Section II Hospital/Critical Access Hospital (CAH)/End Stage Renal Disease (ESRD)218.120 Accepted Tests for Occupational Therapy 9-1-08Tests 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 that is not listed below, the provider must include documentation in the evaluation 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 patient must also be included. The Mental Measurement Yearbook (MMY) is the standard reference for determining the reliability and validity of tests administered in an evaluation. Providers should refer to the MMY for additional information regarding specific tests. The following definitions of terms are applied to the lists of accepted tests:
* Standard: Evaluations that are used to determine deficits.
* Supplemental: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.
* Clinical observations: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.
A. Fine Motor Skills - Standard1. 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 - 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. Handwriting1. 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 - Supplemental1. Sensory Motor Performance Analysis2. Analysis of Sensory Behavior3. Sensory Integration Inventory4. DeGangi-Berk Test of Sensory IntegrationH. 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. 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 - 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 Scale218.130 Accepted Tests for Physical Therapy 9-1-08Tests 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 that is not listed below, the provider must include documentation in the evaluation 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 patient must also be included. The Mental Measurement Yearbook (MMY) is the standard reference for determining the reliability and validity of tests administered in an evaluation. Providers should refer to the MMY for additional information regarding specific tests. The following definitions of terms are applied to the lists of accepted tests:
* Standard: Evaluations that are used to determine deficits.
* Supplemental: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.
* Clinical observations: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.
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. 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 through 20 years of age.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)5. Battelle Developmental Inventory (BDI)C. Physical Therapy Criterion 1. 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 1. Assessment of Persons Profoundly or Severely Impaired218.200 Speech-Language Therapy Guidelines for Retrospective Review 9-1-08A. Medical Necessity Speech-language therapy services must be medically necessary to the treatment of the individual's illness or injury. To be considered medically necessary, the following conditions must be met:
1. The services must be considered under accepted standards of practice to be a specific and effective treatment for the patient's condition.2. The services must be of such a level of complexity or the patient's condition must be such that the services required can be safely and effectively performed only by or under the supervision of a qualified speech and language pathologist.3. There must be a reasonable expectation that therapy will result in meaningful improvement or a reasonable expectation that therapy will prevent a worsening of the condition. (See the medical necessity definition in the Glossary of this manual.) A diagnosis alone is not sufficient documentation to support the medical necessity of therapy. Assessment for speech-language therapy includes a comprehensive evaluation of the patient's speech language deficits and functional limitations, treatment planned and goals to address each identified problem.
B. Evaluations In order to determine that speech-language therapy services are medically necessary, an evaluation must contain the following information:
2. Patient's name and date of birth3. Diagnosis specific to therapy4. Background information including pertinent medical history and gestational age5. Standardized test results, including all subtest scores if applicable. Test results if applicable, should be adjusted for prematurity (less than 37 weeks gestation) if the child is 12 months of age or younger, and this should be noted in the evaluation.6. An assessment of the results of the evaluation, including recommendations for frequency and intensity of treatment7. An explanation why the child was not tested in his or her native language, when such is the case8. Signature and credentials of the therapist performing the evaluationC. Feeding/Swallowing/Oral Motor 1. The patient may be formally or informally assessed.2. The patient must have an in-depth functional profile on oral motor structures and function. An in-depth functional profile of oral motor structure and function is a description of a patient's oral motor structure that specifically notes how such structure is impaired in its function and justifies the medical necessity of feeding/swallowing/oral motor therapy services. Standardized forms are available for the completion of an in-depth functional profile of oral motor structure and function, but a standardized form is not required.3. If swallowing problems and/or signs of aspiration are noted, then a formal medical swallow study must be submitted.D. Voice A medical evaluation is a prerequisite for voice therapy.
E. Progress Notes Progress notes must be legible and must include the following information.
3. Time in and time out of each therapy session4. Objectives addressed (must directly correspond to the plan of care)5. Descriptions of specific therapy services provided daily and activities rendered during each therapy session, along with a form of measurement.6. Measurements of progress with respect to treatment goals and objectives7. Therapist's full signature and credentials for each date of service8. The supervising speech and language pathologist's co-signature on graduate students' progress notes218.210 Accepted Tests for Speech-Language Therapy 9-1-08Tests 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 that is not listed below, the provider must include documentation in the evaluation 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 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. The following definitions of terms are applied to the lists of accepted tests:
* Standard: Evaluations that are used to determine deficits.
* Supplemental: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.
* Clinical observations: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.
