In Oregon, a new rule from the Oregon Health Authority defines when the cost of an adaptive CR is covered by Medicaid and establishes outpatient billing codes for in-person seating assessments conducted by CPSTs who also have Safe Travel for All Children (STAC) training. Billing is allowed for the initial evaluation, vehicle fit assessment, and any follow-up visits.
CPST-Is Ben Hoffman, MD, and Adrienne Gallardo worked to develop and establish the rule in order to bolster their adaptive transportation program at Portland’s Doernbecher Children’s Hospital and support expansion of those services throughout the state of Oregon.
The rule applies to the care of any child with a significant health condition that makes using a conventional CR unsafe or physically incompatible. Covered conditions include, but are not limited to, the inability to sit independently, severe head or trunk instability, neuromuscular disorders, seizures, fragility, casts, congenital anomalies, and neurodevelopmental conditions.
The billing guidelines require prior authorization and specific clinical documentation. Requests must include medical justification from a prescribing doctor and evaluation by a CPST (or licensed physical or occupational therapist). The evaluator must specify the exact CR requested, verify compatibility with the caregiver’s vehicle, document the child’s height, weight, and anticipated growth, and confirm that less costly alternatives were considered and determined to be unsuitable. Initially, the plan at Doernbecher is to bill $133 for a new patient evaluation and $75–$150 for follow-up visits.
Key to the billing process is that the documentation must be co-signed by a licensed practitioner with CPST-instructor certification who is STAC-trained. In Oregon, Dr. Hoffman will perform this supervisory function.
About the watershed CPS accomplishment, Dr. Hoffman says, “We are hoping this will be a game changer in our state and will lead other states to do the same thing.” Find the full text of the new rule here.