As of 10/1/2017, this manual has been retired. For current policies, procedures, and standards for the Texas Workforce Commission Vocational Rehabilitation Division, please refer to the following manuals:

In this manual, references to DARS now refer to TWC. The manual includes both links to public content and links to content available only to staff.

Chapter 6: Physical Restoration Services

(Revised 07/16)

6.1 Physical Restoration Services

6.1.1 Overview

(Revised 05/12)

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

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

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

6.1.2 Key Terms

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

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

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

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

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

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

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

Maximum Affordable Payment Schedule (MAPS) codes—Five-character alpha-numeric codes that DARS uses to identify specific medical procedures, services, and medical equipment and the payment rate for the specific medical procedure, service, or medical equipment. Most MAPS codes are the same as the CPT code.

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

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

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

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

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

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

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

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

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

Regional dental consultant (RDC)—Dental consultant that provides guidance to DRS staff on consumer dental issues to include an explanation of report findings, recommended dental restoration services, expected results with treatment and the value of a second opinion. The RDC review is required for all cast restoration, endodontic procedures, dental implants, and oral surgery.

6.1.3 Restricted Physical Restoration Services

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

Medical services that are not authorized include:

Management exceptions to this list are not allowed.

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

6.1.4 Physical Restoration Services Procedures

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

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

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

  1. review the consumer's medical records related to the reported disability;
  2. get a written recommendation for planned medical services; and
  3. get the current procedural terminology codes from the surgeon or physician for the recommended procedures.

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

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

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

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

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

Exception: The local field office staff member may coordinate a laboratory or radiology diagnostic test at a hospital or facility if the diagnostic test is ordered by a physician in conjunction with a medical evaluation and the laboratory or radiology order does not allow time for MSC coordination of the requested diagnostic test. In that case, the local field office staff member should seek guidance from the MSC before issuing the service authorization.

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

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

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

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

6.1.5 Actions Contrary to a Consultant's Advice

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

6.1.6 Role of the Medical Services Coordinated (MSC)

The medical services coordinator (MSC) must coordinate

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

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

When coordinating medical services, the MSC must

6.1.7 Necessary Unplanned Medical Services

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

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

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

6.1.8 Treatment of Medical Complications

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

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

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

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

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

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

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

6.1.9 Comparable Services and Benefits for Restoration Services

(Revised 06/10, 04/11, 08/14)

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

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

*Based on 34 CFR 361.53(a-c)

The counselor must

Use an identified comparable service or benefit unless

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

If the comparable benefit is

Explanation of Benefits (EOB)

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

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

6.2 Professional Medical Providers

(Revised 06/08)

Medical treatment may include the services of a

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

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

6.2.1 Medical Reports

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

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

6.2.2 Payment to Medical Providers

The following conditions apply to payment for professional medical services:

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

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

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

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

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

Medical providers are not paid maintenance or a per diem.

6.2.3 Professional Surgical Services

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

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

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

Co-Surgeons

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

For approval of co-surgeons

Surgical Assistant

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

Anesthesiology Services

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

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

6.3 Clinical Settings

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

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

6.3.1 Ambulatory Surgery Center (ASC) Services

(Revised 01/10, 08/10, 06/12)

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

6.3.2 Hospital or Medical Facility Services

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

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

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

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

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

6.3.4 Selecting the Appropriate Facility

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

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

6.3.5 Hospital or Medical Facility Payments

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

Refer to 6.5 Specialized Physical Restoration Programs for additional requirements for specialized physical restoration programs.

Documentation Required for Payment of a Hospital or Medical Facility Bill

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

Reduced Payment Agreement

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

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

6.3.6 Length of Hospital Stay—Required Review

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

When a consumer requires hospitalization beyond the length of time to which DARS originally agreed, and DARS' payment will not continue, you must make other arrangements to pay for the additional hospitalization.

Written notification must be provided to

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

Refer to 6.1.8 Treatment of a Medical Complication.

6.3.8 Other Hospital Services

Hospital services that are not covered include

Blood

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

Social Work Charges

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

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

6.4 Physical Restoration Services or Procedures with Special Requirements

(Revised 10/08, 12/09, 04/10, 08/10, 09/10, 04/11, 11/11, 02/12, 06/12, 2/15, 09/15, 10/15)

*Listed below are physical restoration services or procedures that have special requirements. You must review these requirements before including any of them in the consumer's plan.*

*Based on 34 CFR Section 361.50(a)

6.4.1 Adaptive or Assistive Technology

(Revised 09/10)

You may purchase an assistive or adaptive device when it is required to address your consumer's vocational need. Be aware, however, that many assistive and adaptive products on the market today do not meet TWC-VRS' best-value purchasing criteria (see Chapter 17: Purchasing Goods and Services for Consumers, 17.3.2 Best Value Purchasing).

For example, technologically advanced products not shown to be safe and effective by independent clinical evidence are not likely to meet the customer's vocational need in a cost effective manner and should not be purchased with VR funds.

If you are uncertain about whether a product meets TWC-VRS best-value criteria, contact the TWC Central Office program specialist for physical restoration or the TWC Central Office program specialist for physical disabilities for guidance.

