Section II Child Health Management ServicesTOC required
245.110 Accepted Tests for Occupational Therapy Tests used must be norm-referenced, standardized, age appropriate and specific to the therapy provided. The following list of tests is not all-inclusive. When using a test not listed here, the provider must include additional documentation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is ever selected by Medicaid for audit review. An explanation of why a test from the approved list could not be used to evaluate the child must also be included. The MMY is the standard reference to determine the reliability and validity of the test(s) administered in an evaluation. Providers should refer to the MMY for additional information regarding specific tests.
Definitions:
STANDARD: Evaluations that are used to determine deficits.
SUPPLEMENTAL: Evaluations that are used to justify deficits and support other results. These should not "stand alone."
CLINICAL OBSERVATIONS: All clinical observations are supplemental but should be included with every evaluation, especially if standard scores do not qualify the child for therapy. They will be considered during reviews for medical necessity.
A. Fine Motor Skills - Standard 1. Peabody Developmental Motor Scales (PDMS, PDMS2)2. Toddler and Infant Motor Evaluation (TIME)3. Bruininks-Oseretsky Test of Motor Proficiency (BOMP)4. Test of Infant Motor Performance (TIMP)B. Fine Motor Skills - Supplemental1. Early Learning Accomplishment Profile (ELAP)2. Learning Accomplishment Profile (LAP)3. Mullen Scales of Early Learning, Infant/Preschool (MSEL)4. Miller Assessment for Preschoolers (MAP)6. Hawaii Early Learning Profile (HELP)7. Battelle Developmental Inventory (BDI)8. Developmental Assessment of Young Children (DAYC)9. Brigance Developmental Inventory (BDI)C. Visual Motor - Standard1. Developmental Test of Visual Motor Integration (VMI)2. Test of Visual Motor Integration (TVMI)3. Test of Visual Motor Skills4. Test of Visual Motor Skills - R (TVMS)D. Visual Perception - Standard 1. Motor Free Visual Perceptual Test2. Motor Free Visual Perceptual Test - R (MVPT)3. Developmental Test of Visual Perceptual 2/A (DTVP)4. Test of Visual Perceptual Skills5. Test of Visual Perceptual Skills (upper level) (TVPS)E. Handwriting - Standard1. Evaluation Test of Children's Handwriting (ETCH)2. Test of Handwriting Skills (THS)3. Children's Handwriting Evaluation ScaleF. Sensory Processing - Standard 1. Sensory Profile for Infants/Toddlers2. Sensory Profile for Preschoolers3. Sensory Profile for Adolescents/Adults4. Sensory Integration and Praxis Test (SIPT)5. Sensory Integration Inventory Revised (SII-R)G. Sensory Processing - Supplemental 1. Sensory Motor Performance Analysis2. Analysis of Sensory Behavior3. Sensory Integration Inventory4. DeGangi-Berk Test of Sensory IntegrationH. Activities of Daily Living/Vocational/Other - Standard 1. Pediatric Evaluation of Disability Inventory (PEDI) NOTE: The PEDI can also be used for older children whose functional abilities fall below that expected of a 7½ year old with no disabilities. In this case, the scaled score is the most appropriate score to consider.
2. Adaptive Behavior Scale - School (ABS)3. Jacobs Pre-vocational Assessment4. Kohlman Evaluation of Daily Living Skills5. Milwaukee Evaluation of Daily Living Skills6. Cognitive Performance Test8. Functional Independence Measure (FIM) 7 years of age to adult9. Functional Independence Measure - young version (WeeFIM) J.Activities of Daily Living/Vocational/Other - Supplemental 1. School Function Assessment (SFA)2. Bay Area Functional Performance Evaluation4. Grip and Pinch Strength5. Jordan Left-Right Reversal Test6. Erhardy Developmental Prehension8. Social Skills Rating System9. Goodenough Harris Draw a Person Scale245.120 Accepted Tests for Physical Therapy Tests used must be norm referenced, standardized, age appropriate and specific to the therapy provided. The following list of tests is not all-inclusive. When using a test not listed here, the provider must include additional documentation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is ever selected by Medicaid for audit review. An explanation of why a test from the approved list could not be used to evaluate a child must also be included. The MMY is the standard reference to determine the reliability and validity of the tests administered in an evaluation. Providers should refer to the MMY for additional information regarding specific tests. A. Norm Reference 1. Adaptive Areas Assessment2. Test of Gross Motor Development (TGMD-2)3. Peabody Developmental Motor Scales, Second Ed. (PDMS-2)4. Bruininks-Oseretsky Test of Motor Proficiency (BOMP)5. Pediatric Evaluation of Disability Inventory (PEDI)6. Test of Gross Motor Development - 2 (TGMD-2)7. Peabody Developmental Motor Scales (PDMS)8. Alberta Infant Motor Scales (AIM)9. Toddler and Infant Motor Evaluation (TIME)10. Functional Independence Measure for Children (WeeFIM)11. Gross Motor Function Measure (GMFM)12. Adaptive Behavior Scale - School, Second Ed. (AAMR-2)13. Movement Assessment Battery for Children (Movement ABC)14. Test of Infant Motor Performance (TIMP)15. Functional Independence Measure (FIM) 7 years of age to adultB. Physical Therapy - Supplemental 1. Bayley Scales of Infant Development, Second Ed. (BSID-2)2. Neonatal Behavioral Assessment Scale (NBAS)3. Mullen Scales of Early Learning Profile (MSEL)4. Hawaii Early Learning Profile (HELP)C. Physical Therapy Criterion1. Developmental assessment for students with severe disabilities, Second Ed. (DASH-2)2. Milani-Comparetti Developmental ExaminationD. Physical Therapy - Traumatic Brain Injury (TBI) - Standardized 1. Comprehensive Trail-Making Test2. Adaptive Behavior InventoryE. Physical Therapy - Piloted Assessment of Persons Profoundly or Severely Impaired 245.220 Intelligence Quotient (IQ) Testing Children receiving language intervention therapy must have cognitive testing once they reach ten (10) years of age. This also applies to home-schooled children. If the IQ score is higher than the qualifying language scores, then the child qualifies for language therapy; if the IQ score is lower than the qualifying language test scores, the child would appear to be functioning at or above expected level. In this case, the child may be denied for language therapy. If a provider determines that therapy is warranted, an in-depth functional profile must be submitted. However, IQ scores are not required for children under ten (10) years of age.
