Practice FAQ
State Guidelines for OT and PT Services
Scroll down to see the following FAQs (in order):
There are no state OT and/or PT guidelines, but there are documents from TEA on the provision of related services and developing goals/objectives that can assist therapy practitioners working in schools to understand what is expected of them in special education in our state. Those documents, titled Related Services Q&A and Documenting Frequency, Location, and Duration of Related Services, can be found by visiting the Texas Education Agency website. click here to visit TEA website
When a PTA has been providing services in the school setting, is the PT required to do an onsite visit with the student in order to review the plan of care or can the PT use a conference with the PTA to review the plan of care?
PT licensure rules in Texas do not specifically address the manner in which a PT must review the plan of care for a student for whom service is being provided by a PTA. The rules do require that evaluation and reevaluation include onsite reexamination of the child.
§346.1. Educational Settings. (e) Evaluation and reevaluation in the educational setting will be conducted in accordance with federal mandates under Part B of the Individuals with Disabilities Education Act (IDEA), 20 USC §1414, or when warranted by a change in the child's condition and include onsite reexamination of the child. The Plan of Care (Individual Education Program) must be reviewed by the PT at least every 60 school days, or concurrent with every visit if the student is seen at intervals greater than 60 school days, to determine if revisions are necessary.
An answer posted in the Practice section of the PT “Frequently Asked Questions” on the ECPTOTE website to a question regarding how and where conferences between the PT and PTA should be documented states:
"The Board's purpose in requiring documented conferences is to ensure that PT/PTA communication about the patient is part of the record for that patient. The Board has not set out in rule how each conference should be documented, leaving the format up to the PT and PTA. However, you should note the date of the conference, whether it was in person or by phone, and the results of the conference, such as any changes to the treatment plan. See the Board rules, §322.3(4) 11/06"
This would seem to indicate that the review of the plan of care could be conducted as part of the documented student conference and would not require an onsite visit or reexamination of the student.
That being said, licensure rule §322.3. Supervision. (b)(1) also states that, “A supervising PT is responsible for and will participate in the patient's care”. The required frequency of onsite visits for the PT to be responsible for and participate in the student’s care would be determined by the professional judgement of the supervising PT. These visits could occur at a frequency concurrent with the review of the plan of care requirements or more frequently in certain circumstances.
School districts have a responsibility for identifying children with disabilities in their community, including those children whose parents choose to enroll them in schools outside of the ISD. Depending on parent decisions about placement, they may also have a responsibility to serve those students. Here is a link to the Texas Education Agency webpage regarding school district responsibilities:
Guidance on Parentally-Placed Private School Children with Disabilities
At the bottom of this TEA webpage, there is a link to TEA Frequently Asked Questions (FAQs) – we recommend looking at this document also to help you understand the complexity of this issue for school districts.
Your district special education administration must make decisions about the services that will be provided to the child in question. If your district has decided that the student attending Head Start or a private school needs OT and PT services (based on the IEP that has been developed for the student), they will inform you regarding the purpose of your services (i.e. – the goals/objectives needing your support) and the time/frequency/duration obligations they have agreed to through the ARD process. When you provide services, you need to accept the Head Start or private school program as the instructional arrangement for the student, and provide intervention to support the student in the context of that environment.
As to what approach to take when providing intervention, evidence identifies a “blended” intervention in any environment where our services are provided, that is, intervention using both direct and indirect (collaborative consultation with educators) services, as effective and consistent with the special education literature. Here are references on this topic that may be of interest:
Barnes, K. J. & Turner, K. D., (2001). Team collaborative practices between teachers and occupational therapists. American journal of Occupational Therapy. 55 (1). 83-89.
Bergan, J. R. & Kratochwill, T., R. (1990). Behavioral consultation and therapy. New York, NW: Plenum Press.
Chandler, B. E., (October 7, 2001). How to choose service models in the schools. Advance for Occupational Therapy.
Dunn, W. (1988). Models of occupational therapy service provision in the school system. American Journal of Occupational Therapy. 42 (11). 718-723.
