Comprehensive Rehabilitation Services (CRS) Standards for Providers

CRSSP, Chapter 1: CRS Program Overview

The Comprehensive Rehabilitation Services (CRS) Standards for Providers manual is the official reference document of provider requirements for contracted goods and services for the CRS program.

The CRS program service arrays may be provided to eligible persons who have a traumatic brain injury (TBI), traumatic spinal cord injury (TSCI), or both.

The CRS program offers the following service arrays for TBI and TSCI:

  1. Inpatient Comprehensive Medical Rehabilitation Services
  2. Outpatient Therapy Services
  3. Post-Acute Rehabilitation Services
  4. Ancillary Goods and Services

The specific services provided to a consumer are based on the consumer’s rehabilitation needs. The services are available based on service setting and service array governed by the contract’s terms and conditions and by contract standards.

This CRS standards manual is available on https://hhs.texas.gov/laws-regulations/handbooks. This is CRS's preferred method of providing access to the CRS standards and all revisions. Revisions to these CRS standards are made periodically, and a log noting all revisions is available online. Changes to the CRS standards are published on the website at least 30 days in advance of the effective date of the changes. Each provider is contractually responsible for maintaining compliance with the most recent CRS standards.

Any questions about the CRS Standards for Providers, please contact a standards specialist by emailing CRS_Program@hhsc.state.tx.us.

If a printed copy is needed of the CRS Standards for Providers, contact the CRS Inquiries Unit by

Phone: 1-512-424-4309
Fax: (512) 424-4982
Mail: CRS Program, 4900 N. Lamar, MC 3038 Austin, TX 78751

Chapter 2: Credentialing and Enrollment

2.1 Overview

The CRS program purchases services only from providers that comply with the appropriate standards in this manual and applicable federal and state licensing standards and/or certification. Each provider is required to undergo an enrollment approval process, and periodic monitoring ensures continued compliance with these standards. A provider who enrolls must demonstrate the ability to deliver all of the core services in the service array that the provider has chosen. Services may be delivered to the consumer directly or through a third party. Not all services are provided to all consumers.

2.2 Changing a Provider’s Service Locations and Adding Service Locations

Once the provider’s contract is in place, the contract must identify the provider’s services that comply with these standards and, if applicable, the physical location of the facility.

If the location changes or if the provider wishes to offer additional services, the contract manager must first determine that the changes comply with the relevant standards. If the changes comply, a contract amendment must be developed and signed by both parties at least 60 days before the changes are implemented.

2.3 Enrollment

Procurement solicitations are published on the Electronic State Business Daily under the Texas Comptroller of Public Accounts website. Vendors may search daily for open solicitations. A provider uses it to monitor the expiration date of their contract in order to determine when to renew.

If a provider has no renewal options, the provider may responds to an open solicitation for services. If a provider does not see a solicitation for a particular service, the provider may contact the designated contract manager or CRS program staff member.

Chapter 3: Environmental Standards

3.1 Overview

 A facility-based provider that provides CRS must follow all state and federal guidelines for accessibility and must maintain a safe environment for consumers. A facility-based provider must develop and maintain safety protocols and meet all of the applicable building occupancy codes as outlined in this chapter.

3.2 Accessibility

CRS purchased for its consumers must be accessible.

A provider who is subject to these standards must complete the self-evaluation survey published on the Americans with Disabilities Act (ADA) Checklist for Existing Facilities page:

  • before being approved to provide services to CRS consumers for the first time;
  • before renewing a contract;
  • before being approved to provide services at a new address; or
  • at the request of CRS program staff members.

The self-evaluation explains how the provider will make services accessible. In addition to completing the survey, the provider may also submit a written explanation, if necessary.

If the CRS program receives a complaint about the accessibility of services, the CRS program investigates to determine whether the provider has violated the terms of the contract.

The Architectural and Transportation Barriers Compliance Board has issued the ADA Accessibility Guidelines (ADAAG) that must be applied during the design, construction, and alteration of buildings and facilities covered by Titles II and III of the ADA. The U.S. Department of Justice has adopted these guidelines as Appendix A to its ADA Title III rules. These guidelines are published on the United States Access Board's ADA Standards page.

To obtain a copy of the ADAAG or other information from the U.S. Department of Justice, call (800) 514-0301 or (800) 514-0383 TTY. For technical questions, contact the Architectural and Transportation Barriers Compliance Board at 1-800-USA-ABLE.

In addition, the Texas Department of Licensing and Regulation administers the state’s Elimination of Architectural Barriers Act, Texas Government Code, Chapter 469. The Texas Accessibility Standards (TAS) are based on the ADAAG Standards and apply to buildings and facilities constructed on or after April 1, 1994.

3.3 Facility Safety Protocol

The provider must identify the person or persons serving as the governing body of the facility and directing the facility’s general policy, budget, and operation.

The provider’s facility must comply with all applicable federal, state, and local laws, regulations, and codes pertaining to health, safety, and sanitation. The provider must have a plan  to ensure that continuing attention is provided to the safety and health of the staff members, the consumers, and the visiting public.

The plan must include:

  • quarterly fire drills for each shift of personnel;
  • procedures for following in emergencies and disasters (such as, fire, severe weather, or when a consumer is missing);
  • emergency exit diagrams;
  • procedures for getting emergency medical services from a doctor, hospital, or emergency medical service unit; and
  • special procedures for consumers with disabilities who require particular attention or action, including those whose behavior may be detrimental to his or her own or to others health, safety, or successful program completion
  •  

The provider must develop a form for reporting incidents and a system for reporting and responding to incidents.

The incident report form must collect:

  • the date, time, and place of the incident;
  • the nature of incident;
  • the names of CRS consumers, witnesses, or others involved;
  • the name of the person making the report;
  • a description of the incident; and
  • the actions taken and planned by the provider as a result of the incident.

Upon request, the provider must make copies of incident reports pertinent to CRS consumers available to CRS program staff members.

The following incidents must be reported to the referring CRS counselor by the close of business on the next working day after the incident:

  • The use of emergency medical services
  • Treatment at an emergency room
  • Allegations of abuse, neglect, or exploitation involving a CRS consumer
  • Injuries involving a CRS consumer
  • Hospitalization
  • Death

3.4 Provider Vehicles

The provider must ensure that transportation for the consumer is safe and accessible. Access to transportation must be available in accordance with the Americans with Disabilities Act (ADA) and with all applicable state laws.

Each vehicle used to transport consumers must have:

  • appropriate inspections and liability insurance;
  • a working safety belt for each passenger;
  • a first aid kit;
  • a working heating and air conditioning system; and
  • a working ABC fire extinguisher.

The Class ABC fire extinguisher can be used on the following three kinds of fires:

  • Class A (ordinary combustibles, such as wood or paper)
  • Class B (flammable liquid fires, such as grease or gasoline)
  • Class C (electrical fires)

The Federal Transit Administration in Washington, D.C., has information about transportation accessibility, including small passenger vans. Contact the administration at (888) 446-4511 or (800) 877-8339 (TDD/Relay).

3.5 Building Occupancy Codes

Environmental safety must comply with local building occupancy codes, the Americans with Disabilities Act, National Fire Protection Association (NFPA) codes, and all applicable state laws and standards. Documentation of compliance is provided to the CRS program at the time of the original approval and the effective date when there is a change of a location of services. Renters should contact the property owner to get such documentation. A certificate of occupancy from the local municipality is also required.

Chapter 4: General Provider Responsibilities

4.1 Overview

To ensure the health and safety of consumers who receive CRS and the employees who provide services to CRS consumers, providers must ensure that information is kept confidential and there is appropriate staff and training.

The general provider guidelines explained in this chapter apply to all CRS services. For information related to a specific service, see the chapter on that service.

4.2 Consumer Records

A provider must make available to CRS program staff members all documents and records related to the CRS consumer.

Provider records must document compliance with applicable CRS standards. These records must be legible, reflective of services rendered to the consumer, easily retrievable, and made available to CRS program staff members.

Required documentation for both the consumer’s case records and the services purchased must include the following, as applicable to the service offered:

  • Consumer referral information that includes the Individualized Written Rehabilitation Plan received from the CRS counselor
  • Documentation of admission, including initial assessments that must include the Mayo Portland Adaptability Inventory and/or the Functional Inventory Measure
  • Documentation reflecting that the CRS counselor, consumer, and provider are jointly involved in the planning of services, and measurable goals and objectives
  • Documentation of all interdisciplinary team meetings and consumer participation in meetings, including admission, revisions to the treatment plan that occur at least monthly, and discharge meetings
  • Financial records, including copies of service authorizations, copies of invoices submitted for payment of services, and records of CRS payments
  • Evidence of communication with all pertinent interdisciplinary team members
  • Evidence of consumer participation in the planning and implementation of the rehabilitation process
  • Documentation that the Individualized Program Plan (IPP) was signed by the CRS counselor, or evidence that the IPP was provided to the CRS counselor by fax, email, or post
  • Documentation that the IPP was signed by the consumer or  representative
  • Documentation that the IPP was signed by the case manager
  • Prior approval for services (if applicable)
  • Correspondence and collaborative of services with other providers
  • Consents
  • Critical incident reports, including the use of physical or chemical restraint

The provider must ensure that documentation of interventions is based on desired treatment goals and objectives that are measurable and reflect changes to the consumer’s status.

Documentation of daily progress and efficacy to support services must include:

  • the date, time and/or duration of the service;
  •  signature of the individual providing the service and credentials (if individual’s position/certification requires clinical supervision, the supervisor must also sign the documentation);
  • clear details regarding the service provided and how the provided service is related to treatment plan goals and objections;
  • the subjective and objective date, which may include symptoms, consumer statements and clinical observations;
  •  interventions and/or methods used to address goals and objectives;
  • information on the consumer’s progress or lack of progress toward meeting the treatment goals and objectives; and
  • future plans that may be necessary to help the consumer meet the treatment goals and objectives.

Additional information may be requested from CRS program staff members, which may be required to support the services provided.

4.3 Confidentiality of Consumer or Employee Information

To protect the integrity and dignity of each consumer, staff members must maintain confidentiality with respect to consumer or employee information, when applicable, as required by the Health Insurance Portability and Accountability Act. The provider must have policy and procedures in place that facilitate access to confidential records.

The provider must develop and maintain a recordkeeping system that includes a separate record for each consumer, and must keep confidential all information contained in the consumers' records, regardless of the form or storage method of the records.

The provider must develop and use physical safeguards for confidential records and ensure that the records are available to authorized staff members only. Consumer case records must be locked in a location where maximum protection against fire, water damage, and other hazards is in place.