A. IQ Tests - Traditional2. The Wechsler Preschool & Primary Scales of Intelligence, Revised (WPPSI-R)4. Wechsler Intelligence Scale for Children, Third Ed. (WISC-III)5. Kauffman Adolescent & Adult Intelligence Test (KAIT)6. Wechsler Adult Intelligence Scale, Third Ed. (WAIS-III)7. Differential Ability Scales (DAS)8. Reynolds Intellectual Assessment Scales (RAIS)B. Severe & Profound IQ Test/Non-Traditional - Supplemental - Norm-Referenced 1. Comprehensive Test of Nonverbal Intelligence (CTONI)2. Test of Nonverbal Intelligence (TONI-3) - 19973. Functional Linguistic Communication Inventory (FLCI)C. Articulation/Phonological Assessments - Norm-Referenced 1. Arizona Articulation Proficiency Scale, Third Ed. (Arizona-3)2. Goldman-Fristoe Test of Articulation, Second Ed. (GFTA-2)3. Khan-Lewis Phonological Analysis (KLPA-2)4. Slosson Articulation Language Test with Phonology (SALT-P)5. Bernthal-Bankson Test of Phonology (BBTOP)6. Smit-Hand Articulation and Phonology Evaluation (SHAPE)7. Comprehensive Test of Phonological Processing (CTOPP)8. Assessment of Intelligibility of Dysarthric Speech (AIDS)9. Weiss Comprehensive Articulation Test (WCAT)10. Assessment of Phonological Processes - R (APPS-R)11. Photo Articulation Test, Third Ed. (PAT-3)12. Structured Photographic Articulation Test II Featuring Dudsberry (SPAT-D II)D. Articulation/Phonological Assessments - Supplemental - Norm-Referenced Test of Phonological Awareness (TOPA)E. Voice/Fluency Assessments - Norm-Referenced Stuttering Severity Instrument for Children and Adults (SSI-3) F. Auditory Processing Assessments - Norm-Referenced Goldman-Fristoe-Woodcock Test of Auditory Discrimination (G-F-WTAD)G. Oral Motor - Supplemental - Norm-Referenced Screening Test for Developmental Apraxia of Speech, Second Ed. (STDAS-2) H.Traumatic Brain Injury (TBI) Assessments - Norm-Referenced1. Ross Information Processing Assessment - Primary2. Test of Adolescent/Adult Word Finding (TAWF)3. Brief Test of Head Injury (BTHI)4. Assessment of Language-Related Functional Activities (ALFA)5. Ross Information Processing Assessment, Second Ed. (RIPA-2)6. Scales of Cognitive Ability for Traumatic Brain Injury (SCATBI)7. Communication Activities of Daily Living, Second Ed. (CADL-2)Section IIHome Health
TOC not required
218.161 Norm Reference A. Adaptive Areas AssessmentB. Test of Gross Motor Development (TGMD-2)C. Peabody Developmental Motor Scales, Second Ed. (PDMS-2)D. Bruininks-Oseretsky Test of Motor Proficiency (BOT)E. Pediatric Evaluation of Disability Inventory (PEDI)F. Test of Gross Motor Development - 2 (TGMD-2)G. Peabody Developmental Motor Scales (PDMS) H.Alberta Infant Motor Scales (AIM)I. Toddler and Infant Motor Evaluation (TIME)J. Functional Independence Measure for Children (WeeFIM)K. Gross Motor Function Measure (GMFM)L. Adaptive Behavior Scale - School, Second Ed. (AAMR-2)M. Movement Assessment Battery for Children (Movement ABC)N. Test of Infant Motor Performance (TIMP)O. Functional Independence Measure (FIM); Ages 7 through 20218.162 Physical Therapy - Supplemental A. Bayley Scales of Infant Development, Second Ed. (BSID-2)B. Neonatal Behavioral Assessment Scale (NBAS)C. Mullen Scales of Early Learning Profile (MSEL)D. Hawaii Early Learning Profile (HELP) TOC required
218.102 Standardized Testing A. Tests used must be norm-referenced, standardized and specific to the therapy provided. 1. Tests must be age appropriate for the child being tested.2. Test results must be reported as standard scores, Z scores, T scores or percentiles.3. Age-equivalent scores and percentage of delay do not justify the medical necessity of services.B. A score of negative 1.50 standard deviations or more from the mean in at least 1 subtest area or composite score is required to qualify for services.C. The Mental Measurement Yearbook (MMY) is the standard reference for determining a test's reliability and validity.D. When a child cannot be tested with a norm-referenced, standardized test, then criterion-based testing or a functional description of his or her gross and fine motor deficits may be used 1. In such a case, documentation of the reason(s) that a standardized test could not be used must be included in the evaluation.2. Listings of tests that AFMC accepts without requiring documentation of their reliability and validity can be found in this provider manual between sections 218.120 and 218.228, inclusive.218.121 Fine Motor Skills - Standard A. Peabody Developmental Motor Scales (PDMS, PDMS2)B. Toddler and Infant Motor Evaluation (TIME)C. Bruininks-Oseretsky Test of Motor Proficiency (BOMP)D. Test of Infant Motor Performance (TIMP)218.123 Visual Motor - Standard A. Developmental Test of Visual Motor Integration (VMI)B. Test of Visual Motor Integration (TVMI)C. Test of Visual Motor SkillsD. Test of Visual Motor Skills - R (TVMS)E. Pediatric Evaluation of Disability Inventory (PEDI) 1. The PEDI can also be used for older children whose functional abilities fall below that expected of a 7½ year old with no disabilities.2. When the PEDI is used for older children, the scaled score is the most appropriate score to consider.F. Adaptive Behavior Scale - School (ABS)G. Jacobs Pre-vocational Assessment H.Kohlman Evaluation of Daily Living SkillsI. Milwaukee Evaluation of Daily Living SkillsJ. Cognitive Performance TestL. Functional Independence Measure (FIM); 7 through 20 years of age.M. Functional Independence Measure - young version (WeeFIM)218.131 Norm Reference A. Adaptive Areas AssessmentB. Test of Gross Motor Development (TGMD-2)C. Peabody Developmental Motor Scales, Second Ed. (PDMS-2)D. Bruininks-Oseretsky Test of Motor Proficiency (BOMP)E. Pediatric Evaluation of Disability Inventory (PEDI)F. Test of Gross Motor Development - 2 (TGMD-2)G. Peabody Developmental Motor Scales (PDMS) H.Alberta Infant Motor Scales (AIM)I. Toddler and Infant Motor Evaluation (TIME)J. Functional Independence Measure for Children (WeeFIM)K. Gross Motor Function Measure (GMFM)L. Adaptive Behavior Scale - School, Second Ed. (AAMR-2)M. Movement Assessment Battery for Children (Movement ABC)N. Test of Infant Motor Performance (TIMP)O. Functional Independence Measure (FIM); 7 through 20 years of age.218.132 Physical Therapy - Supplemental A. Bayley Scales of Infant Development, Second Ed. (BSID-2)B. Neonatal Behavioral Assessment Scale (NBAS)C. Mullen Scales of Early Learning Profile (MSEL)D. Hawaii Early Learning Profile (HELP)218.133 Physical Therapy Criterion A. Developmental Assessment for Students with Severe Disabilities, Second Ed. (DASH-2)B. Milani-Comparetti Developmental Examination218.220 Intelligence Quotient (IQ) A. Children receiving language intervention therapy must have cognitive testing once they reach 10 years of age, whether they are in public school or they are home-schooled.B. Providers must maintain in their records the IQ scores of their patients who are 10 through 20 years of age and receiving language therapy.C. Language therapy may be determined not medically necessary if a child's IQ is less than or equal to his or her language score, because the child is deemed to be functioning at or above the expected level.1. If a provider determines that therapy is warranted despite the relationship of IQ to language score, the provider must complete an in-depth functional profile.2. If the child's IQ is higher than his or her language scores, then the child qualifies for language therapyD. Accepted IQ tests are listed in sections 218.221 through 218.228.218.221 IQ Tests - Traditional B. The Wechsler Preschool & Primary Scales of Intelligence, Revised (WPPSI-R)D. Wechsler Intelligence Scale for Children, Third Ed. (WISC-III)E. Kauffman Adolescent & Adult Intelligence Test (KAIT)F. Wechsler Adult Intelligence Scale, Third Ed. (WAIS-III)G. Differential Ability Scales (DAS)H. Reynolds Intellectual Assessment Scales (RIAS)218.222 Severe and Profound IQ Test/Non-Traditional - Supplemental - Norm ReferenceA. Comprehensive Test of Nonverbal Intelligence (CTONI)B. Test of Nonverbal Intelligence (TONI-3) - 1997C. Functional Linguistic Communication Inventory (FLCI)218.223 Articulation/Phonological Assessments - Norm Reference A. Arizona Articulation Proficiency Scale, Third Ed. (Arizona-3)B. Goldman-Fristoe Test of Articulation, Second Ed. (FGTA-2)C. Khan-Lewis Phonological Analysis (KLPA-2)D. Slosson Articulation Language Test with Phonology (SALT-P)E. Bankston-Bernthal Test of Phonology (BBTOP)F. Smit-Hand Articulation and Phonology Evaluation (SHAPE)G. Comprehensive Test of Phonological Processing (CTOPP) H.Assessment of Intelligibility of Dysarthric Speech (AIDS)I. Weiss Comprehensive Articulation Test (WCAT)J. Assessment of Phonological Processes - R (APPS-R)K. Photo Articulation Test, Third Ed. (PAT-3)L. Structured Photographic Articulation Test II featuring Dudsberry (SPAT-D-II) TOC not required