A. Speech-Language Tests - Standardized1. 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 (CADeT)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 Language3. Rossetti Infant-Toddler Language Scale (RITLS)4. Mullen Scales of Early Learning (MSEL)5. Reynell Developmental Language Scales6. 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)9. Kaufman Speech Praxis Test (KSPT)C. Literacy/Comprehension - Supplemental1. The Clinical Assessment of Literacy and Language2. The Literacy Comprehension Test 23. Test of Reading Comprehension 3 (TORC3)D. Written Language/Comprehension - Supplemental1. Test of Written Language 3 (TWL3)E. Birth to Age 3: 1. (Negative) -1.5 SD (standard score of 77) below the mean in two areas (expressive, receptive) or a (negative) -2.0 SD (standard score of 70) below the mean in one area is required 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. 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.8. 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.F. Ages 3 through 20 1. (Negative) -1.5 SD (standard score of 77) below the mean in two areas (expressive, receptive, articulation) or a (negative) -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 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. 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.218.220 Intelligence Quotient (IQ) Testing 9-1-08Children 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. Providers must maintain in their records the IQ scores of their patients who are 10 through 20 years of age and receiving language therapy. If a child's IQ score is higher than his or her qualifying language scores, the child qualifies for language therapy; if the IQ score is lower than the qualifying language test scores, the child is deemed 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 despite the relationship of IQ to language score, the provider must complete and document an in-depth functional profile. 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 and 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 Assessments - Supplemental - Norm-Reference 1. Test of Phonological Awareness (TOPA)2. Clinical Assessment of Articulation and Phonology (CAAP)3. Phonology Awareness Test (PAT)E. Apraxia A provider who chooses to address Apraxia in treatment sessions must submit additional norm-referenced testing to support a coexisting deficit in articulation and/or language. Testing must be administered to examine the beneficiary's receptive and expressive language and articulation skills to determine if there is a coexisting problem. The Kaufman Speech Praxis Test (KSPT) can not stand alone to support the medical necessity of speech therapy. A functional communication profile including a detailed case history and description of the child's communicative abilities, including documentation of any neuromuscular deficits and assessments of the child's oral motor abilities must be included. For older children literacy skills should also be addressed. If possible, a speech sample of the beneficiary's speech should be included. Recommendations and a plan of care for treatment should be included in the documentation submitted.
1. Kaufman Speech Praxis Test - (KSPT) - SupplementalF. Voice/Fluency Assessments - Norm Reference 1. Stuttering Severity Instrument for Children and Adults (SSI-3)2. Language Sample - A language sample with an in-depth profile of the percentage of stuttering and type of stuttering that occurs during conversational speechG. Auditory Processing Assessments - Norm Reference1. Goldman-Fristoe-Woodcock Test of Auditory Discrimination (G-F-WTAD)H. Oral Motor - Supplemental - Norm Reference 1. 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)6. Scales of Cognitive Ability for Traumatic Brain Injury (SCATBI)7. Communication Activities of Daily Living, Second Ed. (CADL-2)Section IIRehabilitative Hospital216.120 Accepted Tests for Occupational Therapy 09-01-08Tests 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 that is not listed below, the provider must include documentation in the evaluation 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 patient must also be included. The Mental Measurement Yearbook (MMY) is the standard reference for determining the reliability and validity of tests administered in an evaluation. Providers should refer to the MMY for additional information regarding specific tests. The following definitions of terms are applied to the lists of accepted tests:
* Standard: Evaluations that are used to determine deficits.
* Supplemental: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.
* Clinical observations: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.
A. Fine Motor Skills - Standard1. 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 (BOT2)5. 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. Handwriting1. 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 - Supplemental1. Sensory Motor Performance Analysis2. Analysis of Sensory Behavior3. Sensory Integration Inventory4. DeGangi-Berk Test of Sensory IntegrationH. 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. 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)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 Scale216.130 Accepted Tests for Physical Therapy 9-1-08Tests used must be norm referenced, standardized, age appropriate and specific to the therapy provided. The following lists of tests are not all-inclusive. When using a test that is not listed below, the provider must include documentation in the evaluation 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 patient must also be included. The Mental Measurement Yearbook (MMY) is the standard reference for determining the reliability and validity of tests administered in an evaluation. Providers should refer to the MMY for additional information regarding specific tests. The following definitions of terms are applied to the lists of accepted tests:
* Standard: Evaluations that are used to determine deficits.
* Supplemental: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.
* Clinical observations: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.
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. Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT2)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 through 20 years of ageB. 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)5. Battelle Developmental Inventory (BDI)C. Physical Therapy Criterion 1. 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 1. Assessment of Persons Profoundly or Severely Impaired216.200 Speech-Language Therapy Guidelines for Retrospective Review 9-1-08A. Medical Necessity Speech-language therapy services must be medically necessary to the treatment of the individual's illness or injury. To be considered medically necessary, the following conditions must be met:
1. The services must be considered under accepted standards of practice to be a specific and effective treatment for the patient's condition.2. The services must be of such a level of complexity or the patient's condition must be such that the services required can be safely and effectively performed only by or under the supervision of a qualified speech and language pathologist.3. There must be reasonable expectation that therapy will result in meaningful improvement or a reasonable expectation that therapy will prevent a worsening of the condition. (See the medical necessity definition in the Glossary of this manual). A diagnosis alone is not sufficient documentation to support the medical necessity of therapy. Assessment for speech-language therapy includes a comprehensive evaluation of the patient's speech-language deficits and functional limitations, treatment(s) planned and goals to address each identified problem.