6.4.2 Back Surgery and Steroid Injections

(Revised 09/10)

The area manager must review and approve all back surgery and steroid injections for the treatment of back conditions.

If the back disorder was caused by an on-the-job injury, determine whether workers' compensation insurance medical benefits are available as a comparable benefit. If necessary, contact the Texas Department of Insurance, Division of Workers' Compensation or workers' compensation insurance carrier to determine the current status of the consumer's coverage.

DRS does not provide surgery for consumers who have no radiographic evidence of a back disorder.

Back surgery for herniated nucleus pulposus requires a documented first attempt at conservative treatment.

The LMC must review any recommendation for electrical bone stimulation following back surgery before this service is provided.

6.4.3 Breast Implant Removal

The DRS medical director must approve sponsorship of breast implant removal (to request medical director approval, see Chapter 19: Technical Information and References, 19.1 Required Approvals and/or Consultations).

6.4.4 Cardiac Catheterization or Angiography

(Revised 09/10)

You may authorize cardiac catheterization or angiography before IPE development if necessary to assess employment goals and the services needed to attain employment.

6.4.5 Chiropractic Treatment

(Revised 06/12)

Purchase chiropractic manipulation of the spine from chiropractors after a board-certified physician specializing in musculoskeletal or neuromuscular medicine recommends this treatment in writing. The recommendation must include the number of treatments.

Authorize only the number of outpatient treatments recommended by the referring specialist. After all treatments are completed, the specialist must reevaluate the consumer before authorizing any additional treatments.

DRS pays for a maximum of 10 outpatient visits for chiropractic manipulation during the life of the case. The DRS medical director must approve treatments beyond this maximum (to request medical director approval, see Chapter 19: Technical Information and References, 19.1 Required Approvals and/or Consultations).

MAPS rates apply to chiropractic services. You may authorize and purchase only the following services:

Chiropractors may also perform functional capacity assessments. See 6.4.13 Functional Capacity Assessment (FCA).

6.4.6 Cochlear Implant

(Revised 10/15)

Cochlear implant(s) may be authorized when they are expected to improve the consumer's ability to participate in employment and or training that is required for a specific employment outcome. Document the expected outcomes, such as improved ability to understand spoken communication or respond to environmental cues clearly in the case file as part of the assessing and planning process.

In addition, prior to planning for cochlear implant services, the consumer must have:

The evaluation report completed by the otologic surgeon must include:

The Division for Rehabilitation Services (DRS) counselor must ensure that:

The Division for Rehabilitation Services (DRS) state coordinator for Deaf and Hard of Hearing Services must review a courtesy case packet before planning the surgery.

The courtesy case packet includes the:

All medical services related to cochlear and hearing-aid implants are performed by:

6.4.7 Comprehensive Medical Treatment for Spinal Cord Injury

(Revised 09/10)

One of the principal VR services provided to consumers with spinal cord injury is comprehensive medical treatment in an inpatient rehabilitation center. Ordinarily, this service is

For acute complications of spinal cord injury, such as substantial decubitus ulcers, severe urinary tract infections, severe respiratory conditions, or similar severe medical complications,

6.4.8 Dental Treatment

Dental treatment may be provided as

Area manager approval is required.

An RDC's review is required when planning specific dental procedures. For a list of these procedures, see Chapter 1: Foundations, Roles, and Responsibilities, 1.4.3 Regional Dental Consultant (RDC) Services. The DRS medical director's approval is required for dental implants.

6.4.9 Diabetes Insulin Pumps

DRS does not purchase insulin pumps for the medical management of diabetes.

6.4.10 Discograms

(Added 02/12)

DRS does not usually pay for a discogram because the test has been found to be of limited diagnostic value. The medical director approves discograms on a case-by-case basis. You must get a written justification for a discogram from the treating physician before submitting the case to the medical director for review and approval.

6.4.11 Electrical Bone Stimulators (EBS)

An LMC must review all EBS therapy.

If prescribed for cases of non union fractures, confirm that it has been six months since the initial fracture before authorizing service.

6.4.12 Eyeglasses and Contact Lenses

The purchase of single vision, bifocal, and trifocal glasses and contact lenses requires a prescription from an ophthalmologist or optometrist.

Frames must be the least expensive serviceable type available. The consumer may supplement the additional cost for frames if their cost exceeds the MAPS maximum.

Lenses may have tint and/or be impact-resistant when specified in the prescription. Note: Irlen lenses may not be purchased without review and approval of the TWC ophthalmologist consultant.

You may provide glasses if needed to complete diagnostic studies.

Before purchasing contact lenses,

6.4.13 Functional Capacity Assessment (FCA)

(Added 10/08, Revised 09/10, 04/11, 06/11)

A functional capacity assessment is a comprehensive series of physical tests to determine a person's ability to perform functional tasks, such as walking, lifting, or stooping.

In most cases, an FCA is not required to determine the presence of an impairment and eligibility for services. An FCA may be necessary at the completion of a physical restoration service to objectively determine a consumer's physical capability to return to a specific job or achieve a specific employment goal.