214.310 Accepted Tests for Occupational Therapy Tests used must be norm referenced, standardized, age appropriate and specific to the therapy provided. The following list of tests is not all-inclusive. When using a test not listed here, the provider must include additional documentation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is selected by Medicaid for review. An explanation of why a test from the approved list could not be used to evaluate the child should be included. The MMY is the standard reference to determine the reliability and validity of the test(s) administered in the evaluation. Providers should refer to the MMY for additional information regarding specific tests.
Definitions:
STANDARD: Evaluations that are used to determine deficits.
SUPPLEMENTAL: Evaluations that are used to justify deficits and support other results. These should not "stand alone."
CLINICAL OBSERVATIONS: All clinical observations are supplemental but should be included with every evaluation, especially if standard scores do not qualify the child for therapy. The observations will be considered during reviews for medical necessity.
A. Fine Motor Skills - Standard 1. Peabody Developmental Motor Scales (PDMS, PDMS2)2. Toddler and Infant Motor Evaluation (TIME)3. Bruininks-Oseretsky Test of Motor Proficiency (BOMP)4. Test of Infant Motor Performance (TIMP)B. Fine Motor Skills - Supplemental 1. Early Learning Accomplishment Profile (ELAP)2. Learning Accomplishment Profile (LAP)3. Mullen Scales of Early Learning, Infant/Preschool (MSEL)4. Miller Assessment for Preschoolers (MAP)6. Hawaii Early Learning Profile (HELP)7. Battelle Developmental Inventory (BDI)8. Developmental Assessment of Young Children (DAYC)9. Brigance Developmental Inventory (BDI)C. Visual Motor - Standard1. Developmental Test of Visual Motor Integration (VMI)2. Test of Visual Motor Integration (TVMI)3. Test of Visual Motor Skills4. Test of Visual Motor Skills - R (TVMS)D. Visual Perception - Standard 1. Motor Free Visual Perceptual Test2. Motor Free Visual Perceptual Test - R (MVPT)3. Developmental Test of Visual Perceptual 2/A (DTVP)4. Test of Visual Perceptual Skills5. Test of Visual Perceptual Skills (upper level) (TVPS)E. Handwriting - Standard1. Evaluation Test of Children's Handwriting (ETCH)2. Test of Handwriting Skills (THS)3. Children's Handwriting Evaluation ScaleF. Sensory Processing - Standard 1. Sensory Profile for Infants/Toddlers2. Sensory Profile for Preschoolers3. Sensory Profile for Adolescents/Adults4. Sensory Integration and Praxis Test (SIPT)5. Sensory Integration Inventory Revised (SII-R)G. Sensory Processing - Supplemental 1. Sensory Motor Performance Analysis2. Analysis of Sensory Behavior3. Sensory Integration Inventory4. DeGangi-Berk Test of Sensory IntegrationH. Activities of Daily Living/Vocational/Other - Standard 1. Pediatric Evaluation of Disability Inventory (PEDI) NOTE: The PEDI can also be used for older children whose functional abilities fall below that expected of a 7½ year old with no disabilities. In this case, the scaled score is the most appropriate score to consider.
2. Adaptive Behavior Scale - School (ABS)3. Jacobs Pre-vocational Assessment4. Kohlman Evaluation of Daily Living Skills5. Milwaukee Evaluation of Daily Living Skills6. Cognitive Performance Test8. Functional Independence Measure - 7 years of age to adult (FIM)9. Functional Independence Measure - young version (WeeFIM) I.Activities of Daily Living/Vocational/Other - Supplemental1. School Function Assessment (SFA)2. Bay Area Functional Performance Evaluation4. Grip and Pinch Strength5. Jordan Left-Right Reversal Test6. Erhardy Developmental Prehension8. Social Skills Rating System9. Goodenough Harris Draw a Person Scale214.320 Accepted Tests for Physical Therapy Tests used must be norm referenced, standardized, age appropriate and specific to the therapy provided. The following list of tests is not all-inclusive. When using a test not listed here, the provider must include additional documentation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is selected by Medicaid for review. An explanation of why a test from the approved list could not be used to evaluate a child should be included. The MMY is the standard reference to determine the reliability and validity of the tests administered in the evaluation. Providers should refer to the MMY for additional information regarding specific tests.
