Note: this excludes specialty PT services, such as aqua-therapy, pelvic floor, lymphedema, pediatric cases.
Authorize number of visits for PT services for chronic/nonacute conditions
- Six (6) initial visits: one (1) evaluation visit and five (5) treatment visits, maximum of four (4) units = one (1) hour per visit.
Authorized number of visits for PT services for acute conditions (new post-operative, fracture, new stroke, acute exacerbation of existing condition due to an event)
- Twelve (12) initial visits: one (1) evaluation visit and eleven (11) treatment visits, maximum of four (4) units = one (1) hour per visit.
For initiation evaluation
- The member’s condition is acute, subacute, neurodevelopmental, an acute exacerbation of a chronic condition or a function-limiting chronic condition.
- The member’s condition can be expected to show measurable, significant, sustainable functional improvement within a reasonable and generally predictable period of time as a result of the prescribed PT.
For initiation of PT treatment
- A therapy plan of care (POC) that includes the member’s diagnosis with planned treatment interventions; frequency and duration; measurable, time-specific, functional goals for therapy; and expected potential for achievement of goals and includes patient/caregiver education and training.
- You are required to number the visits/progress notes for each treatment session/visit (i.e., Visit 1, Visit 2, etc.).
Request for extension of the number of visits – documentation requirements
- Visit/progress notes that address each treatment goal, with inclusion of member’s initial status, last reporting period status and current reporting period status, with specific reference to the parameters outlined in previous status. Objective measure parameters must be consistent across reporting periods. You are required to number the visits for each treatment session/visit (i.e., Visit 1, Visit 2, etc.).
- The planned treatment techniques and interventions that are detailed including amount frequency and duration required to achieve ongoing progress toward functional, measurable goals.
- Identification of any health conditions or other factors which could impede the member's ability to benefit from treatment.
- A summary of the member’s response to therapy, with documentation of any issues which have limited progress.
- A brief prognosis statement with clearly established discharge criteria
- An explanation of any significant changes to the member’s POC, and the clinical rationale for revising the treatment plan.
- Completion of the Kaiser Short-Term Rehabilitation Therapy Extension form.
Discontinuation of PT services
- Member no longer demonstrates functional impairment or has achieved goals set forth in the POC or has returned to their prior level of function.
- Member has adapted to impairment with assistive/adaptive equipment or devices.
- Member has been receiving services over an extended period of time and it cannot be determined whether the progress is due to therapeutic intervention or natural development.
- Member is unable to participate in the plan of care due to medical, psychological, or social, complications.
- Member (and/or family/caregiver) is noncompliant with Home Exercise Program and/or lacks participation in scheduled therapy appointments.
- Member does not meet continuation criteria.