For DRS to sponsor an FCA, the consumer must

A licensed physical or occupational therapist or chiropractor must directly supervise the assessment. The assessment must include

The professional completing the assessment must report the results of the FCA to the treating physician or evaluating specialist and the DRS counselor. If needed, consult with the treating physician for interpretation of the report and to determine the consumer's safe work capacity and work restrictions.

6.4.14 Functional Electrical Stimulation (FES) Devices

(Revised 09/10, 08/11, 02/15, 06/16)

Choose the most basic orthotic device that will allow the consumer to complete the job-tasks in the work environment. DRS may purchase lower extremity functional electrical stimulation (FES) devices (for example, the Bioness L300 or the WalkAide) only for consumers:

DRS may consider only lower extremity FES devices that are medically necessary to enable consumers with a spinal cord injury (SCI) to ambulate when all of the clinical criteria are met. FES is not considered medically necessary for all other indications, including disuse atrophy.

To purchase an FES device for a VR consumer with spinal cord injury:

  1. consult with the central office program specialist for physical disabilities with questions about the clinical criteria; and
  2. submit a courtesy case to drs.medicalservices@twc.state.tx.us for the medical director to review.

Area managers may not make exceptions to any part of the FES devices policy.

6.4.15 Gym Memberships and Home Exercise Equipment

(Revised 09/10)

DRS does not purchase gym memberships or home exercise equipment, including home equipment for water therapy or strengthening.

6.4.16 Hearing Aids

(Revised 01/12, 10/15)

Hearing aids may be authorized when they are expected to improve the consumer's ability to participate in employment and or training that is required for a specific employment outcome. Document the expected outcomes clearly in the case file as part of the assessing and planning process.

Develop the individualized plan for employment (IPE) to purchased hearing aids only after you have obtained:

When you receive a recommendation for a complete-in-canal (CIC) hearing aid, ensure that the audiologist sufficiently justifies the added benefits of a CIC aid when compared to an alternative style with the same capabilities.

It is recommended that the DARS counselor consult with a Deaf and Hard of Hearing Services (DHHS) Hearing Loss Resource Specialist (HLRS) for consideration of additional technology needs before purchasing the hearing aid(s).

For specific information on purchasing hearing aids, see Chapter 17: Purchasing Goods and Services for Consumers, 17.8 Purchasing Medical Assistive Devices and Supplies.

Telecoil Circuitry

Because telecoil circuitry allows hearing aids to be compatible with a variety of assistive listening devices, such as telephone headsets, stethoscopes, frequency modulation (FM) systems, and loop systems, purchase hearing aids with a manual (programmable) telecoil. In rare instances, an exception may be appropriate. When an audiologist or hearing instrument specialist provides a vocational justification that warrants an aid without a manual telecoil, it is recommended that the counselor consult with a local HLRS prior to purchasing the aid. The counselor may request that the HLRS conduct a workplace or environmental assessment to identify additional technology needs.

Letter of Specification for Hearing Aid

The selected provider must present a letter of specification (not a bid) that includes:

Service Charge

The service charge is the dispenser's usual and customary charge (not to exceed Maximum Affordable Payment Schedule (MAPS)) for:

DRS pays the hearing-aid manufacturer for the hearing aid(s).

Upon receipt of a postfitting evaluation report that includes a statement that the consumer is satisfied, DRS pays the hearing-aid dispenser for the services provided. DRS must receive the postfitting evaluation report within 30 days of the consumer's receipt of the hearing aid.

Earmolds and Canal Impressions

Earmolds and canal impressions may be:

Binaural

Binaural aids may be purchased:

Repair

Payment of labor charges for repair of a hearing aid plus shipping and handling charges must not exceed the cost of a new hearing aid.

FM System

You may purchase an FM system directly from a manufacturer or an audiologist.

You may not pay a fitting and dispensing fee when you purchase an FM system through an audiologist.

When additional training is needed for an FM system, contact the DHHS HLRS to request training for the consumer as a comparable benefit. Services provided by the HLRS are free and they must be utilized when they are available. Refer to Chapter 4: Assessing and Planning, 4.5 Comparable Services and Benefits for more information about this requirement. If the necessary training is not available from the DHHS HLRS, you may negotiate payment for the time to train the consumer to use an FM system.

6.4.17 Home Health or Nursing Home Care

Provide home health care or care in a nursing home if the attending physician recommends them in the following situations:

See 6.4.23 Outpatient Services for limitations.

Providers of home health care must be licensed by the Texas Department of State Health Services.

Nursing homes must meet the provider qualifications stated in Chapter 17: Purchasing Goods and Services for Consumers, 17.2 Health Care Professionals—Required Qualifications.

6.4.18 Intercurrent Illness

When a short-term illness hinders vocational rehabilitation services, provide acute medical care as necessary. This supplemental service is limited to acute illnesses such as

These illnesses usually require less than 10 days of hospitalization or visits to the doctor's office or clinic for treatment, thus not altering the vocational plan.

6.4.19 Medical Assistive Devices and Supplies

See Chapter 17: Purchasing Goods and Services for Consumers, 17.8 Purchasing Medical Assistive Devices and Supplies.

6.4.20 Nursing Home Care

See 6.4.17 Home Health or Nursing Home Care.