A. Norm Reference 1. Adaptive Areas Assessment2. Test of Gross Motor Development (TGMD-2)3. Peabody Developmental Motor Scales, Second Ed. (PDMS-2)4. Bruininks-Oseretsky Test of Motor Proficiency (BOMP)5. Pediatric Evaluation of Disability Inventory (PEDI)6. Test of Gross Motor Development - 2 (TGMD-2)7. Peabody Developmental Motor Scales (PDMS)8. Alberta Infant Motor Scales (AIM)9. Toddler and Infant Motor Evaluation (TIME)10. Functional Independence Measure for Children (WeeFIM)11. Gross Motor Function Measure (GMFM)12. Adaptive Behavior Scale - School, Second Ed. (AAMR-2)13. Movement Assessment Battery for Children (Movement ABC)14. Test of Infant Motor Performance (TIMP)15. Functional Independence Measure - 7 years of age to adult (FIM)B. Physical Therapy - Supplemental 1. Bayley Scales of Infant Development, Second Ed. (BSID-2)2. Neonatal Behavioral Assessment Scale (NBAS)3. Mullen Scales of Early Learning Profile (MSEL)4. Hawaii Early Learning Profile (HELP)C. Physical Therapy Criteria1. Developmental assessment for students with severe disabilities, Second Ed. (DASH-2)2. Milani-Comparetti Developmental ExaminationD. Physical Therapy - Traumatic Brain Injury (TBI) - Standardized 1. Comprehensive Trail-Making Test2. Adaptive Behavior InventoryE. Physical Therapy - Piloted Assessment of Persons Profoundly or Severely Impaired
214.420 Intelligence Quotient (IQ) Testing Children receiving language intervention therapy must have cognitive testing once they reach ten (10) years of age. This also applies to home-schooled children. If the IQ score is higher than the qualifying language scores, the child qualifies for language therapy; if the IQ score is lower than the qualifying language test scores, the child would appear to be functioning at or above the expected level. In this case, the child may be denied for language therapy. If a provider determines that therapy is warranted, an in-depth functional profile must be documented. However, IQ scores are not required for children under ten (10) years of age.
A. IQ Tests - Traditional 2. The Wechsler Preschool & Primary Scales of Intelligence, Revised (WPPSI-R)4. Wechsler Intelligence Scale for Children, Third Ed. (WISC-III)5. Kauffman Adolescent & Adult Intelligence Test (KAIT)6. Wechsler Adult Intelligence Scale, Third Ed. (WAIS-III)7. Differential Ability Scales (DAS)8. Reynolds Intellectual Assessment Scales (RIAS)B. Severe & Profound IQ Test/Non-Traditional - Supplemental - Norm Reference 1. Comprehensive Test of Nonverbal Intelligence (CTONI)2. Test of Nonverbal Intelligence (TONI-3) - 19973. Functional Linguistic Communication Inventory (FLCI)C. Articulation/Phonological Assessments - Norm-Reference 1. Arizona Articulation Proficiency Scale, Third Ed. (Arizona-3)2. Goldman-Fristoe Test of Articulation, Second Ed. (GFTA-2)3. Khan-Lewis Phonological Analysis (KLPA-2)4. Slosson Articulation Language Test with Phonology (SALT-P)5. Bernthal-Bankson Test of Phonology (BBTOP)6. Smit-Hand Articulation and Phonology Evaluation (SHAPE)7. Comprehensive Test of Phonological Processing (CTOPP)8. Assessment of Intelligibility of Dysarthric Speech (AIDS)9. Weiss Comprehensive Articulation Test (WCAT)10. Assessment of Phonological Processes - R (APPS-R)11. Photo Articulation Test, Third Ed. (PAT-3)12. Structured Photographic Articulation Test II Featuring Dudsberry (SPAT-D II)D. Articulation/Phonological Assessments - Supplemental - Norm-Reference Test of Phonological Awareness (TOPA)E. Voice/Fluency Assessments - Norm-Reference Stuttering Severity Instrument for Children and Adults (SSI-3)F. Auditory Processing Assessments - Norm-Reference Goldman-Fristoe-Woodcock Test of Auditory Discrimination (G-F-WTAD)G. Oral Motor - Supplemental - Norm-Reference Screening Test for Developmental Apraxia of Speech, Second Ed. (STDAS-2)
H.Traumatic Brain Injury (TBI) Assessments - Norm-Reference 1. Ross Information Processing Assessment - Primary2. Test of Adolescent/Adult Word Finding (TAWF)3. Brief Test of Head Injury (BTHI)4. Assessment of Language-Related Functional Activities (ALFA)5. Ross Information Processing Assessment, Second Ed. (RIPA-2)6. Scales of Cognitive Ability for Traumatic Brain Injury (SCATBI)7. Communication Activities of Daily Living, Second Ed. (CADL-2) TOC not required
227.210 Accepted Tests for Occupational Therapy Tests used must be norm referenced, standardized, age appropriate and specific to the therapy provided. The following list of tests is not all-inclusive. When using a test not listed here, the provider must include additional documentation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is ever selected by Medicaid for review. An explanation of why a test from the approved list could not be used to evaluate the child must also be included. The MMY is the standard reference to determine the reliability and validity of the test(s) administered in an evaluation. Providers should refer to the MMY for additional information regarding specific tests.