4.4 Staff Ratios

The provider must provide sufficient direct-care staff members, according to state licensing requirements, to manage and supervise consumers in accordance with his or her Individualized Program Plan (IPP). The provider must have enough direct-care staff members to provide care and services so that consumers do not injure themselves, do not injure others, and do not destroy property. Special staffing needs identified by the IPP (for example, one-to-one ratios) must be provided. Adequate numbers of direct-care staff members must be available to supervise consumers when other direct-care staff members are unavailable (for example, during breaks, meals, meetings, and training).

4.5 Staff Training

Before assuming job responsibilities, and at least annually thereafter, direct-care staff members must receive in-service training in the following areas:

  • Reporting abuse, neglect, or exploitation
  • Maintaining confidentiality of consumer information, including data use agreements
  • Taking universal precautions (that is, following the approach to infection control established by the Occupational Safety and Health Administration)
  • Notifying the provider’s manager about a consumer’s condition
  • Understanding the consumers' rights
  • Following emergency and evacuation procedures
  • Taking safety measures to prevent accidents and injuries
  • Following emergency first-aid procedures, such as the Heimlich maneuver and actions to take when a consumer falls, suffers a laceration, or experiences a sudden change in physical and/or mental status
  • Managing disruptive behavior
  • Implementing behavior management  plans (for example, preventing aggressive behavior and using de-escalation techniques, following practices to decrease the frequency and use of restraints, and using alternatives to restraints)
  • Preventing falls
  • Substance abuse training, including how to recognize substance abuse and understanding the reporting protocol

4.6 Staff Qualifications

Services are provided by qualified staff members who are licensed in accordance with Texas state law and applicable licensing boards, or as specified in the standards explained in this chapter.

Aquatic Therapy

Aquatic therapy services must be delivered by a licensed physical or occupational therapist, or licensed physical or occupational therapist assistant.

Art Therapy

Art therapy services must be provided in accordance with state law by a licensed professional counselor art therapist (LPC-AT) or licensed clinical social worker - art therapist (LCSW-AT).

Behavior Management Plans

Behavior management plans must be developed by a board-certified behavior analyst (BCBA), licensed clinical social worker (LCSW), licensed professional counselor (LPC), licensed psychiatrist, or licensed psychologist. The licensed professional responsible for developing the interventions must train staff members who implement behavior management interventions.

Chemical Dependency Services

Chemical dependency services must be provided by a licensed professional with experience delivering services to consumers who have a brain injury and/or spinal cord injury , such as a licensed chemical dependency counselor (LCDC), licensed professional counselor (LPC), licensed clinical social worker (LCSW), licensed masters social worker (LMSW), licensed psychologist, or licensed psychiatrist.

Cognitive Rehabilitation Therapy

Cognitive rehabilitation therapy services must be provided directly by or supervised in accordance with licensing requirements by a licensed occupational therapist  licensed speech and language pathologist physical , licensed psychologist or licensed psychiatrist.

Dietary Services

Dietary services must be provided by a professional who applies and integrates scientific principles of nutrition in social, cultural, psychological, and physical conditions and is licensed by the Texas State Board of Examiners of Dieticians.

Drivers

A provider must ensure that employees who transport consumers have the type of driver's license that is appropriate for the type of vehicle used (Class B or C).

A driver who transports consumers in motorized vehicles must prove that he or she has an acceptable driving record by providing an official document from the Texas Department of Public Safety showing that the driver has:

  • a valid driver's license;
  • no more than one at-fault accident within the past three years;
  • no more than three moving violation convictions within the past three years; and
  • vehicle liability insurance that meets or exceeds the minimum coverage required by state law.

Family Therapy

Family therapy services must be provided by a licensed or certified professional, such as a psychologist, licensed marriage and family therapist (LMFT), licensed professional counselor (LPC), licensed master’s social worker (LMSW), or licensed clinical social worker (LCSW).

Massage Therapy

Massage therapy services must be provided by a licensed physical therapist (PT), licensed physical therapy assistant (PTA), licensed occupational therapist (OT), or licensed occupational therapy assistant (OTA), as specified in the guidelines of the Executive Council of Physical and Occupational Therapy Examiners.

Music Therapy

Music therapy services must be provided by an individual who is certified by the Certification Board for Music Therapists or listed with the National Music Therapy Registry and is a licensed professional, such as a licensed clinical social worker (LCSW), licensed masters social worker (LMSW), licensed professional counselor (LPC), or licensed marriage and family therapist (LMFT).

Neuropsychiatry

Neuropsychiatric services must be provided by an individual who is licensed by the Texas Medical Board. This category of licensed professional includes neurologists, psychiatrists, and others who are permitted to provide neuropsychiatric services in their scope of professional practice, as designated by the appropriate licensing board.

Neuropsychology

Neuropsychological services must be provided by an individual who is licensed by the Texas State Board of Examiners of Psychologists. This category of licensed professional includes psychologists whose professional experience, education, and background permit neuropsychological services in the scope of their professional practice, as designated by the appropriate licensing board.

Occupational Therapy

Occupational therapy services must be provided by an individual who is licensed by the Executive Council of Physical and Occupational Therapy Examiners. This category of licensed professional includes licensed occupational therapists and licensed occupational therapy assistants. The practice of occupational therapy is designated by the appropriate licensing board.

Paraprofessional Services

Paraprofessional services must be provided by an individual who is qualified by his or her experience, training, or both; and has at least a high school diploma or its equivalent.

Physical Therapy

Physical therapy services must be provided by an individual who is licensed by the Executive Council of Physical Therapy and Occupational Therapy Examiners. This category of licensed professional includes licensed physical therapists and licensed occupational therapy assistants. Practice of physical therapy is designated by the appropriate licensing board.

Recreational Therapy

Recreational therapy services must be provided by an individual who has a current certification from the National Council for Therapeutic Recreation Certification.

Speech-Language Pathology

Speech -language pathology (speech therapy) services must be provided by a licensed speech language pathologist (SLP) or a licensed speech language pathologist assistant (SLPA), under the supervision of an SLP who is licensed by the State Board of Examiners for Speech-Language Pathology and Audiology.

4.7 Background Checks

A provider is directly responsible to obtain and maintain for agency review the criminal history record’s of a staff member or employee of a provider and sub-contractor or employee of a sub-contractor who provides services to consumers under the terms of a contract.

The provider conducts criminal background checks and maintains this information for the agency no later than 30 days after execution of the contract for all employees and before contact with the consumers for new employees. The provider is responsible for reporting to the agency all changes to an employee’s criminal history, in writing within three business days of the provider discovering the change in the criminal history.

Chapter 5: Allegations or Incidents of Abuse, Neglect, or Exploitation of Persons with Disabilities

5.1 Overview

Texas law requires that a provider immediately reports all allegations or suspected incidents of abuse, neglect, or exploitation of persons with disabilities to the appropriate investigative agency, or, if taking place in other than a residential situation, the local law enforcement agency. If a licensed professional is involved, a provider reports to the appropriate professional licensing agency and the local law enforcement agency.

The provider must develop policies and procedures for recognizing and appropriately reporting allegations or incidents. If a CRS consumer is involved in an allegation of abuse, neglect, or exploitation, the appropriate CRS counselor must be notified within one working day. The appropriate investigating agency's toll-free number and the CRS counselor's office number must be posted in a location that is readily accessible to consumers and to staff members.

5.2 Reporting Procedure

Upon notification of abuse, neglect, or exploitation allegations that involve a CRS consumer, the provider must cooperate with CRS program staff members with respect to providing information about the incident.

The following documents must be provided to the designated CRS program staff member, as the documents become available:

  • The incident report
  • Progress notes on the incident
  • Medical assessments
  • A copy of the consumer’s Individualized Program Plan
  • A copy of meeting notes related to the incident
  • The provider’s investigation report with supporting documentation
  • Documentation to illustrate that a report was made to the proper investigative agency, including the intake number, as applicable
  • A copy of the investigative agency’s report upon completion, as applicable
  • A copy of a deficiency report with the investigation report, as applicable

5.3 CRS Service Number

All facility-based providers must post the CRS Inquiries telephone number (1-512-424-4309) that is easily visible and accessible to the consumer, and must specify that the number is for CRS consumer’s use.

5.4 Grievance Procedure

At admission, written grievance procedures for consumers must be distributed and explained to consumers and staff members.

Ombudsman Process and Assisted Living Facilities and Nursing Facilities

Information about the role and purpose of the ombudsman, as well as contact information, must be posted in a public area where residents of the facility(ies) and visitors can view it.

Chapter 6: General Billing Guidelines

6.1 Overview

General billing guidelines are applicable to all services arrays. Some service arrays have additional billing requirements. For additional information, see the chapter that describes the respective service array.

Providers are required to follow all billing guidelines and requirements.

6.2 Service Authorization

Service authorizations are authorizations for services to be rendered. Providers must not provide services until a service authorization has been received.

For all service arrays except outpatient services, the request for services must be based on the recommendations resulting from an interdisciplinary team meeting. The CRS counselor approves the service authorizations for the consumer.

The service authorization identifies who is to receive services, what services are to be received, and the dates for which services are to be rendered.

To continue a service on a service authorization after an end date, the provider must notify the agency about the need to continue the service and obtain approval to continue the service.

Upon approval, the CRS counselor issues an updated service authorization. If the provider provides services outside of the scope of the originally proposed or outlined dates, payment for those services is not guaranteed to be paid.

All invoices associated with issued service authorization must be sent to the appropriate CRS   office as indicated on the service authorization.

6.3 Consumer Participation

The term consumer participation refers to the monthly contribution the consumer may be required to pay for participation in the CRS program. Consumer participation applies to consumers in active services, as well as those on the interest list who are both eligible and receiving services.

The CRS program staff members use net monthly income, liquid assets, and family size as they relate to the federal poverty guidelines for the current fiscal year to determine the amount a consumer must contribute to the cost of services. This is a monthly amount and is applied only in months that a provided billable service or good requires participation in cost of services.

The consumer’s monthly cost to participate cannot exceed the cost of the billable services provided in a given month. A consumer participating in the cost of goods and/or services directly pays the provider and that amount is deducted from the provider's payment from the agency. The cost determined is stated in the service authorization.

The provider is responsible for the billing, collecting, or writing-off the consumer’s cost owed by the liable party.

For additional information about consumer participation, see TAC§107.714, Consumer (Client) Participation.

6.4 Invoices

When billing the CRS program for services, providers must submit with the invoices:

  • the consumer’s Explanation of Benefits; and
  • the denial letters from the insurance company, including denial letters from Medicaid and/or Medicare or other pay sources.

When the provider’s facility is closed within a consumer's dates of service, payment is not made for that date.

