016-06-07 Ark. Code R. § 13

Current through Register Vol. 49, No. 6, June, 2024

Rule 016.06.07-013 - Child Health Management Services Provider Manual Update Transmittal # 90

Section IIChild Health Management Services

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 Mental Measurement Yearbook (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. Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2)

5. 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)

5. Functional Profile

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 - Standard

1. Developmental Test of Visual Motor Integration (VMI)

2. Test of Visual Motor Integration (TVMI)

3. Test of Visual Motor Skills

4. Test of Visual Motor Skills - R (TVMS)

D. Visual Perception - Standard

1. Motor Free Visual Perceptual Test

2. Motor Free Visual Perceptual Test - R (MVPT)

3. Developmental Test of Visual Perceptual 2/A (DTVP)

4. Test of Visual Perceptual Skills

5. Test of Visual Perceptual Skills (upper level) (TVPS)

E. Handwriting - Standard

1. Evaluation Test of Children's Handwriting (ETCH)

2. Test of Handwriting Skills (THS)

3. Children's Handwriting Evaluation Scale

F. Sensory Processing - Standard

1. Sensory Profile for Infants/Toddlers

2. Sensory Profile for Preschoolers

3. Sensory Profile for Adolescents/Adults

4. Sensory Integration and Praxis Test (SIPT)

5. Sensory Integration Inventory Revised (SII-R)

G. Sensory Processing - Supplemental

1. Sensory Motor Performance Analysis

2. Analysis of Sensory Behavior

3. Sensory Integration Inventory

4. DeGangi-Berk Test of Sensory Integration

H. 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 Assessment

4. Kohlman Evaluation of Daily Living Skills

5. Milwaukee Evaluation of Daily Living Skills

6. Cognitive Performance Test

7. Purdue Pegboard

8. Functional Independence Measure (FIM) 7 years of age to adult

9. Functional Independence Measure - young version (WeeFIM)

J.Activities of Daily Living/Vocational/Other - Supplemental

1. School Function Assessment (SFA)

2. Bay Area Functional Performance Evaluation

3. Manual Muscle Test

4. Grip and Pinch Strength

5. Jordan Left-Right Reversal Test

6. Erhardy Developmental Prehension

7. Knox Play Scale

8. Social Skills Rating System

9. Goodenough Harris Draw a Person Scale

245.120 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 Mental Measurement Yearbook (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 Assessment

2. 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. Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2)

6. Pediatric Evaluation of Disability Inventory (PEDI)

7. Test of Gross Motor Development - 2 (TGMD-2)

8. Peabody Developmental Motor Scales (PDMS)

9. Alberta Infant Motor Scales (AIM)

10. Toddler and Infant Motor Evaluation (TIME)

11. Functional Independence Measure for Children (WeeFIM)

12. Gross Motor Function Measure (GMFM)

13. Adaptive Behavior Scale - School, Second Ed. (AAMR-2)

14. Movement Assessment Battery for Children (Movement ABC)

15. Test of Infant Motor Performance (TIMP)

16. Functional Independence Measure (FIM) 7 years of age to adult

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 Criterion

1. Developmental assessment for students with severe disabilities, Second Ed. (DASH-2)

2. Milani-Comparetti Developmental Examination

D. Physical Therapy - Traumatic Brain Injury (TBI) - Standardized

1. Comprehensive Trail-Making Test

2. Adaptive Behavior Inventory

E.Physical Therapy - Piloted Assessment of Persons Profoundly or Severely Impaired

245.210 Accepted Tests for Speech-Language 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 Mental Measurement Yearbook (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.