DEFINITIONS:
STANDARD: Evaluations that are used to determine deficits.
SUPPLEMENTAL: Evaluations that are used to justify deficits and support other results. These should not "stand alone."
CLINICAL OBSERVATIONS: All clinical observations are supplemental but should be included with every evaluation, especially if standard scores do not qualify the child for therapy. It will be considered when reviewing for medical necessity.
A. Fine Motor Skills - Standard 1. Peabody Developmental Motor Scales (PDMS, PDMS2)2. Toddler and Infant Motor Evaluation (TIME)3. Bruininks-Oseretsky Test of Motor Proficiency (BOMP)4. Test of Infant Motor Performance (TIMP)B. Fine Motor Skills - Supplemental1. Early Learning Accomplishment Profile (ELAP)2. Learning Accomplishment Profile (LAP)3. Mullen Scales of Early Learning, Infant/Preschool (MSEL)4. Miller Assessment for Preschoolers (MAP)6. Hawaii Early Learning Profile (HELP)7. Battelle Developmental Inventory (BDI)8. Developmental Assessment of Young Children (DAYC)9. Brigance Developmental Inventory (BDI)C. Visual Motor - Standard1. Developmental Test of Visual Motor Integration (VMI)2. Test of Visual Motor Integration (TVMI)3. Test of Visual Motor Skills4. Test of Visual Motor Skills - R (TVMS)D. Visual Perception - Standard 1. Motor Free Visual Perceptual Test2. Motor Free Visual Perceptual Test - R (MVPT)3. Developmental Test of Visual Perceptual 2/A (DTVP)4. Test of Visual Perceptual Skills5. Test of Visual Perceptual Skills (upper level) (TVPS)F. Handwriting - Standard1. Evaluation Test of Children's Handwriting (ETCH)2. Test of Handwriting Skills (THS)3. Children's Handwriting Evaluation ScaleG. Sensory Processing - Standard 1. Sensory Profile for Infants/Toddlers2. Sensory Profile for Preschoolers3. Sensory Profile for Adolescents/Adults4. Sensory Integration and Praxis Test (SIPT)5. Sensory Integration Inventory Revised (SII-R) H.Sensory Processing - Supplemental 1. Sensory Motor Performance Analysis2. Analysis of Sensory Behavior3. Sensory Integration Inventory4. DeGangi-Berk Test of Sensory Integration I. Activities of Daily Living/Vocational/Other - Standard1. Pediatric Evaluation of Disability Inventory (PEDI) NOTE: The PEDI can also be used for older children whose functional abilities fall below that expected of a 7½ year old with no disabilities. If this is the case, the scaled score is the most appropriate score to consider.
2. Adaptive Behavior Scale - School (ABS)3. Jacobs Pre-vocational Assessment4. Kohlman Evaluation of Daily Living Skills5. Milwaukee Evaluation of Daily Living Skills6. Cognitive Performance Test8. Functional Independence Measure (FIM) 7 years of age to adult9. Functional Independence Measure - young version (WeeFIM) J.Activities of Daily Living/Vocational/Other - Standard 1. School Function Assessment (SFA)2. Bay Area Functional Performance Evaluation4. Grip and Pinch Strength5. Jordan Left-Right Reversal Test6. Erhardy Developmental Prehension8. Social Skills Rating System9. Goodenough Harris Draw a Person Scale227.220 Accepted Tests for Physical Therapy Tests used must be norm referenced, standardized, age appropriate and specific to the therapy provided. The following list of tests is not all-inclusive. When using a test not listed here, the provider must include additional documentation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is ever selected by Medicaid for review. An explanation of why a test from the approved list could not be used to evaluate the child must also be included. The MMY is the standard reference to determine the reliability and validity of the test(s) administered in an evaluation. Providers should refer to the MMY for additional information regarding specific tests.
