (laboratory, radiology, pathology) Hospital Outpatient treatment, Treatment, therapy, or therapy or diagnostic test diagnostic test report PABI Facility Residential Program Progress or staffing notes Discharge summary PABI Facility Non-residential Program Progress or staffing notes

Reduced Payment Agreement

Hospital contracts allow for payments below the contracted rate or in addition to the contracted rate when the consumer's circumstances warrant. A special reduced- payment agreement may be negotiated with a hospital under the terms of the hospital contract when consumer:

 is having an unusual procedure with a projected high cost;  is undergoing a series of surgical procedures over time; or  with medical complications following surgery is having a prolonged hospital stay.

The DARS3422, Reduced Payment Agreement, must be completed by the medical services coordinator and signed by an authorized hospital representative and DARS. A copy of the reduced payment agreement must be placed in the consumer's case file.

6.3.6 Length of Hospital Stay—Required Review

If the treating physician expects the recommended hospitalization to exceed 14 days, excluding in-patient comprehensive rehabilitation services and Post-Acute Brain Injury (PABI) services, the manager must review the medical treatment and consult with the program specialist for physical disabilities to ensure that the proposed treatment or surgery is an appropriate physical restoration service. The manager’s review must be documented in TxROCS. Refer to Chapter 19: Technical Information and References, 19.5 Case Reviews for additional information.

Page 22 of 29 When a consumer requires hospitalization beyond the length of time that to which DARS originally agreed, and DARS’ payment will not continue for any reason, you must make other arrangements to pay for the excess hospitalization.

Written notification must be provided to

 the consumer,  the hospital,  the attending physicians, and  all other parties concerned.

6.3.7 Termination of DARS Sponsored Hospital Services While the Consumer is Still Hospitalized

Refer to 6.1.8 Treatment of a Medical Complication.

6.3.8 Other Hospital Services

Hospital services that are not covered include

 television rental;  telephone calls;  gourmet meals;  cots; and  guest trays and a private room, unless: o the physician orders it as medically necessary; and/or o no other room is available.

Blood

If a consumer needs blood, arrange for replacement, if the physician has not done so. Purchase blood when replacement is impossible.

Social Work Charges

DARS pays for hospital charges for social work services at the hospital contract rate when they are prescribed by attending physicians.

These services are provided by contracts in either a residential or nonresidential program.

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Page 23 of 29 6.4.35 Wound Care

Wound care may be authorized for a consumer when:

 wound care is needed due to a complication of DRS-sponsored surgery; or  there is a reasonable probability that a short course of wound care treatment will result in wound healing of decubitus ulcers or diabetic foot ulcers sufficient to allow the consumer to complete planned services.

Since wound care often involves complicated treatment with an uncertain prognosis, consultation with the local medical consultant (LMC) and program specialist for physical disabilities is required before sponsoring treatment.

When wound care is needed due to a complication of a DRS-sponsored surgery, services must be initiated in a timely manner. Additional approval is not required. Inform the area manager of the status of the case, but do not delay services needed to promote the healing of the wound.

Wound care that is not a complication of a DRS-sponsored surgery often involves complicated treatment with an uncertain prognosis. In these cases, consultation with the local medical consultant (LMC) and program specialist for physical disabilities is required before sponsoring treatment.

…

6.5.7 Post-Acute Brain Injury (PABI) Services for Vocational Rehabilitation (VR)

PABI services are provided as recommended by an interdisciplinary team to address deficits in functional and cognitive skills based on individualized assessed needs. Services may include behavior management, the development of coping skills, and compensatory strategies. These services may be provided in a residential or non- residential setting.

Services are based on an assessment of the individual's assessed deficits. The goal of post-acute brain injury services for vocational rehabilitation consumers is to establish new patterns of cognitive activity and compensatory mechanisms in order to achieve a specific employment outcome.

Duration of Post-Acute Brain Injury Services

Post-acute brain injury (PABI) services are not limited by the time that has passed since the traumatic brain injury (TBI) occurred.

The 180 -day limit on post-acute rehabilitation services is measured from the first day of services sponsored by CRS. Post-acute rehabilitation services are indicated on the

Page 24 of 29 Individualized Plan for Employment (IPE) as "up to 30 days of service” and may be extended to a maximum of 180 days, without an IPE amendment, when recommended by the interdisciplinary team.

When a post-acute rehabilitation facility divides its program into two phases and releases the consumer for a period before bringing the consumer back to complete the program, DARS may sponsor both periods of PABI services up to a cumulative total of 180 days.

For more information about PABI services, see the DRS Standards for Providers Chapter 5: Standards for Post-Acute Brain Injury Service Providers. Providers of PABI services must adhere to all details outlined in that chapter.