6.4.21 Occupational Therapy

Purchase occupational therapy (OT) when the consumer must increase coordination, strength, or range of motion.

A physician recommends, and later reviews, the provision of OT. A licensed occupational therapist provides these services.

See 6.4.23 Outpatient Services for limitations.

6.4.22 Orthoses and Prostheses

(Revised 06/08, 09/09, 12/09, 04/10, 08/11)

Provide an orthosis or prosthesis to enhance a consumer's employability or capability to perform activities of daily living.

Use of orthoses and prostheses is frequently a life-long need. Counsel with the consumer about his or her responsibility for future repairs, modification, and/or replacement of the orthosis or prosthesis.

A physician, physician's assistant, advanced practice nurse, chiropractor, podiatrist, or dentist prescribes orthotic and prosthetic devices. Based on the prescription, the orthotist or prosthetist recommends the design of a device that best meets the consumer's needs (see Chapter 17: Purchasing Goods and Services for Consumers, 17.8 Purchasing Medical Assistive Devices and Supplies).

See 6.4.14 Functional Electrical Stimulation (FES) Devices for information specific to the purchase of this specialized orthotic.

Required Medical Examinations for Orthoses and Prostheses

For orthoses, a physician's examination is required before the purchase of an initial orthosis or if there is difficulty using the current orthosis. Orthoses include

For prostheses, an orthopedist's or physiatrist's examination is required before the purchase of the first prosthesis. If the consumer has difficulty using his or her current prosthesis, an orthopedist's or physiatrist's evaluation is required before planning the purchase of a second prosthesis.

All providers of orthoses and prostheses must

Purchasing Orthoses and Prostheses

Purchase the most basic orthotic or prosthetic device that allows a consumer to meet his or her vocational needs. Consider purchasing more technologically advanced devices or components only if required by the consumer's unique vocational or medical needs. See Counselor Desk Reference, Chapter 2: Amputations, 2.4 Purchasing Prostheses for guidance.

Purchase these medically prescribed items when you receive

The letter of specification reflects the physician's written prescription. It lists the basic orthosis or prosthesis to be fabricated for the consumer and each add-on component with the

With the letter of specification, the provider includes medical or vocational justification for all additions to the basic device.

If the orthosis or prosthesis is a replacement, the letter must fully describe the design and components of the current device. The letter should also

Develop a service record for a recommended orthosis or prosthesis using the letter of specification.

Payments for orthoses or prostheses may not exceed MAPS.

If DRS' cost equals or exceeds $12,500 and the letter of specification contains no unlisted MAPS codes, then a technical review of the letter or specification by the University of Texas Southwestern (UTSW) Medical Center Prosthetics-Orthotics Program is required.

If the letter of specification contains unlisted MAPS codes, then, regardless of cost, approval by the Central Office Orthotic and Prosthetic Review Committee (OPRC) is required.

Approval Procedure for Purchasing a Prosthesis Costing $12,500 or More without Unlisted MAPS Codes

(Revised 01/10, 04/10, 02/11)

If DRS' cost for the prosthesis is $12,500 or more and there are no unlisted MAPS codes, the case will be reviewed by the University of Texas Southwestern (UTSW) Medical Center Prosthetics–Orthotics Program. Follow the procedures below.

Counselor

  1. prepares a packet containing the following required information:
  2. issues a service authorization for $375.00 to

    University of Texas Southwestern Medical Center (UTSW)
    Prosthetics–Orthotics Program
    3323 Harry Hines Blvd.
    Dallas, TX 75390-9091

    VID# 3-729729729-5-000

    Use Service Category: Other Rehab Tech Services

    Level 1: Vehicle Modifications, Rehabilitation Technology Services; Residential and Job Site Modifications;

    Level 2: Prosthesis Specification Review—Contract Required;

    Level 3: Prosthesis Specification Review—Contract Required;

    Level 4: Prosthesis or Orthosis Initial Specification Review; or

    Level 4: Prosthesis or Orthosis Follow-Up Specification Review;

  3. faxes the packet to the Central Office as directed by the DARS Prosthetic Review Cover Sheet; and
  4. makes note of the required review and the submitted packet in ReHabWorks.

PSPD (Program Specialist for Physical Disabilities)

  1. reviews the packet to ensure that all required information is attached;
  2. faxes the packet to UTSW; and
  3. makes note of the packet fax date to UTSW in ReHabWorks.

UTSW

  1. reviews the packet and submits the report with an invoice to the PSPD within 10 working days of receipt. UTSW may contact the counselor directly with case questions or to clarify information.

PSPD

  1. reviews the report for completeness,
  2. acknowledges receipt of the report in ReHabWorks, and
  3. forwards the report and invoice to the counselor for payment.

Counselor

  1. reviews the report with the prosthetist and negotiates an amended letter of specification if needed,
  2. justifies in a case note any variance from the recommendations in the UTSW report, and
  3. purchases the prosthesis.

If an amended letter of specification cannot be negotiated, the prosthetist may submit additional information and the counselor may request a UTSW follow-up review of the case. The additional information must be substantive and customized to the consumer. It should not be generic information or the same information provided in the original documents. Request the UTSW follow-up review using the procedure outlined above at an additional cost of $375.00. Only one follow-up review is allowed. Questions about the UTSW report should be directed to the PSPD.