Invoices must be submitted at least monthly, and no later than the fifteenth of each month, using one of the following forms:

  • UB-04 Centers for Medicare and Medicaid (CMS) 1450
  • HHSC generated invoice
  • Health Insurance Billing Form (CMS 1500)

The provider must submit invoices to the address on the CRS service authorization, comply with the terms and conditions of the CRS contract, and include, at a minimum, the:

  • vendor's complete name and address;
  • vendor's 14-digit Texas identification number (TIN) or 9-digit federal employee identification number (FEIN);
  • vendor's contact name and telephone number;
  • CRS's service authorization number;
  • CRS's delivery address;
  • CRS's contract number;
  • description of the goods or services provided, including CPT (current procedural terminology) codes;
  • dates of service;
  • quantity and unit-cost being billed, as documented on the service authorization;
  • consumer’s Individualized Program Plan (IPP), signed by the interdisciplinary team (IDT) (for initial billing for services only), if applicable;
  • summaries of monthly meetings, signed by the IDT (for monthly services that are not admission or discharge services), if applicable; and
  • discharge summary, signed by the IDT or other appropriate team member and the discharge form (upon final billing).

The provider must:

  • respond to billing-related inquiries from CRS program staff members within two business days; and
  • submit all documentation requested within five business days following the request.

6.5 Use of Comparable Benefits and/or a Third-Party Payer

If a CRS consumer has comparable benefits, the provider must bill the comparable benefit before billing the CRS program.

If comparable services and benefits are available, the CRS program may participate in the cost of services if the combined amount of the CRS payment and the comparable benefit payment does not exceed the maximum amount allowed by the following, as appropriate:

·      Maximum Affordable Payment Schedule (MAPS) rate;

·      Contracted payment rate; or

·      Retail or negotiated lower price (for non-MAPS, noncontract items).

If the comparable benefit is paid by:

·      major medical insurance, a health maintenance organization, or preferred provider organization, the CRS program 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, the CRS program 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, the CRS program pays nothing. The CRS program does not supplement a Medicaid payment for a specific service or procedure.

Chapter 7: Quality Assurance

7.1 Overview

A provider participates in monitoring activities as explained in this chapter, according to CRS policy and the provider’s contract. Program monitoring applies to a provider of post-acute residential and non-residential rehabilitation services and inpatient comprehensive rehabilitation services.

7.2 Quality Reviews

Designated CRS program staff members continuously monitor the services provided to CRS consumers and make regular on-site visits to a provider’s facility. The tasks completed during the visits may include the review of case files.

The quality review process focuses on how well the provider complies with the contract to provide and deliver services.

Ongoing quality reviews of the providers include ensuring that:

  • the services identified by the interdisciplinary team are necessary and appropriate;
  • the services are provided in accordance with the respective service array and other needed services and interventions are provided, as appropriate;
  • consumers are free from abuse, neglect, or exploitation;
  • consumers, families, and guardians participate in identifying and selecting services;
  • services are provided based on assessed need;
  • services are continued, based on their efficacy and promote greater independence;
  • the staff members interact appropriately and effectively with consumers; and
  • all of the consumer’s identified needs are being met.

7.3 On-Site Quality Reviews

 A provider is subject to periodic administrative, programmatic, and financial monitoring by CRS program staff members. Each fiscal year, state and regional offices assess providers to identify which will be monitored on-site during a 12-month period.

If a provider’s facility is selected for an announced quality review, the lead monitor sends a letter announcing the review, provides information about the scope of the review, and provides instructions about how to prepare for the review.

If the CRS program determines the need, a provider that is not identified on the risk assessment may also be monitored. Agency staff members may conduct an unannounced quality review, if the CRS program determines it is necessary.

The unannounced quality review or reviews may consist of:

  • an entrance conference;
  • a records review;
  • interviews;
  • observation;
  • tours of the provider’s facility and grounds; and
  • an exit conference.

7.4 Notification of Quality Review Results

The lead monitor sends the provider a report about the results of the quality review after it is completed. This report includes findings of noncompliance with program or financial standards, if any.

The provider is responsible for providing further documentation to help resolve the findings or completes a correction action plan.

7.5 Corrective Action Plan

Within 28 calendar days after the date on the initial report of findings, the provider must submit:

  • an acceptable written corrective action plan that addresses all of the findings that require a written response;
  • financial restitution for overpayments or questioned costs; and/or
  • a rebuttal of the findings (financial or otherwise), including documentation to substantiate the rebuttal.

The written corrective action plan may include corrective actions other than those recommended in the initial report, if the provider identifies additional ways of correcting the findings.

The monitoring team reviews the correction action plan and may accept it or recommend changes to it.

If the provider does not submit an acceptable corrective action plan or make financial restitution when required, the agency may take adverse action against the provider in, accordance with the terms of the contract.

7.6 Quality Review Closeout

If there are no findings, or when the monitoring team accepts the corrective action plan, the monitoring review is closed. A letter is sent to the provider documenting this result.

Chapter 8: Utilization Review for Post-Acute Rehabilitation Residential Services for Traumatic Brain Injury

8.1 Overview

Utilization reviews help ensure that the appropriate scope and level of services are provided to CRS consumers. The utilization review may be performed as a prospective, concurrent, or retrospective review.

8.2 Review Types

  • Prospective Reviews — Services are reviewed before authorization of the Individualized Program Plan to determine the appropriate level and scope. These reviews may be conducted face-to-face.
  • Concurrent Reviews — Services are reviewed when the consumer is receiving services.
  • Retrospective Reviews — Services are reviewed after delivery or discontinuation of services, or after decisions have been made for authorization. These reviews ensure that services billed according to the tiered rate were delivered specified by the rate and if services were provided as recommended by the Individualized Program Plan and interdisciplinary team.

8.3 Review Processes

Reviews of a consumer’s records, services, and billing can occur from the point of entry into the CRS program until after the consumer ends or completes treatment and may include prospective, concurrent, and retrospective review activities.

The purpose of a CRS utilization review is to:

  • ensure the program fiscal integrity of the provider;
  • address the state laws and regulations that require program funds be spent only as allowed; and
  • ensure that services are provided based on medical necessity and are continued based on their efficacy.

A consumer’s records may be chosen for review through a random sample or based on billing issues noted by CRS program staff members.

8.3.1 Prospective Reviews

During a prospective review, services are reviewed before they are authorized to determine if the consumer and/or current processes were followed.

The purpose is to ensure that:

  • a consumer meets eligibility requirements;
  • services will meet the consumer’s needs; and
  • CRS program staff members are following CRS policies and procedures.

The review may include:

  • a review of intake and assessment information;
  • a diagnostic interview;
  • a review of the consumer’s records that support eligible diagnosis or diagnoses;
  • a determination of eligibility by the CRS counselor;
  • a review of the basic eligibility requirements, as they apply to the consumer’s unique case and circumstances;
  • a review of the consumer’s Individualized Written Rehabilitation Plan;
  • assessments made at the request of or by the CRS counselor; and
  • interviews held with the consumer, consumer’s family and/or guardian.

8.3.2. Concurrent and/or Retrospective Reviews

Concurrent and/or Retrospective reviews can occur currently or retrospectively relating to the care the consumer receives or has received.

The purpose is to ensure that:

  • a consumer is receiving or has received services;
  • the services occur or occurred in the frequency and duration specified in the Individualized Written Rehabilitation Plan and the treatment outcomes meet or met the consumer’s needs; and
  • CRS program staff members are following billing requirements from CRS policies and procedures and providers are rendering services as determined by the CRS counselor and consumer.

The review may include:

  • a review of the Individualized Program Plan and Individualized Written Rehabilitation Plan;
  •  medical and/or nursing assessment and diagnoses;
  • therapy assessments and therapy notes, along with treatment plans and treatment data;
  • changes in treatment strategies based on data or assessments;
  • a review of the Interdisciplinary team meeting summaries;
  • consumer schedules;
  • a review of the consents from the consumer;
  • a review of the consumer restraints reports;
  • a review of the consumer’s records documenting the care of the consumer provided by the provider, paraprofessionals, and professionals;
  • discharge planning;
  • review of documentation confirming all billing activities;
  • interviews held with consumer, consumer’s family and/or guardian;
  • on-site visits and outings; and
  • a review of documentation to support billing or care according to CRS policy and standards.

8.4 Review Outcomes

Recoupment of Overpayments

Recoupment is required if the results of a utilization review indicate overpayment for services delivered, payment made for services not delivered, or payment made for services provided without preauthorization.

The agency notifies the provider in writing about the overpayment identified and explains the method of recoupment to be used.

Administrative Actions and Sanctions

The administrative actions or sanctions from a utilization review may result in one or more of the following being taken by the agency:

1. Closure of the review with written notification to the provider.

2. Discussion and interpretation of the results of the review with the provider.

3. Referral to the appropriate state licensing board or to the Texas Office of the Inspector General.

8.5 Appeal Process for Providers

After a utilization review, the CRS program gives the provider a report of the findings.

The provider may appeal the report within 30 days of receiving the findings by submitting a written report that includes supporting documentation disputing the findings.

The provider may appeal specifically about billing for tier services. (For information about tier rates, see the 13.6 Residential and it subsections.)

The CRS program reviews the provider’s appeal and sends the outcome of the review to the provider.

Chapter 9: Admission Policies and Procedures

9.1 Overview

The provider must develop written criteria and procedures for admission. Admission policy and procedures must be communicated clearly to CRS counselors.

The criteria and procedures do not release the provider from the obligation to obtain consent from the consumer, guardian, or representative before using restrictive procedures or behavior modification plans. Representative signatures are not valid, unless the consumer completes Form 1487, Designation of Applicant or Consumer Representative, at the time of admission. In that case, the CRS counselor informs the provider that the consumer has agreed to be represented and has a signed Form 1487.

The provider is encouraged to develop a referral form for use by the counselors. The form should list available services and admission criteria. It should also capture the information required before the consumer is admitted.

9.2 Referrals to CRS

Referrals for the CRS program come from a variety of sources, such as hospitals, therapists, and other community providers. The source must inform the consumer who is being referred that eligibility is determined by the CRS counselor.

The CRS counselor and the consumer, having informed choices, jointly:

  • develop an Individualized Written Rehabilitation Plan;
  • choose the services necessary to meet the consumer's goals and objectives; and
  • choose the providers of the planned services.

9.3 Intake Process

During the intake process providers must familiarize the consumer with the services that the consumer has selected. Familiarizing the consumer may include:

  • explaining the physical arrangements;
  • explaining the provider’s expectations of the consumer (such as, the expectations for attendance and hygiene);
  • explaining the processes for reporting grievances and complaints; and
  • discussing what the consumer may expect to receive from the CRS program.

CRSSP, 9.4 Consumer Information

The provider must inform the consumer about the consumer’s responsibilities, safety concerns, and other matters of importance. This information can be provided in a brochure, manual, or fact sheet. The provider must explain all CRS program rules or house rules to the consumer, and the consumer or the consumer’s legal guardian, or representative must consent to all of the rules. (If the consumer’s legal guardian or representative will consent, the CRS counselor ensures that Form 1487, Designation of Applicant or Consumer Representative, is completed and submitted at the time of admission).