A. Speech-Language Tests - Standardized

1. Preschool Language Scale, Third Ed. (PLS-3)

2. Preschool Language Scale, Fourth Ed. (PLS-4)

3. Test of Early Language Development, Third Ed. (TELD-3)

4. Peabody Picture Vocabulary Test, Third Ed. (PPVT-3)

5. Clinical Evaluation of Language Fundamentals - Preschool (CELF-P)

6. Clinical Evaluation of Language Fundamentals, Third Ed. (CELF-3)

7. Clinical Evaluation of Language Fundamentals, Fourth Ed. (CELF-4)

8. Communication Abilities Diagnostic Test (CADT)

9. Test of Auditory Comprehension of Language, Third Ed. (TACL-3)

10. Comprehensive Assessment of Spoken Language (CASL)

11. Oral and Written Language Scales (OWLS)

12. Test of Language Development - Primary, Third Ed. (TOLD-P:3)

13. Test of Word Finding, Second Ed. (TWF-2)

14. Test of Auditory Perceptual Skills, Revised (TAPS-R)

15. Language Processing Test, Revised (LPT-R)

16. Test of Pragmatic Language (TOPL)

17. Test of Language Competence, Expanded Ed. (TLC-E)

18. Test of Language Development - Intermediate, Third Ed. (TOLD-I:3)

19. Fullerton Language Test for Adolescents, Second Ed. (FLTA)

20. Test of Adolescent and Adult Language, Third Ed. (TOAL-3)

21. Receptive One-Word Picture Vocabulary Test, Second Ed. (ROWPVT-2)

22. Expressive One-Word Picture Vocabulary Test, 2000 Ed. (EOWPVT)

23. Comprehensive Receptive and Expressive Vocabulary Test, Second Ed. (CREVT-2)

24. Kaufman Assessment Battery for Children (KABC)

25. Receptive-Expressive Emergent Language Test, Third Edition (REEL-3)

B. Speech Language Tests - Supplemental

1. Receptive/Expressive Emergent Language Test, Second Ed. (REEL-2)

2. Nonspeech Test for Receptive/Expressive Language

3. Rossetti Infant-Toddler Language Scale (RITLS)

4. Mullen Scales of Early Learning (MSEL)

5. Reynell Developmental Language Scales

6. Illinois Test of Psycholinguistic Abilities, Third Ed. (ITPA-3)

7. Social Skills Rating System - Preschool & Elementary Level (SSRS-1)

8. Social Skills Rating System - Secondary Level (SSRS-2)

C. Birth to Age 3:

1. - (minus)1.5 SD (standard score of 77) below the mean in two areas (expressive, receptive) or a - (minus) 2.0 SD (standard score of 70) below the mean in one area to qualify for language therapy.

2. Two language tests must be reported, with at least one of these being a global, norm-referenced, standardized test with good reliability and validity. The second test may be criterion referenced.

3. All subtests, components and scores must be reported for all tests.

4. All sound errors must be reported for articulation including positions and types of errors.

5. If phonological testing is submitted, a traditional articulation test must also be submitted with a standardized score.

6. Information regarding the child's functional hearing ability must be included as a part of the therapy evaluation report.

7. Non-school-age children must be evaluated annually.

8. If the provider indicates that the child cannot complete a norm-referenced test, the provider must submit an in-depth functional profile of the child's functional communication abilities. An in-depth functional profile is a description of a child's communication behaviors that specifically notes where such communication behaviors are impaired and justifies the medical necessity of therapy. Standardized forms are available for the completion of an in-depth functional profile, but a standardized form is not required.

9. Children must be evaluated at least annually. Children (birth to age 2) in the Child Health Management Services (CHMS) Program must be evaluated every 6 months.

D. Ages 3 to 21:

1. - (minus)1.5 SD (standard score of 77) below the mean in two areas (expressive, receptive, articulation) or a - (minus) 2.0 SD (standard score of 70) below the mean in one area (expressive, receptive, articulation)

2. Two language tests must be reported, with at least one of these being a global, norm-referenced, standardized test with good reliability and validity. Criterion-referenced tests will not be accepted for this age group.

3. All subtests, components and scores must be reported for all tests.

4. All sound errors must be reported for articulation including positions and types of errors.

5. If phonological testing is submitted, a traditional articulation test must also be submitted with a standardized score.

6. Information regarding child's functional hearing ability must be included as a part of the therapy evaluation report.

7. Non-school-age children must be evaluated annually.

8. School-age children must have a full evaluation every three years (a yearly update is required) if therapy is school related; outside of school annual evaluations are required. "School related" means the child is of school age, attends public school and receives therapy provided by the school.

9. If the provider indicates that the child cannot complete a norm-referenced test, the provider must submit an in-depth functional profile of the child's functional communication abilities. An in-depth functional profile is a description of a child's communication behaviors that specifically notes where such communication behaviors are impaired and justifies the medical necessity of therapy. Standardized forms are available for the completion of an in-depth functional profile, but a standardized form is not required.

10. IQ scores are required for all children who are school age and receiving language therapy. Exception: IQ scores are not required for children under ten (10) years of age.

262.120 Treatment Procedure Codes

The following treatment procedures are payable for services included in the child's treatment plan. Prior authorization is required for all CHMS treatment procedures. See section 240.000 of this manual for prior authorization requirements.

Procedure Codes
90804 90806	90808	90847	90849
97762* 99211	99212	99213	99214
99215

*Effective for dates of service on and after March 1, 2006, procedure code 97703 was made non-payable and was replaced with procedure code 97762.

