Section 85 Physical Therapy Services
Q: What are Physical Therapy Services (PT)?
A: The evaluation, treatment and instruction of human beings to detect, assess, prevent, correct, alleviate and limit physical disability, bodily malfunction and pain from injury, disease and other bodily condition; the administration, interpretation and evaluation of tests and measurements of bodily functions and structures for the purpose of treatment planning including the planning, administration, evaluation and modification of treatment and instruction; and the use of physical agents and procedures, activities and devices for preventative and therapeutic purposes; and the provision of consultative, educational and other advisory services for the purpose of reducing the incidence and severity of physical disability, bodily malfunction and pain. The services must be of such a level, complexity and sophistication that the judgment, knowledge and skills of a licensed therapist is required and must be in accordance with acceptable standards of medical practice and be a specific and effective treatment for the child’s condition. PT must be prescribed by a physician or other licensed practitioner of the healing arts within the scope of practice under Maine law. The prescription must be documented for audit purposes (Order/Referral form).
Q: Do PT Services have to be “Medically Necessary?”
A: Yes. 
Q: What is “Medically Necessary?”
A: Reasonably necessary and remedial services that are provided in an appropriate setting; recognized as standard medical care based on national standards for best practices and safe, effective, quality care; required for the diagnosis, prevention and/or treatment of illness, disability, infirmity or impairment and which are necessary to improve, restore or maintain health and well-being; defined as a covered service; provided by properly qualified practitioners within their scope of practice and are provided within the boundaries of the MaineCare regulations.
Q: Are there particular “settings” in which PT services can be delivered?
A: Yes: All outpatient settings.
Q: Does a “Personalized Plan of Service” have to be generated for all PT Services?
Q: What is a “Personalized Plan of Service?”
- Type of PT needed; 
- How the service can best be delivered and by whom the service shall be delivered;
- Frequency of services and expected duration of services
- Long and short range goals;
- Plans for coordination with other health service agencies for the delivery of services;
- Splinting supplies for which a Practitioner of the Healing Art’s order is necessary;
- Practitioner of the healing arts order
Q: What are the “covered” PT Services?
- Evaluations or re-evaluations
- Therapeutic procedures
- Tests and measurements
- Splinting supplies
Q: Who can deliver PT?
A: A licensed physical therapist or a licensed physical therapy assistant providing PT under the supervision of a licensed physical therapist.
Q: For Evaluations or Re-evaluations, are consultations, meetings, reporting and planning reimbursable?
A: No. DHHS considers consultations, meetings, reporting and planning as inclusive in the session with the child. These activities are not separately billable activities. Start and stop time in the progress note should indicate face-to-face clock times that the PT provider spent providing service to the child.
Q: What are PT “Modalities?”
A: Physical agents applied to produce therapeutic changes to biologic tissues including, but not limited to thermal, acoustic, light, mechanical or electric energy. Except when performing supervised modalities (by a physical therapy assistant), the therapist is required to have one-to-one continuous patient contact.
Q: Are “group” PT modalities reimbursable in the school setting?
A: No, it would not appear so.
Q: What are PT “Therapeutic Procedures?”
A: Procedures that cause change through the application of clinical skills and/or services that attempt to improve function. 
Q: Are “group” PT therapeutic procedures reimbursable in the school setting?
Q: Are “group” PT “Tests and Measurements” reimbursable?
A: No, it would not appear so.
Q: What are “Splinting Supplies?”
A: Providers may bill for splinting supplies necessary for the provision of PT. The supplies must be billed at acquisition cost and be documented by an invoice in the child’s file. 
Q: Is PT “Co-Therapy” reimbursable?
Q: Are there limits on the amount of reimbursable PT services per day?
A: Yes. 2 hours per day. The physical therapist cannot seek reimbursement for supervised modalities on any day that modalities requiring constant attendance or any other therapeutic procedures are provided. Otherwise, supervised modalities as stand-alone treatment are limited to 1 unit per modality per day.
Q: What records are required to be maintained for PT?
- The child’s name, address, birthdate and MaineCare ID number;
- The child’s social and medical history and diagnosis, indicating the medical necessity of the services;
- A personalized “plan of service;”  and
- Written progress notes.
Q: What must be documented in the PT written progress notes?
- Identification of the nature, date and provider of any service given;
- The start time and stop time of the service, indicating the total time spent delivering the service;
- Any progress toward the achievement of established long and short range goals;
- The signature of the service provider for each service provided; and
- A full account of any unusual condition or unexpected event, including the date and time when it was observed and the name of the observer. When services delivered vary from the plan of care, entries must justify why more, less or different care than that specified in the plan of care was provided.
Q: May Schools submit claims for PT services?
A: Public schools will be considered just as any other qualified community-based MaineCare provider. Schools will be able to re-enroll in MIHMS and bill MaineCare on behalf of the PTs the schools employ. If the PT being utilized by the school is contracted staff, the school district may bill MaineCare as long as the district falls under one of the four models as designated in the Provider Notification of January 20, 2012.
 §85.04, §85.05.
 §85.06, §85.09-1.
 DHHS response to comment to proposed rule as published with the final rule on 11/23/11.
 Id. DHHS’ responses to comments submitted during rulemaking, 8/26/10.
 DHHS’ responses to comments submitted during rulemaking, 8/26/10. The plan of care will need to address the medical necessity of the co-therapy.
 Guidance provided by Kathy Bubar, December 2010; Guidance in CMS Claims Processing Manual.
 Provider Notification from Maine DHHS, 1/20/12.