*Note: A consumer may designate someone to serve as his or her representative in all or part of the rehabilitation process. The legal guardian or representative may be authorized to sign documents, speak on the consumer’s behalf, or serve in other capacities indicated on Form 1487.

Chapter 10: Assessment and Planning

10.1 Overview

The provider must ensure that appropriate assessment and planning policies and procedures are in place, so that each consumer receives the maximum benefit from the CRS program.

The services for CRS are individualized to ensure that a consumer gets the maximum benefit identified in the service arrays and the variety of processes described in this manual.

10.2 Assessment

Each staff member of the interdisciplinary team (IDT), as appropriate, assesses a consumer's abilities and limitations in relation to that staff member's area of expertise. The case manager writes a report of the assessments within two weeks of a consumer's admission into the program. Each member of the IDT receives a copy of the report.

The assessment of the consumer must address each of the following areas:

  • Specific developmental strengths and consumer preferences
  • Specific functional and adaptive social skills that the consumer acquires from treatment
  • Presenting disabilities and, when possible, their causes
  • Need for services (without regard to their availability)
  • Preauthorization of benefits
  • Medical and/or physical history
  • Nutritional status (determining the appropriate diet; the adequacy of the consumer’s total food intake; and the consumer’s eating skills, including disorders related to chewing, sucking, and swallowing disorders), the food service practices, and the consumer’s ability to monitor and supervise his or her own nutritional status.
  • Social history
  • Ability to self-administer medication
  • Cognitive status
  • Activities of daily living, as follows:
    • Bathing and showering
    • Dressing
    • Self-feeding
    • Functional mobility
    • Personal hygiene and grooming
    • Toilet hygiene
    • Managing money
    • Shopping for groceries or clothing
    • Using the telephone or other form of communication
    • Using technology
    • Transportation within the community
  • Mobility
  • Behavior
  • Communication
  • Required level of supervision
  • Avocational skills
  • Ongoing support needs
  • Access to public benefits, including the Supplemental Nutritional Assistance Program
  • Initial discharge plan
  • Recommended course of treatment, duration/frequency of therapy and how progress will be tracked and monitored.

10.3 Interdisciplinary Team Meetings

The interdisciplinary team (IDT), at a minimum, must include the:

  • CRS counselor;
  • consumer;
  • consumer’s representative (if applicable) or advocate;
  • professional staff appropriate to the consumer’s needs;
  • provider case manager; and
  • any community resources (such as family members, friends, or individuals invited by the consumer).

For example, if a consumer is experiencing health problems, the consumer’s nurse would attend the IDT meeting; or a consumer’s best friend may be asked by the consumer to participate in the IDT meeting.

Attendance and participation in the IDT meetings by such IDT members must be documented.

Meetings formally occur at least monthly to:

  • develop measurable goals and objectives;
  • review a consumer's progress in attaining the goals and objectives;
  • review the efficacy of the services being provided; and
  • determine whether to change the consumer’s goals, objectives, and timelines and the persons designated as responsible.

The CRS counselor, the consumer, and the consumer's representative or advocate must be notified of the date, time, and location of all IDT meetings at least one week in advance.

The results of the IDT meeting must be documented in a written report. A copy of the report is provided to the CRS counselor within 10 working days after the meeting. A copy must be made available to the consumer and/or the consumer's representative.

In addition to holding the required monthly meeting, the IDT must meet as frequently as prudent and necessary, based on need, to maintain an effective treatment program.

10.4 Behavior Management Plans

Behavior management plans are developed and monitored by licensed professionals or board certified professionals. Plans may include therapeutic medication;  interventions that include positive reinforcement, verbal cues, and rewards.

If restrictive procedures (such as the use of routine, sedative, or psychotropic medications to control behavior; the removing and/or restricting of access to personal property; and the use of restraint) are used as a behavior modification technique. The provider's policies and procedures must clearly state when and how the procedures are implemented.

In the case of consumers who are minors or persons who are incapacitated, as determined by a court, informed consent for use of restrictive programs, practices, or procedures must be obtained from the consumer’s legal guardian or representative (see 9.4 Consumer Information), in accordance with state law, to act on behalf of the consumer.

Informed consent for restrictive procedures must be indicated on a separate document from the general programmatic consents obtained when a consumer enters the program. The consent lists the risks and benefits of the restrictive interventions and states how the restrictive interventions are monitored and faded.

Standing or as-needed programs to control inappropriate behavior are not permitted. All interventions addressing the control of inappropriate behaviors must be justified by the assessment and the consumer’s current level of behavior.

A behavior management plan:

  • must be developed and signed by a licensed professional (see Appendix B Post-Acute Rehabilitation Core Services – Modality and Staff Qualifications for provider qualifications);
  • must identify the triggers and prevention strategies that are incorporated into the plan;
  • must be reviewed and approved by the interdisciplinary team (IDT) member and CRS counselor, as indicated by an attendance sheet with the IDT members’ signatures and a short summary of the team’s discussion before the plan is implemented by the IDT;
  • must be written in a manner that can be understood by the consumer and staff;
  • must provide evidence that staff members were trained before implementing the behavior management plan;
  • must indicate that a licensed professional must oversee the staff members who implement the plan; and
  • must be incorporated into the consumer’s Individualized Program Plan.

10.5 Emergency Restrictive Procedures

Emergency restrictive procedures are the least-restrictive procedures possibly used for the briefest time necessary to control severely aggressive or destructive behaviors that place the consumer or others in imminent danger and when those behaviors could not have been reasonably anticipated. Emergency restrictive procedures are used only as necessary within the context of positive behavioral programming.

Each time a consumer is restrained, a written report must document the details of the incident. This written report must be filed in the consumer’s file maintained by the provider. Each report must be reviewed by the consumer’s interdisciplinary team (IDT) at the next scheduled monthly team meeting to determine whether modifications to the treatment plan are needed.

The provider may use restraint as an emergency measure only if absolutely necessary to protect the consumer or others from injury.

The provider's policy must include providing training on the appropriate procedures and techniques for physical restraint to staff members who have direct contact with consumers. The procedures must clearly indicate the training required for all staff members at hire and at least annually thereafter.

The use of restraints to control inappropriate behavior:

  • must be approved by the IDT, noted in the consumer’s Individualized Program Plan (IPP), and agreed to by the CRS counselor, as indicated by an attendance sheet with the CRS counselor’s and IDT members’ signatures and a short summary reflecting team discussions;
  • must be used only as an integral part of the consumer's IPP and specifically to reduce and eventually eliminate the behaviors for which the restraint and/or drugs are employed;
  • must be monitored by the IDT closely in conjunction with the physician to ensure appropriateness, desired responses, and adverse consequences;
  • must be justified in that the harmful effects of the behavior clearly outweigh the potentially harmful effects of the restraint; and
  • must be part of a developed plan that includes less-restrictive interventions to address behaviors that requires more than two physical and/or chemical restraints in 30 days.

If chemical or physical restraints are used more than twice in 30 days, the IDT must meet to discuss changing the consumer’s treatment to address behaviors that place the consumer or others at risk. Changes must be made to treatment approaches, treatment goals and strategies, and behavior management strategies must be developed.

If restraints are required for the consumer to participate in the program, the IDT must determine whether the program is in the consumer’s best interest or whether the consumer should be discharged from the program.

The CRS counselor must be notified within 48 hours after restraint is used.

Documentation of the IDT meeting must indicate the modifications made to the treatment plans and/or treatment approaches. Efficacy of this intervention should be reflected in data and decreasing trends in the use of emergency restrictive procedures.

10.6 Substance Abuse

If the CRS consumer has a substance abuse disability and there are observations or other evidence of the consumer's use of alcohol or drugs, the provider must report the observations and evidence immediately to the CRS counselor. The provider must document that the counselor was informed and document all observations and other evidence of the consumer's use of alcohol or drugs.

Chemical dependency services may be delivered only to a consumer who has a traumatic brain injury, traumatic spinal cord injury, or both, either individually or in a group setting.

Chemical dependency services must:

  • be provided based on assessed needs;
  • be developed and approved by the interdisciplinary team; and
  • become part of the consumer’s Individualized Program Plan.

Chapter 11: Traumatic Brain Injury and Traumatic Spinal Cord Injury – Inpatient Comprehensive Medical Rehabilitation Services

11.1 Overview

To address medical and rehabilitation issues that require 24-hour-a-day nursing services, inpatient comprehensive medical rehabilitation services are provided as recommended by an interdisciplinary team in a hospital setting. These services are available to people who have a traumatic brain injury (TBI), a traumatic spinal cord injury (TSCI), or both. An interdisciplinary team of professionals closely coordinates services to achieve the team’s treatment goals, thereby minimizing a person's physical or cognitive disabilities and maximizing a person's functional capacity. DARS, or its successor agency, negotiates contracts with inpatient facilities to provide services based on data from the Healthcare Cost Report Information System of the Centers for Medicare and Medicaid Services.

Inpatient comprehensive medical rehabilitation services are delivered through contract with hospitals and are governed by the terms of those contracts. The services are specified in the service array and, unless otherwise specified, should be considered all inclusive. If a consumer requires medication, the medication is provided by the hospital pharmacy. Pharmacy charges appear as a line item on the invoice and are paid according to the contracted rate. Goods or services approved by the CRS program that are not part of the contracted rate for inpatient comprehensive medical rehabilitation services are considered ancillary. See Chapter 14: Traumatic Brain Injury and Traumatic Spinal Cord Injury – Ancillary Goods and Services for additional details.

11.2 Required Documentation

The provider: submits:

  • a list of specialists who provide inpatient comprehensive medical rehabilitation services;
  • an estimate of the number of visits that will be needed during the consumer’s hospitalization; and
  • a report detailing the charges and services provided during the consumer’s stay in the hospital.

See Chapter 4: General Provider Responsibilities for additional documentation requirements.

11.3 Billing Guidelines

Inpatient comprehensive medical rehabilitation services are billed at a contracted rate. Ancillary goods and services must be preauthorized by a CRS program staff member and are reimbursed based on the fee for service in accordance with 1 TAC §355.9040.

The provider:

  • submits a prescription or a physician’s order to the CRS program staff member to issue a service authorization; and
  • submits the consumer’s Individualized Program Plan, which identifies the services needed; and
  • obtains authorization from the CRS program staff member.

The CRS program does not pay for personal items, such as television rental, telephone calls, gourmet meals, cots, and guest trays. In addition, the CRS program does not pay for a private room unless the physician orders it as medically necessary, and/or no other room is available. If the provider provides services without a service authorization or outside of the scope of originally proposed or approved dates, payment for those services is not guaranteed. See Chapter 6: General Billing Guidelines.