Procedure Code	Required Modifier(s)	Description
T1024		Brief Consultation, on site - A direct service contact by a CHMS professional on-site with a patient for the purpose of: obtaining the full range of needed services; monitoring and supervising the patient's functioning; establishing support for the patient and gathering information relevant to the patient's individual treatment plan.
T1024	U1	Collateral Services, on site - Face-to-face contact on-site by a CHMS professional with other professionals, caregivers or other parties on behalf of an identified patient to obtain or provide relevant information necessary to the patient's assessment, evaluation or treatment.
90846	U4	Family therapy, on-site, for therapy as part of the treatment plan, without the patient present (1 unit = 15 minutes)
90847	U4	Family therapy, on site, for therapy as part of the treatment plan, with the patient present (1 unit = 15 minutes)
99361	UA	Treatment Plan - Plan of treatment developed by CHMS professionals and the patient's caregiver(s). Plan must include short- and long-term goals and objectives and include appropriate activities to meet those goals and objectives (1 unit = 15 minutes).
H2011	-	Crisis Management Visit, on site - An unscheduled/ unplanned direct service contact on site with the identified patient for the purpose of preventing physical injury, inappropriate behavior or placement in a more restrictive service delivery system (one unit = 15 minutes)
S9470	-	Nutrition Counseling/Consultation - Conference with parent/guardian and/or PCP to provide results of evaluation, discuss medical nutrition therapy plan and goals of treatment and education. May provide detailed menus for home use and information on sources of special nutrition products (1 unit = 30 minutes)
90853	-	Group Psychotherapy/counseling (1 unit = 5 minutes)
92507	-	Individual Speech Session by Speech-Language Pathology Therapist (1 unit = 15 minutes)
92507	UB	Individual Speech Therapy by Speech-Language Pathology Assistant (1 unit = 15 minutes)
92508	-	Group Speech Session by Speech-Language Pathology Therapist (1 unit = 15 minutes), maximum of 4 clients per group
92508	UB	Group Speech Therapy by Speech-Language Pathology Assistant (1 unit = 15 minutes), maximum of 4 clients per group
97110	-	Individual Physical Therapy by Physical Therapist (1 unit = 15 minutes)
97110	UB	Individual Physical Therapy by Physical Therapy Assistant (1 unit = 15 minutes)
97150	-	Group Physical Therapy by Physical Therapist (1 unit = 15 minutes), maximum of 4 clients per group
97150	U2	Group Occupational Therapy by Occupational Therapist (1 unit = 15 minutes), maximum of 4 clients per group
97150	U1, UB	Group Occupational Therapy by Occupational Therapy Assistant (1 unit = 15 minutes), maximum of 4 clients per group
97150	UB	Group Physical Therapy by Physical Therapy Assistant (1 unit = 15 minutes), maximum of 4 clients per group
97530	-	Individual Occupational Therapy by Occupational Therapist (1 unit = 15 minutes)
97530	UB	Individual Occupational Therapy by Occupational Therapy Assistant (1 unit = 15 minutes)
97530	U1	Developmental Motor Activity Services - Individualized activities provided by, or under the direction of, an Early Childhood Developmental Specialist to improve general motor skills by increasing coordination, strength and/or range of motion. Activities will be directed toward accomplishment of a motor goal identified in the patient's individualized treatment plan as authorized by the responsible CHMS physician (1 unit = 15 minutes)
97532	-	Cognitive Development Services - Individualized activities to increase the patient's intellectual development and competency. Activities will be those appropriate to carry out the treatment plan for the patient as authorized by the responsible CHMS physician. Cognitive Development Services will be provided by or under the direction of an Early Childhood Developmental Specialist. Activities will address goals of cognitive and communication skills development: (1 unit = 15 minutes).
97535	UB	Self Care and Social/Emotional Developmental Services - Individualized activities provided by or under the direction of an Early Childhood Developmental Specialist to increase the patient's self-care skills and/or ability to interact with peers or adults in a daily life setting/situation. Activities will be those appropriate to carry out the treatment plan for the patient as authorized by the responsible CHMS physician. (1 unit = 15 minutes).
97803	-	Nutrition follow-up: Reassess recent nutrition history, new anthropometer and laboratory data to evaluate progress toward meeting medical nutritional goals. May include a conference with parent or other CHMS professional (1 unit = 15 minutes).

262.130 CHMS Procedure Codes - Foster Care Program

Refer to section 202.000 of this manual for Arkansas Medicaid Participation Requirements for Providers of Comprehensive Health Assessments for Foster Children.

The following procedure codes are to be used for the mandatory comprehensive health assessments of children entering the Foster Care Program. These procedures do not require prior authorization.

Procedure Code	Required Modifier(s)	Description
T1016		Informing (1 unit = 15 minutes), maximum of 4 units
T1023		Staffing (1 unit = 15 minutes), maximum of 4 units
T1025		Developmental Testing
90801	U1	Diagnostic Interview, includes evaluation and reports (1 unit = 15 minutes), maximum of 8 units
92506	U1	Speech Testing (1 unit = 15 minutes), maximum of 8 units
92551	U1	Audio Screen
92567	U1	Tympanometry
92587**	U1	Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)
95961	UA	Cortical Function Testing
96101*	U1, UA	Psychological Testing, 2 or more (1 unit = 15 minutes), maximum of 8 units
96101*	UA	Interpretation (1 unit = 15 minutes), maximum of 8 units
99173		Visual Screen
99205 99215	U1 U1	High Complex medical exam

* Effective for dates of service on and after March 1, 2006, procedure code 96100 was made non-payable and was replaced with procedure code 96101.

** Effective for dates of service on and after January 1, 2007, procedure code 92587 is payable.

016.06.07 Ark. Code R. § 013

9/10/2007