Physiotherapy: serious conditions (E-pathology)
For the treatment of serious conditions, patients are reimbursed for more sessions and pay less co-payment.
The serious conditions are included in an exhaustive list . The approval of the consulting physician is required for reimbursement of the treatment . The benefits in kind are stated in art. 7, §1, 2° of the nomenclature. The application rules are in art. 7, §11 of the nomenclature and in the Royal Decree of 23-03-1982, art. 7, §3, 2nd paragraph, 3°.
First request
For a first application, send the following documents to the advising doctor:
- the diagnosis, confirmed by a medical specialist;
- the disorders, accurately described according to the WHO-ICF:
- extent of the disorder;
- reason for intensive and long-term physiotherapy or physiotherapy treatment;
- a documented link between the diagnosis and the disorders for which reimbursement is requested;
- a clarification of the treatment plan and the physiotherapy or physiotherapy techniques with which the intended functional result is intended to be achieved, on the basis of a functional balance;
- for the treatment of lymphedema: the results of perimetry, volumetry or lymphoscintigraphy in three steps;
- for the treatment of structural anomaly of the locomotor system: prevalence and recent publications demonstrating the need for intensive and long-term physiotherapy or physiotherapy treatment.
Except for the first document, all others can be drawn up by the specialist, the general practitioner or in consultation between the two with the possible cooperation of a physiotherapist.
Extension
If the agreement is to be extended, the patient's situation must be demonstrated again with a detailed medical justification from the general practitioner or specialist. This contains the same elements as a first application, except for confirmation of the diagnosis.
For lymphedema it must be demonstrated that the clinical reduction of the edema is only maintained by physiotherapy or physiotherapy services. No new lymphoscintigraphy is required.
Maximum number and nomenclature
An agreement or extension is possible for a maximum of three years . During the term, the number of sessions is not limited , except for the general rule of one session per day or even two under certain conditions, and except for the exceptions below.
- Maximum 120 sessions per calendar year.
- An exceedance is only possible with regular sessions 56XXXX.
- A maximum of fifty sessions per year (from the first specific provision) after a stay in a hospital or rehabilitation center (subacute phase).
- Without interruption of care unless for medical reasons.
- Once per patient, unless the initial condition recurs or a new specific condition occurs.
- Maximum thirty sessions per calendar year in case of additional bronchopulmonary infection.
- An exceedance is only possible with normal sessions 56XXXX of 20 or 30 minutes.
Precedence of the serious condition agreement
During the period of the agreement, you must charge for all treatments using the dispensation codes for serious conditions, except for:
- treatment of palliative home patients ;
- perinatal physiotherapy ;
- session during day hospitalization;
- the second session per day described in art. 7, §12 of the nomenclature:
- attestable during the entire duration of certain stays in intensive care, local neonatal care, intensive neonatology;
- or attestable a maximum of fourteen times during thirty days after certain provisions for resuscitation or orthopedics in patients who are or have been admitted to a hospital.
Notifications F-acute or F-chronic , or agreements for additional sessions (current or F) have no effect during the term of an agreement for a serious condition.
Specific treatments
In the event of an agreement to reimburse the specific sessions 639XXX for the treatment of lymphedema as a serious condition, the conditions below must be met.
- Treatment of unilateral damage to a limb (upper or lower) due to post-radiotherapy or post-surgical lymphedema
- Either a perimetry performed on the entire limb or a volumetry of the hand or foot shows a difference of more than 10% compared to the contralateral limb (30% for the 120-minute sessions). The measurements must be carried out according to the protocols of the RIZIV .
- Or a three-step lymphoscintigraphy confirms the severity of the diagnosis and that an important criterion has been met according to the lymphoscintigraphic classification of the edema.
- Keep proof that the diagnostic, perimetric, volumetric or lymphoscintigraphic conditions have been met in the patient's file and keep it available to the consulting physician. You state the results with the application.
- Treatment of other types of lymphedema
A three-step lymphoscintigraphy should confirm the diagnosis by meeting an important criterion according to the lymphoscintigraphic classification of the edema.
Lymphoscintigraphy is not required for:
- cervico-facial lymphedema;
- children under the age of 14 for whom three-step lymphoscintigraphy is not indicated;
- motivated physical inability to perform a three-step lymphoscintigraphy.
In these cases, the specialist provides a substantiated report to the consulting physician, justifying the diagnosis and the need for treatment. You keep the report in the physiotherapy file.
The initial prescription stating the diagnosis must be drawn up by a specialist doctor in one of the following disciplines:
- rheumatology;
- physical medicine and rehabilitation;
- neurology;
- internal medicine.
This after clinical research and in accordance with the most recent criteria applicable at international level.
Before the end of the year following the year in which the first treatment was provided, the specialist doctor will reassess the evolution of the patient's symptoms. This is to confirm that it is necessary for the treatment to be continued in the context of § 14 (treatment of a condition of a chronic nature). This confirmation, signed by the specialist doctor, must be kept in the individual physiotherapy file.
From August 1, 2024, the number of sixty-minute sessions for people with an injury of encephalic origin will be determined by the target group to which the patient belongs.
Number of sessions
Target group 1A: congenital cerebral palsy
- Until the end of the calendar year of the patient's 21st birthday, one session per day (i.e. 365 or 366 times a year) is possible.
- From January of the calendar year following the 21st birthday:
| GMFCS score | Maximum |
|---|---|
| 1 | 100 |
| 2 or 3 | 150 |
| 4 or 5 | 200 |
Target group 1B: non-congenital brain injury, diagnosed before the 21st birthday
- Until the end of the calendar year of the patient's 21st birthday, one session per day (i.e. 365 or 366 times per year) is possible.
- From January of the calendar year following the 21st birthday:
100 times per calendar year
Target group 2: non-congenital brain injury, diagnosed after the 21st birthday
- 100 times per calendar year
These patients are also entitled to treatments of twenty or thirty minutes on the other days.
Points of attention
As a physiotherapist, you complete the modified notification form Appendix 5c for the following situations:
- for all patients around the 21st birthday of target group 1A: mention of the GMFCS score;
- for all patients aged 21 years and over from target group 1A who change their GMFCS score;
- for all patients aged 21 and over from target group 1B and target group 2
- to request 50 additional sessions of 60 minutes for target groups 1A, 1B and 2 (you keep the motivation for these extra sessions in the patient's file).
The GMFCS score is mandatory and must therefore always be stated in the medical report drawn up by the specialist doctor for the advising doctor (for target group 1A).
For patients belonging to target group 1B and target group 2, you must also provide a functional assessment, drawn up according to the ICF model.