11.4 Exceptions and Limitations

Inpatient comprehensive medical rehabilitation services:

  • is approved in 30-day increments; and
  • cannot exceed 90 days, total (that is, three increments).

Extensions are prohibited by policy.

To preauthorize a second or third increment, the CRS counselor or other assigned CRS program staff member must receive supporting data from the provider every 30 days.

The supporting data must include information on:

  • the consumer’s condition;
  • the course of treatment;
  • the progress the consumer’s is making toward the treatment goals;
  • the physician’s hand-written prescriptions for the rehabilitation service;
  • the physician’s current treatment plan;
  • data supporting the treatment plan;
  • staffing summaries and assessments; and
  • the consumer’s current medication regime.

Reauthorization is not approved, if the CRS program:

  • does not receive the initial required documentation (see 11.2 Required Documentation); or

does not receive an updated status every 30 days

Chapter 12: Traumatic Brain Injury and Traumatic Spinal Cord Injury – Outpatient Therapy Services

12.1 Overview

Outpatient therapy services refer to occupational therapy, physical therapy, and speech therapy. Outpatient therapy services are provided on a one-on-one basis by licensed therapists to consumers who have a traumatic brain injury, a traumatic spinal cord injury, or both.

Outpatient therapy services must be prescribed by a physician and are provided without admittance to a hospital. The goal is to correct or modify a stable or slowly progressive physical or mental impairment that constitutes a substantial impediment to independence.

Goods and services that are not delivered under contract and are not considered outpatient therapy services are considered ancillary. See Chapter 14: Traumatic Brain Injury and Traumatic Spinal Cord Injury – Ancillary Goods and Services for billing guidelines and reimbursement of ancillary services.

12.2 Required Documentation

Assessments for outpatient therapy services must be completed by a qualified, licensed professional, as defined in Appendix B: Post-Acute Rehabilitation Core Services – Modality and Staff Qualifications.

Before providing outpatient therapy services, the provider must recommend to the CRS program the specific type of service, frequency, and duration necessary for the consumer to reach the outcomes noted in the treatment plan. The assessment and treatment plan can be contained in the same document, as long as all of the essential elements of both are included.

The treatment plan must be developed with the consumer and/or the consumer’s family, guardian and/or representative and licensed professional before outpatient therapy services are provided. The treatment plan must contain clearly defined, measurable objectives and sent by the provider to the CRS program staff member.

To justify continuing outpatient therapy services, the licensed professional must provide data at least monthly. The data provided must support the need to provide services to the consumer. If the consumer’s progress is inadequate or the consumer regresses, additional documentation is necessary in order to revise the treatment plan and continue the outpatient therapy services. Providers must keep on file documentation showing that the services were preauthorized by the CRS program. The provider must respond to CRS program staff member inquiries pertaining to billing within two business days  after receiving the request. The provider must submit documentation within five business days after receiving the request. See Chapter 4: General Provider Responsibilities for additional documentation requirements.

12.3 Billing Guidelines

The provider must submit a prescription or physician’s recommendation for requested outpatient therapy services in order for the CRS program staff member to issue a service authorization. Following the evaluation, if the provider determines that it is necessary for the consumer to receive therapy, the provider submits a written report and recommendations identifying the type of therapy needed, the duration, and the frequency. If the CRS program staff member approves the therapy, a service authorization will be issued.

If the provider provides services without a service authorization or provides services outside of the originally proposed or approved dates, payment for the services is not guaranteed.

Billing for services must be submitted within 30 days following each therapy session. Data supporting the service must accompany each invoice. Outpatient therapy services are delivered according to the contract and/or the terms and conditions set forth in the service authorization. These services are authorized by CRS counselors and are reimbursed according to the reimbursement methodology described in 1 TAC §355.9040.

Ancillary goods and services must be identified on the Individualized Program Plan) and preauthorized by a CRS program staff member and are reimbursed based on fee for service in accordance with 1 TAC §355.9040. See Chapter 6: General Billing Guidelines for general billing guidelines.

12.4 Exceptions and Limitations

Outpatient therapy services are approved only when no more than two years have elapsed between the date of injury and the date of initial contact. The CRS counselor or CRS program staff member must receive an update on the individual’s condition, course of treatment, progress made toward reaching the treatment goals, with supporting data provided every 60 days in order to preauthorize the next 60 days of services. Services cannot exceed 120 hours.

Chapter 13: Traumatic Brain Injury and Traumatic Spinal Cord Injury – Post-Acute Rehabilitation Services

13.1 Overview

Post-acute rehabilitation services for traumatic brain injury (TBI) and traumatic spinal cord injury (TSCI) are advanced rehabilitation services provided through an interdisciplinary team approach. For residential services, the consumer must have a TBI or have a TBI with a TSCI and for a non-residential setting, the consumer may have a TBI or TSCI.

Services that are provided are based on an assessment of the individual's deficits. The goal is to achieve independence in the home and community and/or establish new patterns of cognitive activity or compensatory mechanisms.

13.2 Required Documentation

For a consumer receiving traumatic brain injury post-acute rehabilitation services in a residential setting, the provider uses the Mayo Portland Adaptability Inventory (MPAI-4) or Functional Inventory Measure (FIM), as applicable, based on service:

  • on admission;
  • on discharge; and
  • when the six-month follow-up is provided, after discharge.

The Individualized Program Plan (IPP) must document the progress or lack of progress that the consumer is making toward reaching the measurable goals and objectives.

Activity schedules must facilitate participation and provide opportunities for the consumer to be independent. Schedules must indicate the consumer’s general activities for the day, including meals, therapeutic activities, and recreation and/or leisure activities. The activity schedule must address the goals in the IPP and be made available to each consumer. Copies of schedules for each consumer must be made available to CRS counselors for review. The activity schedule directs the intensity of the daily work that the consumer must do to implement the IPP, about both informal and formal training.

The provider must submit and maintain all documentation pertaining to billing. Providers of residential services for consumers who have a traumatic brain injury are required to submit service record details into the CRS Data Reporting System. The service record details must be submitted by the 10th working day of the month following service delivery (for example, services delivered in September must be uploaded by the tenth of October). Providers are supplied with an Excel file format or layout and with access to the web-based system to upload the service record details. The details required are outlined in Appendix D: Service Record for CRS Data Reporting System. (See Chapter 4: General Provider Responsibilities for additional documentation requirements.)

13.3 Assessment and Planning

The Individualized Program Plan (IPP) is based on the findings of the assessment and must address all deficit areas noted therein. All planned and needed services for the consumer must be documented in the IPP. All interdisciplinary team (IDT) members must participate in developing the IPP, and their participation must be documented by their attendance as shown by sign-in sheets with signatures. The IDT meets to develop the IPP after the assessment is completed, but no later than 30 days after a consumer's admission to the program.

Note: The word participate means to provide input through whatever means is necessary to ensure that the consumer's IPP meets the consumer's needs. The IDT process is designed to allow team members to review and discuss information and make recommendations that are relevant to the consumer's needs. The IDT reaches decisions as a team, rather than individually, about how best to address the consumer’s needs. Everyone involved in the consumer's care must work together to provide a uniform and consistent approach to implementation of the IPP.

The IPP must direct how the consumer will develop behaviors that the consumer must have in order to function with as much self-determination and independence as possible. The IPP must also direct how to prevent or slow regression and prevent the loss of current optimal functional status.

The IDT must prepare an IPP that includes opportunities for consumer choice and self-management and identifies the following:

  • Assessments performed by licensed professionals in the areas of service, including occupational therapy, physical therapy, speech therapy, cognitive rehabilitation therapy, neuropsychological, or other assessments used to develop and provide therapy services.
  • The frequency and duration of therapy services (as noted in the recommendations section of the assessments), if the assessments indicated that services are warranted.
  • The goals and objectives to be met, including long- and short-term goals that are stated in measurable terms and that relate to increasing a consumer's ability to live more independently.
  • The team member who will implement the plan and the specific strategies that will be used.

The provider must provide a copy of the assessment report and the IPP to the CRS program staff member within 10 working days of the IPP meeting. A copy is made available to the consumer and to the consumer's representative. The results of the assessment and the IPP may be combined into a single report, signed by all pertinent IDT members.

Each consumer must receive a continuous program of needed interventions and services in sufficient intensity and frequency to support the achievement of the IPP objectives. Except for those facets of the IPP that must be implemented only be licensed personnel, each consumer’s IPP must be implemented by all staff members who have been trained to work with the consumer, including professional and paraprofessional staff members.

The IDT reviews the IPP at each monthly meeting to determine whether to continue and possibly modify the services. The IDT may also meet as frequently as is prudent and necessary to maintain an effective treatment program. Adjustments to the IPP, including discharge planning, are made as necessary.

The CRS counselor and the consumer's representative, if applicable, are notified at least one week in advance about the date, time, and location of the IPP review meeting.

13.4 Outcome Measures

Providers of post-acute rehabilitation residential and non-residential services for traumatic brain injury must administer the Mayo-Portland Adaptability Inventory (MPAI-4) to all CRS consumers. For non-residential services for traumatic spinal cord injury, providers must administer the Functional Independence Measure (FIM) to all CRS consumers.  MPAI must be completed and signed by a licensed professional.

The MPAI-4 or FIM scores must be administered at:

  • Admission
  • Discharge
  • Six months after discharge (when possible) with documented effort to obtain it.

Providers must report all outcome measures and send the report to the CRS Program. Below are the state fiscal year quarters and due dates:

Table 1, State Fiscal Year Quarters and Due Dates

Months

Due dates

September

Quarterly progression measures due December 10

October

November

December

Quarterly progression measures due March 10

January

February

March

Quarterly progression measures due June 10

April

May

June

Quarterly progression measures due September 10

July

August

If the due date falls on a weekend or state holiday, the report is due the following business day.

13.5 Customer Satisfaction

All providers who provide post-acute rehabilitation services in a residential setting must include consumer satisfaction measures based on input from consumers about benefits received from the services.

Each provider may develop its own survey instrument and procedure. However, at a minimum, the survey instrument must include the following prompt:

Using the Likert scale in the table below, rate the following statements:

  1. I was treated in a friendly, caring, and respectful manner by the staff of [insert provider’s name].
  2. Services were provided in a timely manner.
  3. The services met my needs.
  4. I was satisfied with the services provided.

Likert Scale

1

Strongly disagree

2

Disagree

3

Neither agree nor disagree

4

Agree

5

Strongly agree

Providers must give all consumers, both successful and unsuccessful, an opportunity to respond upon discharge from the CRS program. Providers must keep in the consumer's file all attempts to get the consumer to respond to the consumer satisfaction survey. The CRS program may request the responses from the provider every six months.

13.6 Residential

Post-acute rehabilitation services for consumers who have a traumatic brain injury (TBI), or who have both a TBI and a traumatic spinal cord injury (TSCI), are provided in a residential setting and are based on a tiered billing system. Each tier is a preauthorized level of service.