Post-acute Brain Injury Service Array

A detailed list of post-acute brain injury residential services includes:

Service Delivery Core Services Provider Qualifications Modality Aquatic Therapy Individual and Group LP Art Therapy Individual and Group LP Behavior Management Individual LP or CP Case Management Individual CP Chemical Dependency Individual and Group LP Cognitive Rehabilitation Therapy Individual and Group LP (CRT) Dietary Nutritional Services Individual and Group LP Massage Therapy Individual LP Medical Services Individual LP Mental Restoration Individual and Group LP Music Therapy Individual and Group CP Neuropsychiatric Services Individual and Group LP Neuropsychological Services Individual and Group LP Occupational Therapy Individual and Group LP or CP Personal Assistance Individual and Group PP Physical Therapy Individual and Group LP or CP Recreational Therapy Individual and Group CP Qualifications not Room and Board Individual stipulated Speech and Language Pathology Individual and Group LP or CP

Page 25 of 29 Service Delivery Ancillary Services Provider Qualifications Modality Audiology Individual LP DME and Supplies Qualifications not Individual stipulated Family Therapy Individual and Group LP Family and/or Caregiver Education and Individual and Group LP or CP Training Home Modification Individual LP Limited Skilled Nursing Individual LP Orthosis/Prosthesis Individual LP Over-the-Counter Medications Qualifications not Individual stipulated Physical Restoration Individual LP Prescription Medications Individual LP Rehabilitation Technology Individual LP, other professionals Transportation Qualifications not Individual stipulated

A detailed list of post-acute brain injury nonresidential services includes:

Service Delivery Core Services Provider Qualifications Modality Aquatic Therapy Individual and Group LP Art Therapy Individual and Group LP Behavior Management Individual LP or CP Case Management Individual CP Chemical Dependency Individual and Group LP Cognitive Rehabilitation Therapy Individual and Group LP (CRT) Dietary Nutritional Services Individual and Group LP Massage Therapy Individual LP Mental Restoration Individual and Group LP Music Therapy Individual and Group CP Neuropsychiatric Services Individual and Group LP Neuropsychological Services Individual and Group LP Occupational Therapy Individual and Group LP or CP Physical Therapy Individual and Group LP or CP Recreational Therapy Individual and Group CP Speech and Language Pathology Individual and Group LP or CP

Page 26 of 29 Service Delivery Ancillary Services Provider Qualifications Modality Audiology Individual LP DME and Supplies Qualifications not Individual stipulated Family Therapy Individual and Group LP Family and/or Caregiver Education and Individual and Group LP or CP Training Home Modification Individual LP Limited Skilled Nursing Individual LP Orthosis and Prosthesis Individual LP Over-the-Counter Medications Qualifications not Individual stipulated Personal Attendant Care Individual PP Physical Restoration Individual LP Prescription Medications Individual LP Rehabilitation Technology Individual LP, other professionals Transportation Qualifications not Individual stipulated Vision Services Individual LP

Exceptions to Service Array

Should services be medically necessary for rehabilitation purposes (i.e.that is, not for medical emergencies) and are not included as a core or ancillary service, a formal request process must be followed before services may be provided to DARS consumers.

Step Issue Notes 1 The Interdisciplinary Team (IDT) or Identification of service and/or therapy medical expert identifies a need for needed for rehabilitation purposes is based a service and/or therapy, which is on medical assessment not offered in the Service Array 2 The IDT or medical expert sends theThe request for service must include counselor a request for the service supporting medical documentation and assessments to illustrate the necessity of the service and/or therapy and proposed billing codes (for example, Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), DARS rates) which will be used

Page 27 of 29 for billing purposes. If additional information is needed for decision making purposes, the counselor contacts the facility. 3 The counselor sends an email to his The central office includes the program or her chain of command and specialist for physical disabilities, the central office with the following program manager, and the administrative information: assistant. The chain of command includes the area  Consumer name manager or staff acting on behalf of an area  Consumer ID manager.  Consumer injury  Recommended therapy  Medical needs

 Associated CPT,/ Maximum Affordable Payment Schedule (MAPS),/ or HCPCS Codes 4 The counselor and the area The counselor and the area manager manager discuss and determine consider all information related to the whether the service is appropriate consumer to determine whether the service and medically necessary. is necessary. If the service is not appropriate or medically necessary, the service is denied by the counselor and area manager. This decision is communicated to the facility and central office by the counselor. A case note must be entered to document the reason for denial. If the service is appropriate and medically necessary, the case is shared with the chain of command, seeking approval. 5 The counselor sends a request to review and approve the proposed service to regional management. 6 Regional management reviews the If the service is determined appropriate and request and determines whether the medically necessary, an email indicating service is or is not appropriate. approval by the area manager and regional management is sent to central office requesting final review and approval. If the service is not appropriate or medically necessary, the service is denied by the counselor and area manager. This decision is communicated to the facility and central office by the counselor.

Page 28 of 29 7 Central office reviews the service Note: If more information is needed for and determines whether it is or is decision-making purposes, the counselor not appropriate to provide the must get the information at the request of service to the consumer. central office. 8 Upon determining whether the The counselor provides answers to service is approved or not approved,questions about the decision. If the facility the counselor communicates the disagrees with the decision, the appeals decision to the facility. process must be implemented. 9 An approved service requires a This must be signed by the respective completed DARS3472, Contracted regional director or assistant commissioner Service Modification be completed. of DARS. 10 Issue a service authorization (SA) All of the steps above must be completed for services before issuing an SAa service authorization.

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