Dunn, W., (1990). A comparison of service provision models in school-based occupational therapy services: A pilot study. The Occupational Therapy Journal of Research. 10 (5). 301-320.
Idol, L., Paolucci-Whitcomeb, P. & Nevin (1986). Collaborative Consultation. Austin, TX: PRO-ED.
Kampwirth, T. J. (2006). Collaborative consultation in the schools: Effective practices for students with learning and behavior problems (3rd ed.). Upper Saddle River, NJ: Pearson/Merrill/Prentice Hall.
Rainforth, B. & York, J., & Macdonald, C. (1992). Collaborative teams for students with severe disabilities: Integrating therapy and educational services. Baltimore: Brookes.
The Texas Occupational Therapy Practice Act, 454.006 (c) states, "The practice of occupational therapy does not include diagnosis..." So the basic answer to your question is, "No."
Additionally, sensory processing disorder (SPD) remains a diagnosis not recognized by most of the medical community. Dr. Stanley Greenspan, before his death, included SPD in his Interdisciplinary Council on Development and Learning (ICDL) publication, IDCL Clinical Practice Gridelines. However, the Diagnostic and Statistical Manual - 5 (used by most of the medical community, including those CMS and private payers) does not find that the reaearch on sensory processing yet reaches the threshold of a diagnosis separate from other conditions (e.g., anxiety disorder, ADHD). Lucy Jane Miller, PhD, OTR of the STAR Institute for Sensory Processing Disorders, is working on it, but has not yet achieved the necessary evidentiary threshold.
In school practice, the ARD/IEP team is the authority that determines whether the child meets state criteria for one or more of the specified disability categories that result in access to special education and related services (see the Texas State Commissioner's Rules Concerning Special Education). Our role as related services providers is to 1) assist the team with data-gathering so that they can make the determination(s), and/or 2) determine whether there is an educational need for our services in order for the student to benefit from his or her special education.
Must a referral for PT/OT in the school setting be signed by an MD or can it be signed by a Nurse Practitioner or Physician Assistant?
The answer to your question lies in the TBOTE Rules and the TBPTE Rules.
On the OT side, a Non-Medical Condition does not require a referral (see 372.1 (c)). A referral for a Medical Condition must be from a “licensed referral source” (see 372.1 (b)). The overwhelming majority of students OTs see in the schools fit the definition of Non-Medical Condition under TBOTE Rules.
Texas Board of Occupational Therapy Examiners Rules June 2022
For PTs, the list of qualifying referral sources is identified in 322.1 (a) (1) of the TBPTE Rules, and includes the two types of credentialed professionals you refer to in your question.
One important note: It is typically the practice (although not necessarily policy or procedure) of those school districts that bill SHARS to seek physician referrals for OT and PT as that is required by CMS for Medicaid reimbursement through SHARS billing.
A question has come up in my district about when Occupational Therapy (OT) requires a medical referral for students receiving OT services in school.
Our policy manual states that we need physician’s orders on all OT students; but according to what I read on this website, OT needs physician’s orders only if the student has a medical condition and for SHARS. Can you clarify?
It is true that the Texas Board of Occupational Therapy Examiners (TBOTE) Rules do not require a referral for occupational therapy services unless there is a medical condition as defined by the Rules. The majority of the children with disabilities we serve in school do not meet this definition and therefore do not require a referral in order for services to be delivered.
However, CMS (the Centers for Medicare and Medicaid) sets its own rules and specifically requires a referral in order for Medicaid claims to be reimbursed. The School Health and Related Services (SHARS) program is the name of the Medicaid program in Texas that allows public schools to access Medicaid reimbursement for eligible children with an IEP. According to SHARS, referrals for OT (and PT) do not have to be from a physician; SHARS determines others who are authorized to prescribe physical therapy and occupational therapy services for SHARS.
Here is a link to the most recent SHARS Document where you will find more information:
School Health and Related Services (SHARS)
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