A. Norm Reference 1. Adaptive Areas Assessment2. Test of Gross Motor Development (TGMD-2)3. Peabody Developmental Motor Scales, Second Ed. (PDMS-2)4. Bruininks-Oseretsky Test of Motor Proficiency (BOMP)5. Pediatric Evaluation of Disability Inventory (PEDI)6. Test of Gross Motor Development - 2 (TGMD-2)7. Peabody Developmental Motor Scales (PDMS)8. Alberta Infant Motor Scales (AIM)9. Toddler and Infant Motor Evaluation (TIME)10. Functional Independence Measure for Children (WeeFIM)11. Gross Motor Function Measure (GMFM)12. Adaptive Behavior Scale - School, Second Ed. (AAMR-2)13. Movement Assessment Battery for Children (Movement ABC)14. Test of Infant Motor Performance (TIMP)15. Functional Independence Measure (FIM) 7 years of age to adultB. Physical Therapy - Supplemental 1. Bayley Scales of Infant Development, Second Ed. (BSID-2)2. Neonatal Behavioral Assessment Scale (NBAS)3. Mullen Scales of Early Learning Profile (MSEL)4. Hawaii Early Learning Profile (HELP)C. Physical Therapy Criterion1. Developmental assessment for students with severe disabilities, Second Ed. (DASH-2)2. Milani-Comparetti Developmental ExaminationD. Physical Therapy - Traumatic Brain Injury (TBI) - Standardized 1. Comprehensive Trail-Making Test2. Adaptive Behavior InventoryE. Physical Therapy - Piloted Assessment of Persons Profoundly or Severely Impaired
227.320 Intelligence Quotient (IQ) Testing Children receiving language intervention therapy must have cognitive testing once they reach ten (10) years of age. This also applies to home-schooled children. If the IQ score is higher than the qualifying language scores, the child qualifies for language therapy; if the IQ score is lower than the qualifying language test scores, the child would appear to be functioning at or above the expected level. In this case, the child may be denied for language therapy. If a provider determines that therapy is warranted, an in-depth functional profile must be documented. However, IQ scores will not be required for children under ten (10) years of age.
A. IQ Tests - Traditional 2. The Wechsler Preschool & Primary Scales of Intelligence, Revised (WPPSI-R)4. Wechsler Intelligence Scale for Children, Third Ed. (WISC-III)5. Kauffman Adolescent & Adult Intelligence Test (KAIT)6. Wechsler Adult Intelligence Scale, Third Ed. (WAIS-III)7. Differential Ability Scales (DAS)8. Reynolds Intellectual Assessment Scales (RAIS)B. Severe & Profound IQ Test/Non-Traditional - Supplemental - Norm Reference 1. Comprehensive Test of Nonverbal Intelligence (CTONI)2. Test of Nonverbal Intelligence (TONI-3) - 19973. Functional Linguistic Communication Inventory (FLCI)C. Articulation/Phonological Assessments - Norm Reference 1. Arizona Articulation Proficiency Scale, Third Ed. (Arizona-3)2. Goldman-Fristoe Test of Articulation, Second Ed. (FGTA-2)3. Khan-Lewis Phonological Analysis (KLPA-2)4. Slosson Articulation Language Test with Phonology (SALT-P)5. Bankston-Bernthal Test of Phonology (BBTOP)6. Smit-Hand Articulation and Phonology Evaluation (SHAPE)7. Comprehensive Test of Phonological Processing (CTOPP)8. Assessment of Intelligibility of Dysarthric Speech (AIDS)9. Weiss Comprehensive Articulation Test (WCAT)10. Assessment of Phonological Processes - R (APPS-R)11. Photo Articulation Test, Third Ed. (PAT-3)12. Structured Photographic Articulation Test II Featuring Dudsberry (SPAT-D II)D. Articulation/Phonological - Supplemental - Norm ReferenceE. Test of Phonological Awareness (TOPA)F. Voice/Fluency Assessments - Norm Reference Stuttering Severity Instrument for Children and Adults (SSI-3)G. Auditory Processing Assessments - Norm Reference Goldman-Fristoe-Woodcock Test of Auditory Discrimination (G-F-WTAD)H. Oral Motor - Supplemental - Norm Reference Screening Test for Developmental Apraxia of Speech, Second Ed. (STDAS-2) I.Traumatic Brain Injury (TBI) Assessments - Norm Reference1. Ross Information Processing Assessment - Primary2. Test of Adolescent/Adult Word Finding (TAWF)3. Brief Test of Head Injury (BTHI)4. Assessment of Language-Related Functional Activities (ALFA)5. Ross Information Processing Assessment, Second Ed. (RIPA-2)6. Scales of Cognitive Ability for Traumatic Brain Injury (SCATBI)7. Communication Activities of Daily Living, Second Ed. (CADL-2) TOC required