The tiers are:

  • Tier Base;
  • Tier Base Plus; and
  • Core Therapy services.

13.6.1 Licensure and Accreditation

All providers who provide post-acute rehabilitation services in a residential setting that do business with the CRS program must be licensed by at least one of the following regulatory agencies, as appropriate:

The providers must maintain accreditation from:

  • the Commission on Accreditation of Rehabilitation Facilities;
  • the Joint Commission on Accreditation of Healthcare Organizations; or
  • the Disease-Specific Care Certification in Brain Injury Rehabilitation Program.

New facility-based providers doing business with CRS that do not already meet this requirement are granted up to two years from the date of their CRS contract for post-acute brain injury or post-acute spinal cord injury services to obtain the accreditation.

CRSSP, 13.6.2 Billing Guidelines-Tiers

DARS, or its successor agency, negotiates contracts with providers to provide post-acute rehabilitation, which is reimbursed in accordance with 1 TAC §355.9040. Residential services for traumatic brain injury are authorized based on a tiered rate structure. Each tier represents a preauthorized number of hours allotted for providing core therapy services. A week is defined as Sunday through Saturday. To determine the appropriate tier, use the clinical recommendation for services, frequency, and duration; for example, if the interdisciplinary team (IDT) recommends the following core therapy service—PT 2 times per week for 1 hour, OT recommended 3 times a week for 1 hour and Art Therapy 1 times a week for 1hour—the appropriate tier would be Tier 1.

Based on the consumer’s need, which will be determined during the initial pre-admission assessment, the provider may request an admission tier of level 2 through level 8. This request is to be submitted in writing using Form 3149, Comprehensive Rehabilitation Services Request for Tier Change, or included in the pre-admission evaluation, which identifies services needed, frequency, duration and requested tier. With prior authorization, the tier may be changed to reflect the level recommended on a weekly basis by the IDT.  Justification must include information related to the consumer's needs, goals, and recommended core therapy services. Note: Additional supporting documentation (i.e., daily therapy notes, etc.) may be requested during utilization review activities.

All post-acute rehabilitation residential services providers must submit billing for services within 30 days of the last date of services. Consumers should receive core therapy services at the authorized tier.

The invoice submitted by the provider indicates the tier level and the core therapy services provided to the consumer each day of service. The CRS counselor or CRS program staff member then confirms the data in the CRS Data Reporting System to ensure that the total hours for the week do not exceed the approved tier.  For example: a consumer is authorized for Tier 4 services, the number of hours of core therapy services provided cannot exceed 28 hours within the week. Payment will be based on the services provided within the authorized tier.

When submitting an invoice, Post-Acute Rehabilitation providers are required to submit a monthly summary that includes a descriptive breakdown of services provided; frequency, duration, progress, or lack of progress made towards the consumer's goals; actions to be taken; and preliminary discharge information. Providers are also required to upload service record details of daily services provided in the CRS Data Reporting System, per Chapter 13.2, Required Documentation. Providers will only be required to submit daily therapy documentation if a consumer's file is randomly selected for utilization review. The provider will receive a written request with a time frame outlining when documentation is to be returned to the CRS requestor.

Consumer needs are the foundation of the CRS program and as such, minor fluctuations in the delivery of core therapy services is expected to accommodate a consumer’s medical needs. If a consumer is unable or unwilling to participate in core therapy services for a day or two, the provider must provide appropriate clinical documentation for increasing core therapy service hours on a subsequent day. Core therapy service hours must not be increased for the purposes of maximizing billing. For example, a consumer is authorized for Tier 4 services, the consumer is ill for three of the seven days that week. Upon recovery, the consumer must not be asked to participate in increased hours of core therapy services that could potentially be harmful to the consumer simply to ensure that maximum billing occurs for the assigned tier.

Patterns where Base or Base Plus Tier services are provided, followed by days with increased hours of therapy services above the recommended number of hours of core therapy services per day, must be supported by written clinical justification from assigned therapists.

The CRS counselor or other CRS program staff member compares the submitted invoice and the supporting documentation (which includes the approved tier) to what has been submitted in the CRS Data Reporting System. Disparity between the submitted documentation and invoice will be addressed by CRS program staff members and resolution obtained before payment is issued.

13.6.3 Co-Pay and Co-Insurance

Co-pay and co-insurance is covered when a consumer has third-party insurance that is being billed for services. All other pay sources must be exhausted before the CRS program is billed for services.

13.6.4 Tier Base and Tier Base-Plus

Tier Base services include administrative costs, room and board, paraprofessional services, medical services (that is, physician and nursing services), dietary and nutritional services, and case management. These services may not be billed separately to the CRS program.

Tier Base-Plus services include the base services plus one- to three-quarter hours of core therapy services.

13.6.5 Core Therapy Services

Core therapy services include physical therapy, occupational therapy, speech therapy, cognitive therapy, and neuropsychological services.

Core therapy services are based on the recommended tier and must be provided by a licensed or certified professional. If an identified core therapy service is provided by a non-licensed or certified professional, the service is not billable as part of the core therapy service for the tier.

For example, nursing services are considered part of base services and therefore are not billable as part of core therapy services. Goods and services that are not considered base or core therapy services are defined as Ancillary and must be authorized by the CRS counselor.

See Chapter 14 for details. See Appendix B for a complete list of core therapy services and provider qualifications.

CRSSP, 13.6.6 Preauthorization for Changing Tiers

Changes in the approved tier require preauthorization from a CRS program staff member. The provider must document in the consumer’s record why a consumer received less than the preauthorized or approved tier and/or why it is clinically recommended to increase the tier.

When a provider requests a change in Tier for a consumer, the provider must complete the Form 3149, Comprehensive Rehabilitation Services Request for Tier Change. The form will include the requested Tier change and the justification of need detailing goals, progress or lack of progress and the type, frequency and duration of therapy services. The Request for Tier Change Form must be faxed or sent via secure email to the CRS Counselor. The CRS Counselor will review, make a determination and return to the requesting provider within five business days.Unauthorized services may not be reimbursed by the CRS program. The CRS program staff member may request documentation supporting the provider’s request. If requested, the documentation must be submitted before delivering services at the newly requested tier; otherwise, the change in tier is considered unauthorized.

13.6.7 Utilization Review

Utilization review is required only when post-acute rehabilitation for traumatic brain injury is provided in a residential setting. See Chapter 8: Utilization Review.

13.6.8 Exceptions and Limitations

Post-acute rehabilitation services that are provided in a residential setting are limited to 180 days from the first day of services are sponsored by the CRS program. All services must be preauthorized.

Tier Base: A consumer does not receive any core therapy services on a given day. The provider bills Tier Base for that day to indicate that the provider is being reimbursed only for the base services and that no core therapy services were provided. The CRS program does not expect that consumers will be approved for Tier Base. The tier is provided to account for days of service that fall below the authorized tier.

Tier Base Plus: A consumer receives a limited core therapy service of one- to three-quarter hours per day. The CRS program does not expect that consumers will be approved for Tier Base Plus. The tier is provided to account for days of service that fall below the authorized tier.

Core Individual and/or Group Therapy: One hour of individual therapy or two hours of group therapy count as one hour toward a tier. The total number of hours applied to a tier equals the sum of the individual and group hours; for example: One hour of individual and one hour of group equals 1.5 hours total and is billed as Tier 1; one hour of individual and four hours of group equals three hours total and is billed as Tier 3. For group therapy, group size is limited to ten participants.

Billing Core Therapy Services: Two therapists cannot bill for the same period of time. Therapy units and/or time are divided by the number of therapists delivering the service to determine the number of hours attributed to each; for example, if a physical therapist and an occupational therapist deliver one hour of individual therapy to a consumer together, the therapy counts as one hour toward the tier. On the supporting documentation, the therapy is shown as .5 hours of physical therapy and .5 hours of occupational therapy. (The providers may split the hour differently, such as three-quarter hours of physical therapy and one-quarter hours of occupational therapy, if the sum does not exceed one hour. For staff qualifications, see Appendix B Post-Acute Rehabilitation Core Services – Modality and Staff Qualifications.

Billing for a partial week: If billing for fewer than seven calendar days, the billing guidelines for the maximum number of hours provided at the approved tier apply; for example, if a consumer is approved for Tier 4, the sum must not exceed 28 hours, regardless of the number of days involved.

Copays: Providers bill a third party or the consumer’s insurance company for services. The CRS program pays the consumer’s required copay or coinsurance for the service. Tiered rates do not apply; however, the provider must still submit detailed billing information on the services delivered to the consumer.

Day of Admission or Discharge: Admission and discharge days are handled the same as any other service day. If no core therapy services are delivered, the provider bills for Tier Base services. If core therapy services are delivered, the provider bills for the appropriate tier for the number of hours delivered, in accordance the prior authorization.

Therapeutic Passes: A therapeutic pass allows a consumer to leave a residential facility for up to eight hours to attend a planned activity, unaccompanied by facility staff. The consumer must return to the facility by 10 pm. If the consumer is away from the facility for more than eight hours and does not return by 10 pm, the consumer is considered absent and the facility-based provider cannot bill for services. If a consumer has more than two therapeutic passes per month, the provider must notify the CRS counselor. During a month, a consumer may take no more than three therapeutic passes. Therapeutic pass days are billed at the Tier Base rate. A therapeutic pass must be planned and included in the consumer’s Individualized Program Plan. The purpose of the therapeutic pass is to facilitate a consumer’s transition from a residential facility to his or her own home and the community; for example, a consumer may go shopping with family members or practice taking the bus or metro lift into town. While a consumer is on therapeutic pass, staff members from the residential facility must be available to provide the consumer and the consumer’s family or others with guidance and instruction, usually by phone.

Within one day of the consumer’s return to the facility, the facility team reviews with the consumer all of the issues noted during the pass. If the facility team determines that changes in the consumer’s core therapy services or ancillary services are required, a team member notifies the CRS counselor, and the counselor arranges for the consumer’s interdisciplinary team to meet. If the counselor and the interdisciplinary team approve, the facility team incorporates techniques into the consumer’s therapy and/or ancillary services to address the issues.

13.7 Non-residential

Post-acute rehabilitation non-residential services for traumatic brain injury and traumatic spinal cord injury offer the same core therapy as residential services. Also included is a standard facility or community base fee for non-residential which covers the coordination of services by the IDT and appropriate personal assistance, administration, and facility and operations costs. Staff qualifications for providing core services remains unchanged. See Appendix B for Post-Acute Rehabilitation Core Services – Modality and Staff Qualifications.