Approval Procedure for Purchasing an Orthosis or Prosthesis with Unlisted MAPS Codes

If the L-code for a device or component is not listed in MAPS when the service record is generated, the OPRC must approve the purchase of the specialized device or component regardless of cost. Refer to the Counselor's Toolbox for a complete list of specialized prosthetic and orthotic devices and components requiring OPRC approval. OPRC approval for purchase of a specialized device or component does not require a technical review by UTSW. Use the following procedures to submit a case to the OPRC for approval.

Counselor

  1. prepares a packet containing the following required information:

OPRC

  1. reviews the request to purchase the item and decides whether to approve it based on a justified medical, vocational, or independent living need of the consumer.

DRS Central Office program specialist for physical restoration

  1. enters the committee's decision in ReHabWorks.

Counselor

  1. contacts the DRS Central Office program specialist for physical restoration by emailing darsrhw.maps@twc.state.tx.us when they are ready to issue the service authorization.

Warranties on Orthoses and Prostheses

Provider Warranty. The provider agrees to replace, without cost to DRS, defective parts and materials within 90 days of the consumer receiving the completed orthosis or prosthesis.

Exclusions: The following are not covered by—and do not create exclusions to—the provider's warranty:

The provider honors the manufacturer warranties and pays all costs associated with warranty replacements.

Extended Warranty. The consumer pays all costs associated with extended warranties.

Repair

Repair the current orthosis or prosthesis unless the repair cost is more than 60 percent of the replacement cost.

Calculate labor charges at prevailing hourly rates for individual providers, not to exceed $50 per hour.

Training

You must arrange training in the use of above-knee prostheses to consumers who

A prosthetist may provide training in the use of a below-knee prosthesis. If the prosthetist recommends additional training, arrange for it from a qualified physical or occupational therapist.

A qualified physical or occupational therapist may provide training in the use of an upper-extremity prosthesis.

6.4.23 Osteomyelitis of the Extremities

(Revised 09/15, 11/15)

Osteomyelitis is a bone infection that can cause an unstable medical condition with an uncertain prognosis. This condition may require complicated and extensive medical treatment.

DRS considers sponsoring medical treatment for osteomyelitis only when:

Exceptions require review by a DARS medical director and approval by an area manager before DARS-sponsored treatment for osteomyelitis is included in a consumer's individualized plan for employment (IPE).

6.4.24 Outpatient Services

(Revised 03/08, 03/09, 04/11)

Outpatient services may include

Provide outpatient services only when prescribed by a physician, and *only if they are likely, within a reasonable period of time, to correct or modify substantially a stable or slowly progressive physical or mental impairment that constitutes a substantial impediment to employment.*

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

If the service provider requests an extension of treatment beyond his or her initial recommendation, assess the consumer's potential for continued progress. Your assessment may involve reviewing treatment progress notes and/or contacting the physician, LMC, and/or provider. If you determine that continuing treatment is appropriate,

6.4.25 Pain Treatment

(Revised 09/10, 09/15)

Short term pain treatment may be authorized for a consumer to improve their functional ability to achieve an employment goal as defined on their individualized plan for employment (IPE). DRS does not sponsor long-term medical treatment for chronic medical conditions, including chronic pain.

When a consumer reports functional limitations related to chronic pain:

Refer the consumer to available comparable benefits to meet long-term treatment needs.

6.4.26 Physical Therapy

Purchase physical therapy (PT) when required to increase

A physician recommends, and later reviews, the provision of PT. A licensed physical therapist provides these services.

See Outpatient Services for limitations.

6.4.27 Prescription Drugs and Medical Supplies

DRS may provide prescription drugs and medical supplies, as needed, when a consumer cannot buy or obtain them from comparable sources (see Chapter 17: Purchasing Goods and Services for Consumers, 17.8 Purchasing Medical Assistive Devices and Supplies).

When a consumer is discharged from a medical rehabilitation facility or hospital that has an in-house pharmacy, DRS may pay for a 30-day take-home supply of the prescription drugs and medical supplies provided to the consumer.

If prescription drugs and supplies are needed beyond the 30 days, arrange with a pharmacy in the consumer's home area. Buy from the least expensive available source. When specialized prescription drugs or supplies are not readily available from a local source, buy from the hospital pharmacy.

6.4.28 Procedures for Pregnant Consumers

(Revised 09/10)

If an eligible consumer is pregnant, ensure that she understands DRS provides only disability-related vocational services. DRS does not pay for medical services related to the pregnancy.

Planning with the consumer how she will manage child care after the baby is born will help ensure her successful participation in the VR program.

Ectopic (tubal) pregnancy may be treated as an intercurrent illness.

6.4.29 Severe (Morbid) Obesity Surgery

(Revised 10/08, 08/10, 09/10, 08/11, 05/12)

A consumer is severely obese when his or her body mass index (BMI) is 40 or more. Severe obesity is a disability if it results in an impediment to employment. Before considering bariatric surgery as a service for a severely obese consumer, identify the consumer's impediment to employment.