216.102 Standardized Testing A. Tests used must be norm-referenced, standardized and specific to the therapy planned. 1. Tests must be age appropriate for the child being tested.2. Test results must be reported as standard scores, Z scores, T scores or percentiles.3. Age-equivalent scores and percentage of delay do not justify the medical necessity of services.B. A score of negative 1.50 standard deviations or more from the mean in at least 1 subtest area or composite score is required to qualify for services.C. The Mental Measurement Yearbook (MMY) is the standard reference for determining a test's reliability and validity.D. When a child cannot be tested with a norm-referenced, standardized test, then criterion-based testing or a functional description of his or her gross and fine motor deficits may be used. 1. In such a case, documentation of the reason(s) that a standardized test could not be used must be included in the evaluation.2. Listings of tests that AFMC accepts without requiring documentation of their reliability and validity can be found in this provider manual between sections 216.120 and 216.228, inclusive.216.121 Fine Motor Skills - Standard A. Peabody Developmental Motor Scales (PDMS, PDMS2)B. Toddler and Infant Motor Evaluation (TIME)C. Bruininks-Oseretsky Test of Motor Proficiency (BOMP)D. Test of Infant Motor Performance (TIMP)216.123 Visual Motor - Standard A. Developmental Test of Visual Motor Integration (VMI)B. Test of Visual Motor Integration (TVMI)C. Test of Visual Motor SkillsD. Test of Visual Motor Skills - R (TVMS)E. Pediatric Evaluation of Disability Inventory (PEDI) 1. The PEDI can also be used for older children whose functional abilities fall below that expected of a 7½ year old with no disabilities.2. When the PEDI is used for older children, the scaled score is the most appropriate score to consider.F. Adaptive Behavior Scale - School (ABS)G. Jacobs Pre-vocational AssessmentH. Kohlman Evaluation of Daily Living SkillsI. Milwaukee Evaluation of Daily Living SkillsJ. Cognitive Performance TestL. Functional Independence Measure (FIM); 7 through 20 years of ageM. Functional Independence Measure - young version (WeeFIM)216.131 Norm Reference A. Adaptive Areas AssessmentB. Test of Gross Motor Development (TGMD-2)C. Peabody Developmental Motor Scales, Second Ed. (PDMS-2)D. Bruininks-Oseretsky Test of Motor Proficiency (BOMP)E. Pediatric Evaluation of Disability Inventory (PEDI)F. Test of Gross Motor Development - 2 (TGMD-2)G. Peabody Developmental Motor Scales (PDMS) H.Alberta Infant Motor Scales (AIM)I. Toddler and Infant Motor Evaluation (TIME)J. Functional Independence Measure for Children (WeeFIM)K. Gross Motor Function Measure (GMFM)L. Adaptive Behavior Scale - School, Second Ed. (AAMR-2)M. Movement Assessment Battery for Children (Movement ABC)N. Test of Infant Motor Performance (TIMP)O. Functional Independence Measure (FIM); 7 through 20 years of age216.132 Physical Therapy - Supplemental A. Bayley Scales of Infant Development, Second Ed. (BSID-2)B. Neonatal Behavioral Assessment Scale (NBAS)C. Mullen Scales of Early Learning Profile (MSEL)D. Hawaii Early Learning Profile (HELP)216.133 Physical Therapy Criterion A. Developmental Assessment for Students with Severe Disabilities, Second Ed. (DASH-2)B. Milani-Comparetti Developmental Examination216.220 Intelligence Quotient (IQ) A. Children receiving language intervention therapy must have cognitive testing once they reach ten (10) years of age, whether they are in public school or they are home-schooled.B. Providers must maintain in their records the IQ scores of their patients who are 10 through 20 years of age and receiving language therapy.C. Language therapy may be determined not medically necessary if a child's IQ is less than or equal to his or her language score, because the child is deemed to be functioning at or above the expected level.1. If a provider determines that therapy is warranted despite the relationship of IQ to language score, the provider must complete an in-depth functional profile.2. If the child's IQ is higher than his or her language scores, then the child qualifies for language therapyD. Accepted IQ tests are listed in sections 216.221 through 216.228.216.221 IQ Tests - Traditional B. The Wechsler Preschool & Primary Scales of Intelligence, Revised (WPPSI-R)D. Wechsler Intelligence Scale for Children, Third Ed. (WISC-III)E. Kauffman Adolescent & Adult Intelligence Test (KAIT)F. Wechsler Adult Intelligence Scale, Third Ed. (WAIS-III)G. Differential Ability Scales (DAS)H. Reynolds Intellectual Assessment Scales (RIAS)216.222 Severe and Profound IQ Test/Non-Traditional - Supplemental - Norm ReferenceA. Comprehensive Test of Nonverbal Intelligence (CTONI)B. Test of Nonverbal Intelligence (TONI-3) - 1997C. Functional Linguistic Communication Inventory (FLCI)216.223 Articulation/Phonological Assessments - Norm Reference A. Arizona Articulation Proficiency Scale, Third Ed. (Arizona-3)B. Goldman-Fristoe Test of Articulation, Second Ed. (GFTA-2)C. Khan-Lewis Phonological Analysis (KLPA-2)D. Slosson Articulation Language Test with Phonology (SALT-P)E. Bankston-Bernthal Test of Phonology (BBTOP)F. Smit-Hand Articulation and Phonology Evaluation (SHAPE)G. Comprehensive Test of Phonological Processing (CTOPP)H. Assessment of Intelligibility of Dysarthric Speech (AIDS)I. Weiss Comprehensive Articulation Test (WCAT)J. Assessment of Phonological Processes - R (APPS-R)K. Photo Articulation Test, Third Ed. (PAT-3)L. Structured Photographic Articulation Test II featuring Dudsberry (SPATD-II)