13.7.1 Licensure and Accreditation

All post-acute rehabilitation non-residential service providers that do business with the CRS program and are not licensed by the Department of Aging and Disability Services (DADS) as an assisted living facility or nursing home and are not licensed by the Department of State Health Services as a hospital or chemical dependency center, must be

13.7.2 Billing Guidelines

DARS, or its successor agency, negotiates contracts with providers which are reimbursed in accordance with 1 TAC §355.9040.

Post-acute rehabilitation non-residential services for traumatic brain injury and traumatic spinal cord injury can be either facility based or community based. Providers will bill a standard facility ($11.21) or community ($10) base fee plus an hourly rate for the core therapy services provided to the consumer using CPT codes.

For example, a consumer receives services in a non-residential setting on Monday. The consumer receives one hour of physical therapy, one hour of occupational therapy, one hour of speech therapy, and one hour of art therapy. The provider bills for four hours of therapy, submitting a separate bill for each therapy with supporting CPT code(s) and providing supporting documentation for each i.e., therapy notes, assessments, and/or reports.  The provider submits a separate bill for four hours of service at the base rate to cover administrative services, paraprofessional services, and facility and operations costs.

If the consumer does not receive therapy services from an approved certified or licensed professional while at the facility, the provider bills only for the time that the consumer is at the facility and bills only at the base rate. For example, the consumer attends the program for four hours, but does not receive any therapy services. The provider submits a bill for four hours at the base rate.

Bills for services must be submitted monthly. Data supporting the service must accompany each invoice. See Chapter 6 General Billing Guidelines for additional billing guidelines.

Note: All services must be pre-authorized by the CRS counselor before services can be provided to a consumer.

13.7.3 Exceptions and Limitations

Post-acute rehabilitation services are limited to 180 days starting on the first day that services are sponsored by the CRS program.

Chapter 14: Traumatic Brain Injury and Traumatic Spinal Cord Injury – Ancillary Goods and Services

14.1 Overview

Goods and services related to an individual’s traumatic brain injury or traumatic spinal cord injury, which are not outpatient therapy services and are not delivered as part of inpatient comprehensive medical rehabilitation services or post-acute rehabilitation services, are considered ancillary. Ancillary services are preauthorized by CRS counselors according to CRS policy, are reimbursed according to the reimbursement methodology described in 1 TAC §355.9040. These services may include orthotics, prosthetics, assistive technology devices, medications that are not part of a contract, medical equipment and supplies, home modifications, transportation that is required to enable participation in a CRS-approved service, and paraprofessional services that are required to enable participation in therapy sessions or post-acute non rehabilitation residential services.

14.2 Required Documentation

The provider must submit an Individualized Program Plan that identifies the ancillary goods and services needed for the consumer in order to obtain authorization from the CRS program staff member.

The provider summarizes in detail the ancillary goods and services provided, justifies the need (for example, by including assessments and quotes for costs), and submits supporting documentation (such as receipts for prescriptions). See Chapter 6 General Billing Guidelines for additional information.

14.3 Billing Guidelines

The provider must submit a detailed summary of the ancillary goods or services provided, along with the invoice. If the provider provides services outside of the proposed or confirmed dates, payment is not guaranteed. The provider is responsible for billing, collecting, or writing-off costs owed by the liable party. The CRS program is the payer of last resort.

14.4 Exceptions and/or Limitations

If a consumer requires medical treatment for an injury sustained while receiving rehabilitation services or requires treatment for an illness that is not related to the consumer’s traumatic brain injury or traumatic spinal cord injury, the consumer is considered medically unstable’ and the services are not covered by the CRS program as post-acute rehabilitation services.

Chapter 15: Discharge and Termination

15.1 Overview

The provider must develop and establish policies and procedures with respect to consumer discharge and termination.

15.2 Discharge Summary

The provider must develop a discharge summary for each consumer and provide a copy to the CRS program staff member within 10 business days after services are completed or terminated.

The discharge summary must include:

  • the strengths, abilities, needs and preferences of the consumer;
  • the goals established in the Individualized Program Plan;
  • the services provided, and the relationship to the status of each goal;
  • the reason for discharge; and
  • referrals and recommendations to help the consumer maintain and/or improve functioning, and increase independence.

15.3 Termination from Program

The provider must inform the CRS counselor that a consumer's services are being terminated before the termination takes place. The provider must document that the provider informed the counselor about the termination of services to a consumer.

The provider must follow the state and federal requirements applicable to the license or certification relating to discharge procedures. The provider must ensure that the consumer is safe and must determine a discharge site and facilitate placement.

Some reasons for termination are:

  • behaviors dangerous to one’s self or others;
  • no progress made toward rehabilitation goals; or
  • refusal to participate in services.

CRSSP, Appendices

CRSSP, Appendix A: Definitions

The following definitions apply, unless the context clearly indicates otherwise:

  • - The negligent or willful infliction of injury, unreasonable confinement, intimidation, or threat thereof, or cruel punishment with resulting physical or emotional harm or pain; or sexual abuse, including any involuntary or nonconsensual sexual conduct that would constitute the offenses of indecent exposure or assault, committed by the person's caretaker, family member, or other individual who has an ongoing relationship with the person.

Agency - Department of Assistive and Rehabilitative Services (DARS) or its successor agencies

Aquatic therapy - A type of therapy that involves an exercise method in water to improve a person’s range of motion, flexibility, muscular strength and toning, cardiovascular endurance, fitness, and/or mobility.

Art therapy - A type of therapy in which persons use art media, the creative process, and the resulting artwork to explore their feelings, reconcile emotional conflicts, foster self-awareness, manage behavior, develop social skills, improve reality orientation, reduce anxiety, and/or increase self-esteem.

Audiological services - The evaluation and treatment of disorders related to hearing and balance.

Behavior management - A set of coordinated services that provide a person with specialized forms of interventions designed to improve adaptive behaviors and reduce maladaptive or socially unacceptable behaviors, including violent dyscontrol, that prevent or interfere with the person's inclusion at home and in the community.

Case management - Services that help consumers plan, coordinate, monitor, and evaluate the services they receive, with emphasis on the quality of care, continuity of services, and cost-effectiveness.

Case manager - A case manager collaborates with the consumer’s interdisciplinary team and with external entities to assess, coordinate, implement, and evaluate all of the services required to meet the consumer's needs.

Certified professional - A professional who has the knowledge, experience, and skills to do a specific job and paid to do the job. The person’s expertise is verified by a certificate earned by passing an exam that is accredited by an organization or association that monitors and upholds prescribed standards for the profession involved. Examples of certified professionals include a certified brain injury specialist, certified nursing assistant, certified medical assistant, certified medication aide, and certified nurse aide.

Chemical dependency services - Planned services that are structured to help a person abstain from using drugs and/or alcohol. Services include identifying and changing behavior patterns that are maladaptive, destructive, or injurious to health and are related to or result from substance-related disorders, and identifying and changing behavior patterns to restore appropriate levels of physical, psychological, and social functioning.

Cognitive rehabilitation therapy (CRT) - A type of therapy intended to enable a person to compensate for lost cognitive functions. CRT includes reinforcing, strengthening, or re-establishing previously learned patterns of behavior, or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems.

Core services - Services that are provided by a licensed or certified therapist in post-acute rehabilitation and are provided in residential or non-residential settings.

Dietary and nutritional services - Services that involve developing a prescribed diet to meet a consumer’s basic or special therapeutic nutritional needs.

Durable medical equipment and supplies - Items that provide therapeutic benefits to a person with a medical condition.

Exploitation - The illegal or improper act or process of a caretaker, family member, or other individual who has an ongoing relationship with a person with a disability and uses the resources of the person, including the person’s Social Security number and other identifying information, without the person’s informed consent, for monetary and/or personal benefit, profit, or gain.

Family therapy - A specialized type of psychotherapy that facilitates education, training, and support to families and caregivers to nurture healing and development.

Functional Independence Measure (FIM) – An 18-item, 7-level functional assessment designed to measure the level of an individual’s disability and indicate how much assistance is required for the individual to carry out the activities of daily living.

Group therapy - A type of therapy that is conducted by a therapist for two or more persons who have a common therapeutic purpose or goal.

Home modification - Installing assistive or adaptive equipment or devices in a person's home to enable the person to perform household tasks. This equipment or devices must be removable without causing permanent damage to the property. Examples include grab bars in bathrooms or portable ramps for persons who use wheelchairs or who have other mobility impairments.

Individual therapy - A collaborative process between a therapist and one person that is intended to facilitate change and improve the person’s quality of life.

Individualized Program Plan (IPP) - A document developed by a consumer’s interdisciplinary team for the consumer, based on the consumer’s individual needs. At a minimum, the IPP identifies the consumer’s long-term and short-term goals and objectives; the treatment modalities to be used in achieving the goals and objectives; the individuals responsible for each treatment modality; the target date by which each goal and objective is to be achieved; and the discharge plan.

Individualized Written Rehabilitation Plan (IWRP) - A plan developed by CRS program staff members that outlines the goals, services, and other aspects of the services provided by the CRS program. A consumer’s IWRP may include elements of the Individualized Program Plan developed by the provider and other members of the interdisciplinary team.

Interdisciplinary team (IDT) - A team of professionals that coordinates services intended to achieve treatment goals that minimize a consumer's physical or cognitive disabilities and maximize the consumer’s ability to function.

Lawful permanent resident - Any person who is not a U.S. citizen but lives in the United States and has legally recognized and lawfully recorded documentation identifying himself or herself as a lawful permanent resident. A lawful permanent resident is also known as a permanent resident alien, resident alien permit holder, and a green card holder.

Licensed professional - A person who has completed a prescribed program of study in a health field and who has obtained a license indicating his or her competence to practice in that field. Examples of licensed professionals include a registered nurse, physician, and social worker.

Massage therapy - A type of therapy involving the manipulation of soft tissue by hand or through a mechanical or electrical apparatus for therapeutic purposes. Massage therapy constitutes a health care service, if the massage is for therapeutic purposes.

Mental restoration services - Limited or short term psychiatric services, including treatment and psychotherapy, for mental conditions that are stable or slowly progressive.

Music therapy - A type of therapy using musical or rhythmic interventions to restore, maintain, or improve a person's social or emotional functioning, mental processing, or physical health.

Neglect - The failure of a caretaker or provider, through indifference or carelessness, to provide goods or services, including medical services, that are necessary to avoid physical or emotional harm or pain.

Net monthly income - Monthly take-home pay after taxes and other payroll deductions.

Neuropsychological and neuropsychiatric services - A comprehensive battery of tests to evaluate neurocognitive, behavioral, and emotional strengths and weaknesses and their relationship to normal and abnormal functioning of the central-nervous-system.

Occupational therapy - A type of therapy using evaluation and treatment to develop, recover, or maintain the daily living skills of persons who have a physical, mental, and/or cognitive disorder consistent with the Occupational Therapy Practice Act, Texas Occupations Code, Chapter 454.