Determining If Severe Obesity Results in an Impediment to Employment

To determine if a consumer has an impediment to employment related to severe obesity, you must use the following procedure:

  1. obtain documentation from a physician that shows the consumer's height and weight and verify that the consumer has a BMI of 40 or more;
  2. purchase a functional capacity assessment (FCA) to evaluate the consumer's functional capabilities and accurately measure the consumer's work capacity;
  3. if the consumer is employed, purchase a job analysis to determine the functional requirements of the consumer's job, and review the FCA and job analysis to determine whether the consumer can perform the critical tasks of his or her job. If the consumer can perform the critical tasks of his or her job, there is no impediment to employment related to severe obesity; and
  4. if the consumer is unemployed, use the results of the FCA and determine if the consumer can meet the physical demands of the chosen realistic job goal as defined in Choices, O*NET, or an equivalent resource. If the consumer can perform the critical job tasks of the chosen realistic job goal, there is no impediment to employment related to severe obesity.

Considering Alternatives to Bariatric Surgery

If a consumer has an impediment to employment related to severe obesity, determine whether services such as workplace modifications or assistive devices would be appropriate alternatives to bariatric surgery. Also, determine if the impediment to employment would be removed if the consumer could lose 50 to 60 pounds in a 6-month weight-loss program. If so, refer to 6.4.33 Weight-Loss Programs.

Procedure for Requesting Approval for Bariatric Surgery

If you have determined that a consumer has significant impediments to employment related to severe obesity and nonsurgical services will not remove the impediment to employment, you may request approval to provide bariatric surgery services. Submit a courtesy file to the DRS medical director that includes documentation described in the following steps:

  1. obtain from a primary care physician or internal medicine specialist clearance for bariatric surgery and documentation of medical stability of other conditions the consumer may have;
  2. arrange for an evaluation with a bariatric focus by a psychologist or psychiatrist that includes
    • the Minnesota Multiphasic Personality Inventory (MMPI) and the Millon Behavioral Health Inventory;
    • questions to the psychologist to determine the consumer's motivation, family support, life stressors, coping ability, realistic expectations, and the presence of mental health diagnoses that may interfere with successful dietary compliance and weight loss;
    • the need for medication management or psychological counseling to treat the underlying mental health condition (for example, anxiety or depression) that may interfere with successful dietary compliance and healthy lifestyle changes;
  3. refer the consumer to an experienced bariatric surgeon for evaluation. Use a bariatric surgeon affiliated with a "Bariatric Surgery Center of Excellence" if available. Refer to "Bariatric Surgery Centers of Excellence";
  4. have the LMC review the consumer's case;
  5. if the bariatric surgeon and the LMC determine that the consumer is an appropriate candidate for surgery, have the consumer successfully participate in at least a 3-month prebariatric surgery, multidisciplinary program. The focus of a prebariatric surgery program is to evaluate the consumer's motivation to make healthy lifestyle changes and comply with necessary dietary restrictions. Use the bariatric surgeon's in-house program if one is available or create a multidisciplinary program using independent providers. Refer to "Tips For Creating a Multidisciplinary Prebariatric or Weight-Loss Program with Independent Providers." You should
    • verify that the multidisciplinary program includes nutrition, weight management, exercise, and behavioral modification counseling;
    • set appropriate expectations with the consumer for participation, responsibilities, attendance, and attaining goals;
    • set appropriate consequences for noncompliance; and
    • monitor consumer progress in the prebariatric program using the DARS3515, Prebariatric Surgery Program Progress Report, and
  6. following the consumer's successful completion of a prebariatric program, send the courtesy case to the DRS medical director for consideration of final approval of bariatric surgery. (To request the medical director's approval, see Chapter 19: Technical Information and References, 19.1 Required Approvals and/or Consultations.)

6.4.30 Postbariatric Surgery Case Management

Identify the medical provider responsible for monitoring the consumer's nutritional status and weight loss after surgery. Verify that the consumer understands and accepts responsibility to comply with the postsurgical treatment plan. Monitor the consumer's compliance with postsurgical instructions, dietary restrictions, and progress with weight loss. Refer to "The Importance of Postbariatric Surgery Monitoring."

6.4.31 Speech Therapy and Speech Training

(Revised 03/08)

Speech therapy provides treatment for disorders of

A physician recommends, and later reviews, the provision of speech therapy. A licensed speech-language pathologist provides these services.

The speech-language pathologist may also provide

A physician's recommendation and review are not required for speech training.

See 6.4.24 Outpatient Services for limitations.

See 6.4.1 Adaptive or Assistive Technology for information about purchasing technology to treat speech disorders.

6.4.32 Spinal Cord Stimulator or Dorsal Column Stimulator

(Added 11/11)

The DRS medical director must approve sponsorship of a trial or permanent implantation of a spinal cord stimulator or dorsal column stimulator. To request the medical director's approval, see Chapter 19: Technical Information and References, 19.1 Required Approvals and/or Consultation.

6.4.33 Weight-Loss Programs

For information on weight-loss programs, see 6.5.8 Weight-Loss Programs.

6.4.34 Wheelchairs

The procedures for buying a wheelchair are outlined in Chapter 17: Purchasing Goods and Services for Consumers, 17.8 Purchasing Medical Assistive Devices and Supplies.

6.4.35 Wound Care

(Added 09/15)

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

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

6.5 Specialized Physical Restoration Programs

This section covers the following topics:

6.5.1 Fees for Specialized Programs

For review and consideration of potential sponsorship and subsequent fee negotiation, provide information on specific services not otherwise described below to the DRS Central Office program specialist for physical restoration.

6.5.2 Back Schools

(Revised 08/12)

The curriculum previously provided by a back school is now incorporated into the consumer's individualized physical therapy or occupational therapy program. DRS no longer sponsors back schools.

6.5.3 Cardiac Rehabilitation Facilities

(Revised 08/12)

For DRS to sponsor services in a cardiac rehabilitation facility, the consumer's physician must refer the consumer to that facility.

A cardiac rehabilitation facility must meet these criteria:

6.5.4 Rehabilitation Hospital Programs

(Revised 09/15)

These programs provide a coordinated and integrated service package, which can include:

These are appropriate prevocational services for many consumers with the most significant disabilities (spinal cord injuries, etc.). See Chapter 3: Eligibility, 3.8 Required Assessments and Policies for Selected Conditions/Spinal Cord Injury, for information on providing these services before the consumer is accepted for regular vocational rehabilitation services.

For questions on selecting the most appropriate facility, contact the Central Office program specialist for neuromuscular disabilities.

See Chapter 17: Purchasing Goods and Services for Consumers, 17.2 Health Care Professionals—Required Qualifications, for criteria that apply to inpatient rehabilitation facilities.

6.5.5 Work Hardening

(Revised 10/08)

Work hardening teaches proper body mechanics, combined with functional exercises and activities, to condition muscles specifically for job-related tasks.

To determine whether work hardening is appropriate for a consumer, obtain a functional capacity assessment. For DRS to sponsor work hardening, the consumer's physician must refer the consumer. The services provided in the work-hardening program must be consistent with the assessment.

The services provided in the work-hardening program are customized to the consumer and may include

The work-hardening facility staff must include a

The facility staff also may include a

DRS does not purchase home equipment because all sponsored physical therapy programs must be conducted under the supervision of a licensed physical therapist.

6.5.6 Pain Management Programs or Pain Clinics

To be considered for DRS sponsorship of services in a pain clinic, the consumer's physician must refer the consumer to that facility, and the consumer must meet VR eligibility criteria.

Pain management programs or pain clinics must meet these requirements:

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

(Revised 09/15)

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

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

Duration of Post-Acute Brain Injury Services

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

The 180-day limit on post-acute rehabilitation services is measured from the first day of services sponsored. Post-acute rehabilitation services are indicated on the Individualized Plan for Employment (IPE) as "up to 30 days of service" and may be extended to a maximum of 180 days, without an IPE amendment, when recommended by the interdisciplinary team.

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

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

Post-acute Brain Injury Service Array

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

Core Services Service Delivery Modality Provider Qualifications

Aquatic Therapy

Individual and Group

LP

Art Therapy

Individual and Group

LP

Behavior Management

Individual

LP or CP

Case Management

Individual

CP

Chemical Dependency

Individual and Group

LP

Cognitive Rehabilitation Therapy (CRT)

Individual and Group

LP

Dietary Nutritional Services

Individual and Group

LP

Massage Therapy

Individual

LP

Medical Services

Individual

LP

Mental Restoration

Individual and Group

LP

Music Therapy

Individual and Group

CP

Neuropsychiatric Services

Individual and Group

LP

Neuropsychological Services

Individual and Group

LP

Occupational Therapy

Individual and Group

LP or CP

Personal Assistance

Individual and Group

PP

Physical Therapy

Individual and Group

LP or CP

Recreational Therapy

Individual and Group

CP

Room and Board

Individual

Qualifications not stipulated

Speech and Language Pathology

Individual and Group

LP or CP

 

Ancillary Services Service Delivery Modality Provider Qualifications

Audiology

Individual

LP

DME and Supplies

Individual

Qualifications not stipulated

Family Therapy

Individual and Group

LP

Family and/or Caregiver Education and Training

Individual and Group

LP or CP

Home Modification

Individual

LP

Limited Skilled Nursing

Individual

LP

Orthosis/Prosthesis

Individual

LP

Over-the-Counter Medications

Individual

Qualifications not stipulated

Physical Restoration

Individual

LP

Prescription Medications

Individual

LP

Rehabilitation Technology

Individual

LP, other professionals

Transportation

Individual

Qualifications not stipulated

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

Core Services Service Delivery Modality Provider Qualifications

Aquatic Therapy

Individual and Group

LP

Art Therapy

Individual and Group

LP

Behavior Management

Individual

LP or CP

Case Management

Individual

CP

Chemical Dependency

Individual and Group

LP

Cognitive Rehabilitation Therapy (CRT)

Individual and Group

LP

Dietary Nutritional Services

Individual and Group

LP

Massage Therapy

Individual

LP

Mental Restoration

Individual and Group

LP

Music Therapy

Individual and Group

CP

Neuropsychiatric Services

Individual and Group

LP

Neuropsychological Services

Individual and Group

LP

Occupational Therapy

Individual and Group

LP or CP

Physical Therapy

Individual and Group

LP or CP

Recreational Therapy

Individual and Group

CP

Speech and Language Pathology

Individual and Group

LP or CP

 