Orthosis - A custom-fabricated or custom-fitted medical device designed to provide for the support, alignment, prevention, or correction of a neuromuscular or musculoskeletal disease, injury, or deformity, consistent with the Orthotics and Prosthetics Act, Texas Occupations Code, Chapter 605.

Over-the-counter medication - Medication that can be obtained without a prescription.

Paraprofessional - A person who is responsible for a particular aspect of a professional task, but who is not licensed as a fully qualified professional. Paraprofessional services can be provided in all service arrays, for approved medical needs only, but are provided in the home only when necessary to enable consumer participation. Services may include, assisting with medication or therapeutic regimens; preparing and serving meals; assuring that health and safety needs are met; assisting with activities of daily living, such as hygiene and laundry; providing supervision and other care to meet a consumer’s basic needs; and ensuring evacuation in case of an emergency.

Physical restoration services - Services that correct or substantially modify, within a reasonable period of time, a physical condition that is stable or slowly progressive.

Physical therapy - A type of therapy that prevents, identifies, corrects, or alleviates acute or prolonged movement dysfunction or pain that is anatomical or physiological origin.

Post-acute rehabilitation services - Services for post-acute brain injury and post-acute spinal cord injury.

Preauthorization – Approval by a CRS counselor before services are provided.

Prescription medication - A medicine that legally requires a medical prescription to be dispensed.

Prosthesis - A custom-fabricated or custom-fitted medical device used to replace a missing limb, appendage, or other external human body part but that is not surgically implanted, consistent with the Orthotics and Prosthetics Act, under the Texas Occupations Code, Chapter 605. Accordingly, the term includes an artificial limb, hand, or foot.

Provider type - The certified professionals, licensed professionals, and paraprofessionals who contract with the CRS program to provide services.

Rancho Los Amigos Levels of Cognitive Functioning Scale - A scale developed at the Rancho Los Amigos Hospital in Downey, California, that describes the eight levels of cognitive function experienced by persons who have a post-acute brain injury. For example, at Level IV Confused/Agitated, the patient is in a heightened state of activity with severely decreased ability to process information. The patient is detached from the present and responds primarily to his or her own internal confusion. Behavior is frequently bizarre and not purposeful relative to the patient's immediate environment.

Recreational therapy - A type of therapy involving recreational or leisure activities that help restore, remediate, or rehabilitate a person's level of functioning and independence, promotes health and wellness, and reduces or eliminates the limitations on activities that are associated with traumatic brain injury, traumatic spinal cord injury, or both.

Rehabilitation technology - Equipment or technology designed to help persons with disabilities perform tasks that would otherwise require assistance.

Representative – A consumer may designate someone to serve as his or her representative in all or part of the rehabilitation process. The representative may be authorized to sign documents, speak on the consumer’s behalf, or serve in other capacities indicated on Form1487, Designation of Applicant or Consumer Representative.

Room and board - Shelter, facilities, and food, including the customary and usual meal plans offered in residential settings and any prescribed nutritional meals or supplements.

Service array - A set of services provided to eligible persons who have a traumatic brain injury, traumatic spinal cord injury, or both. Services are based on assessed individualized rehabilitation needs. The service arrays for traumatic brain injury and traumatic spinal cord injury are outpatient therapy, inpatient comprehensive medical rehabilitation, post-acute rehabilitation, and ancillary goods and services.

Speech-language pathology (speech therapy) - The application of nonmedical principles, methods, and procedures for measurement, testing, evaluation, prediction, counseling, habilitation, rehabilitation, or instruction related to the development and disorders of communication, including speech, voice, language, oral pharyngeal function ,or cognitive processes, for the purpose of evaluating, preventing, or modifying, or offering to evaluate, prevent, or modify, those disorders and conditions in an individual or a group, consistent with the Orthotics and Prosthetics Act, under the Texas Occupations Code, Chapter 605.

Texas resident - A person who lives in Texas, as evidenced by one of the following unexpired documents: a Texas driver's license, an identification card with an address issued by a governmental entity, a utility bill with an address, a voter registration card, a vehicle registration receipt, or another document approved by DARS or its successor agency.

Third-party payer--A company, organization, insurer, or government agency other than DARS or its successor agency that pays for the goods and services provided to a consumer.

Tier - A preauthorized number of hours allotted for providing core therapy services.

Transportation – Travel and related expenses.

Traumatic brain injury (TBI) - An injury to the brain that is not degenerative or congenital and is caused by an external physical force that produces a diminished or altered state of consciousness, resulting in temporary or permanent impairment of cognitive abilities and/or physical functioning and partial or total functional disability and/or psychosocial maladjustment.

Traumatic spinal cord injury (TSCI) - An acute, traumatic lesion of neural elements in the spinal canal resulting in any degree of temporary or permanent sensory or motor deficit and/or bladder or bowel dysfunction.

Utilization review - An evaluation of the necessity, quality, effectiveness, or efficiency of therapeutic services, procedures, and facilities. Reviews may include prospective, concurrent, or retrospective reviews to ensure that services provided to consumers are consistent with the policies and standards of the CRS program.

Vision services - A sequence of neurosensory and neuromuscular activities individually prescribed and monitored by a doctor to develop, rehabilitate, and enhance visual skills.

CRSSP, Appendix B: Post-Acute Rehabilitation Core Services Modality and Staff Qualifications

Modality and Staff Qualifications for Core Services

Code

Core Services

Service Delivery Modality

Provider Qualifications

101

Aquatic Therapy

Individual and Group

PT, PTA, OT, OTA

102

Art Therapy

Individual and Group

LPC- AT, LCSW-ATR

103

Behavior Management

Individual

Board Certified Behavior Analyst, LPC, LMSW/LCSW, Licensed Psychologist, Licensed Psychiatrist

104

Chemical Dependency

Individual and Group

LCDC, LMSW/LCSW, Licensed Psychologist, LPC, Licensed Psychiatrist

105

Cognitive Rehabilitation Therapy (CRT)

Individual and Group

OT, SLP, Licensed Psychologist, Licensed Psychiatrist

106

Family Therapy

Family

LPC, LMFT, LMSW/LCSW, Licensed Psychologist, Licensed Psychiatrist

107

Massage Therapy

Individual

PT, PTA, OT, OTA

108

Mental Restoration

Individual and Group

LPC, LMSW/LCSW, Licensed Psychologist, Licensed Psychiatrist

109

Music Therapy

Individual and Group

Certified Music Therapist with a LPC, LCSW/LMSW, LMFT

110

Neuropsychiatric Services

Individual and Group

Licensed Psychiatrist

111

Neuropsychological Services

Individual and Group

Licensed Psychologist

112

Occupational Therapy

Individual and Group

OT, OTA

113

Physical Therapy

Individual and Group

PT, PTA

114

Recreational Therapy

Individual and Group

Certified Recreation Therapist

115

Speech/Language Pathology (Speech Therapy)

Individual and Group

SLP, SLPA

CRSSP, Appendix C: Base Services and Tier Structure

BASE SERVICES:TRAUMATIC BRAIN INJURY(TBI) POST-ACUTE REHABILITATION SERVICES-RESIDENTIAL

Case Management

Dietary and Nutritional Services

Medical (Nursing & Physician) Services

Administrative Cost

Paraprofessional Services (services by CNA,CA)

Room and Board

 

CORE SERVICES:TRAUMATIC BRAIN INJURY(TBI) POST-ACUTE REHABILITATION SERVICES-RESIDENTIAL

Tiers

Description

Copay

Residential Copay only

Base

Tier base—no billable core

Base Plus

greater than 0 but less than 1 hour

1

greater than or equal to 1 hour per day but less than 2 hours per day, not exceeding 7 hours per week

2

greater than or equal to 2 hours per day but less than 3 hours per day, not exceeding 14 hours per week

3

Greater than or equal to 3 hours per day but less than 4 hours per day, not exceeding 21 hours per week

4

greater than or equal to 4 hours per day but less than 5 hours per day, not exceeding 28 hours per week

5

greater than or equal to 5 hours per day but less than 6 hours per day, not exceeding 35 hours per week

6

greater than or equal to 6 hours per day but less than 7 hours per day, not exceeding 42 hours per week

7

greater than or equal to 7 hours per day but less than 8 hours per day, not exceeding 49 hours per week

8

greater than or equal to 8 hours per day but less than 9 hours per day, not exceeding 56 hours per week

CRSSP, Appendix D: Service Record for CRS Data Reporting System

Required Information

Description

Facility Name

Provider name

Facility Number

ReHabWorks/Contract number

CRS ID Case Number

CRS assigned id case number

Facility case number

Facility assigned case or medical record number; if facility does not have such a number, repeat CRS ID case number in this field

Consumer First Name

Consumer first name

Consumer Last Name

Consumer last name

Service Authorization number

(ID purchase order)

Id purchase order (same as service authorization) number

PABI Setting

Residential or Non Residential

Service Type

See Service list

Service Description

See Service List

Service Location

See Location list

Service Location Other (Specify)

If other, specify

Service Start Date

Service date of therapy

Provided by

See Provider Type List

Total Number of Therapists

Number of therapists delivering service

Number of 15 Minute Units Delivered

Number of 15 minute units delivered

Setting type – “Individual” or “Group”

Individual or Group

If Group, Enter # of Participants

If group, number of participants.

CRSSP, Forms

 

ES = Spanish version available.

Form Title
1487 Designation of Applicant or consumer Representative ES
3149 Comprehensive Rehabilitation Services Request for Tier Change  

CRSSP, Policy Revisions

CRSSP, 17-1, Chapter 13.6.2, Billing Guidelines - Tiers

Effective September 1, 2017

 

The following changes were made:

Chapter Title Change
13.6.2 Billing Guidelines - Tiers Adds based on the consumer’s need, which will be determined during the initial pre-admission assessment, the provider may request an admission tier of level 2 through level 8. This request is to be submitted in writing using Form 3149, Comprehensive Rehabilitation Services Request for Tier Change, or included in the pre-admission evaluation, which identifies services needed, frequency, duration and requested tier. Explains when submitting an invoice, Post-Acute Rehabilitation providers are required to submit a monthly summary that includes a descriptive breakdown of services provided; frequency, duration, progress, or lack of progress made towards the consumer's goals; actions to be taken; and preliminary discharge information. Providers are also required to upload service record details of daily services provided in the CRS Data Reporting System, per Chapter 13.2, Required Documentation. Providers will only be required to submit daily therapy documentation if a consumer's file is randomly selected for utilization review. The provider will receive a written request with a time frame outlining when documentation is to be returned to the CRS requestor.

CRSSP, Contact Us

 

For technical or accessibility issues with this handbook, please email: Editorial_Services@hhsc.state.tx.us

For questions about the Comprehensive Rehabilitation Services (CRS) Standards for Providers Handbook, email: CRS_Program@hhsc.state.tx.us