Ancillary Services Service Delivery Modality Provider Qualifications

Audiology

Individual

LP

DME and Supplies

Individual

Qualifications not stipulated

Family Therapy

Individual and Group

LP

Family and/or Caregiver Education and Training

Individual and Group

LP or CP

Home Modification

Individual

LP

Limited Skilled Nursing

Individual

LP

Orthosis and Prosthesis

Individual

LP

Over-the-Counter Medications

Individual

Qualifications not stipulated

Personal Attendant Care

Individual

PP

Physical Restoration

Individual

LP

Prescription Medications

Individual

LP

Rehabilitation Technology

Individual

LP, other professionals

Transportation

Individual

Qualifications not stipulated

Vision Services

Individual

LP

Exceptions to Service Array

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

Step Issue Notes

1

The Interdisciplinary Team (IDT) or medical expert identifies a need for a service and/or therapy, which is not offered in the Service Array

Identification of service and/or therapy needed for rehabilitation purposes is based on medical assessment

2

The IDT or medical expert sends the counselor a request for the service

The request for service must include supporting medical documentation and assessments to illustrate the necessity of the service and/or therapy and proposed billing codes [for example, Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), DARS rates] which will be used for billing purposes.

If additional information is needed for decision making purposes, the counselor contacts the facility.

3

The counselor sends an email to his or her chain of command and central office with the following information:

  • Consumer name
  • Consumer ID
  • Consumer injury
  • Recommended therapy
  • Medical needs
  • Associated CPT, Maximum Affordable Payment Schedule (MAPS), or HCPCS codes

The central office includes the program specialist for physical disabilities, the program manager, and the administrative assistant.

The chain of command includes the area manager or staff acting on behalf of an area manager.

4

The counselor and the area manager discuss and determine whether the service is appropriate and medically necessary.

The counselor and the area manager consider all information related to the consumer to determine whether the service is necessary.

If the service is not appropriate or medically necessary, the service is denied by the counselor and area manager. This decision is communicated to the facility and central office by the counselor. A case note must be entered to document the reason for denial.

If the service is appropriate and medically necessary, the case is shared with the chain of command, seeking approval.

5

The counselor sends a request to review and approve the proposed service to regional management.

 

6

Regional management reviews the request and determines whether the service is or is not appropriate.

If the service is determined appropriate and medically necessary, an email indicating approval by the area manager and regional management is sent to central office requesting final review and approval.
If the service is not appropriate or medically necessary, the service is denied by the counselor and area manager. This decision is communicated to the facility and central office by the counselor.

7

Central office reviews the service and determines whether it is or is not appropriate to provide the service to the consumer.

Note: If more information is needed for decision-making purposes, the counselor must get the information at the request of central office.

8

Upon determining whether the service is approved or not approved, the counselor communicates the decision to the facility.

The counselor provides answers to questions about the decision. If the facility disagrees with the decision, the appeals process must be implemented.

9

An approved service requires a completed DARS3472, Contracted Service Modification.

This must be signed by the respective regional director or assistant commissioner of DARS.

10

Issue a service authorization (SA) for services

All of the steps above must be completed before issuing a service authorization.

6.5.8 Weight-Loss Programs

(Revised 10/10, 06/11, 04/12)

DRS sponsors comprehensive, medically managed programs to help a consumer lose weight.

A weight loss program may be considered for a consumer if the consumer has a body mass index of 30 or greater and needs to lose up to 60 pounds in a timeframe of 6 months or less. The reason for the weight loss should be

Note: While obesity is not considered a primary disability, severe (morbid) obesity, defined as a body mass index of 40 or more, is considered a primary disability.

Document the rationale for the consumers' participation in the case file. Include copies of medical and psychological reports and case notes documenting

The program in which the consumer receives treatment must meet the following criteria:

If a multidisciplinary program is not available, a program may be created using independent providers.

See the guidance piece, Tips for Creating a Multi-Disciplinary Pre-Bariatric or Weight Loss Program with Independent Providers.

The local medical consultant (LMC) can provide guidance and must review all weight-loss plans. The DRS medical director must approve providing the service (to request the medical director's approval, see Chapter 19: Technical Information and References, 19.1 Required Approvals and/or Consultations).

The DRS Central Office program specialist for physical disabilities coordinates the medical director's review. For any services or procedures not listed in MAPS, contact the DRS Central Office program specialist for physical restoration by emailing darsrhw.maps@twc.state.tx.us. You may purchase participation in a weight-loss program following the approval and payment determination.

Discuss with the consumer expectations for his or her program attendance, participation, and attainment of goals. Explain the consequences for non-compliance. Work closely with the physician, weight-loss program coordinator, or independent provider to ensure that the consumer is complying with the regimen and making appropriate, documented progress. Use the DARS3510, Weight-Loss Progress Report to document monthly progress. Stop sponsoring the weight-loss program if the consumer is not complying with the weight-loss program or not making substantive progress.