B. Evaluations In order to determine that speech-language therapy services are medically necessary, an evaluation must contain the following information:
2. Child's name and date of birth3. Diagnosis specific to therapy4. Background information including pertinent medical history and gestational age5. Standardized test results, including all subtest scores if applicable. Test results, if applicable, should be adjusted for prematurity (less than 37 weeks gestation) if the child is 12 months of age or younger, and this should be noted in the evaluation6. An assessment of the results of the evaluation, including recommendations for frequency and intensity of treatment7. The child should be tested in his or her native language; if not, an explanation must be provided in the evaluation.8. Signature and credentials of the therapist performing the evaluationC. Feeding/Swallowing/Oral Motor 1. The patient may be formally or informally assessed2. The Patient must have an in-depth functional profile on oral motor structures and function. An in-depth functional profile of oral motor structure and function is a description of a patient's oral motor structure that specifically notes how such structure is impaired in its function and justifies the medical necessity of feeding/swallowing/oral motor therapy services. Standardized forms are available for the completion of an in-depth functional profile of oral motor structure and function, but a standardized form is not required.3. If swallowing problems and/or signs of aspiration are noted, a formal medical swallow study must be submitted.D. Voice A medical evaluation is a prerequisite for voice therapy.
E. Progress Notes Progress notes must be legible and must include the following information:
3. Time in and time out of each therapy session4. Objectives addressed (must directly correspond to the plan of care)5. Descriptions of specific therapy services provided daily and activities conducted during each therapy session, along with a form of measurement6. Measurements of progress with respect to treatment goals and objectives7. Therapist's must sign each date of entry with a full signature and credentials8. The supervising speech and language pathologist's co-signature on graduate students' progress notes.216.210 Accepted Tests for Speech-Language Therapy 9-1-08Tests 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 that is not listed below, the provider must include documentation in the evaluation 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 patient must be included in the documentation. The Mental Measurement Yearbook (MMY) is the standard reference for determining the reliability and validity of test(s) administered in an evaluation. Providers should refer to the MMY for additional information regarding specific tests. The following definitions of terms are applied to the lists of accepted tests:
* Standard: Evaluations that are used to determine deficits.
* Supplemental: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.
* Clinical observations: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.
A. Speech-Language Tests - Standardized1. 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 (CADeT)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 Language3. Rossetti Infant-Toddler Language Scale (RITLS)4. Mullen Scales of Early Learning (MSEL)5. Reynell Developmental Language Scales6. 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)9. Kaufman Speech Praxis Test (KSPT)C. Literacy/Comprehension - Supplemental1. The Clinical Assessment of Literacy and Language2. The Literacy Comprehension Test 23. Test of Reading Comprehension 3 (TORC3)D. Written Language/Comprehension - Supplemental 1. Test of Written Language 3 (TWL3)E. Birth to Three 1. (Negative) -1.5 SD (standard deviation) (standard score of 77) below the mean in two areas (expressive, receptive) or (negative) -2.0 SD (standard score of 70) below the mean in one area is required 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 used, a traditional articulation test must also be included with a standardized score.6. Information regarding the patient's functional hearing ability must be included in the therapy evaluation report.7. Non school-age children must be evaluated annually. If the provider indicates the patient cannot complete a norm-referenced test, the provider must submit an in-depth functional profile of the patient's functional communication abilities. An in-depth functional profile is a description of a patient's communication behaviors that specifically notes where such communication behaviors are impaired and justifies the medical necessity of therapy.8. 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 six (6) months.F. Ages 3 through 201. (Negative) -1.5 SD (standard score of 77) from the mean in two areas (expressive, receptive, articulation) or a (negative) -2.0 SD (standard score of 70) from the mean in one area (expressive, receptive, articulation) is required to qualify for language therapy. Two language tests must be reported, with at least one of these being a global, norm-referenced, standardized test with good reliability and validity.
2. 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 used, a traditional articulation test must also be completed with a standardized score.6. Information regarding patient's functional hearing ability must be included in the therapy evaluation report.7. Children who are not of school age or who do not attend public school must be evaluated annually. School-aged children who attend public school and whose therapy is provided by the school must have a full evaluation every three years, with an annual update.
If the provider indicates that the patient cannot complete a norm-referenced test, the provider must complete an in-depth functional profile of the patient's functional communication abilities. An in-depth functional profile is a description of a patient's communication behaviors that specifically notes where such communication behaviors are impaired and justifies the medical necessity of therapy.
8. Standardized forms are available for the completion of an in-depth functional profile, but a standardized form is not required.9. 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.216.220 Intelligence Quotient (IQ) Testing 9-1-08Children receiving language intervention therapy must have cognitive testing once they reach ten (10) years of age. This also applies to home-schooled children. Providers must maintain in their records the IQ scores of their patients who are 10 through 20 years of age and receiving language therapy. If a child's IQ score is higher than his or her qualifying language score, the child qualifies for language therapy; if the IQ score is lower that the qualifying language test scores, the child is deemed 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 despite the relationship of IQ to language score, the provider must complete and document an in-depth functional profile. 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 and 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. 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 (SPATD-II)D. Articulation/Phonological Assessments - Supplemental 1. Test of Phonological Awareness (TOPA)2. Clinical Assessment of Articulation and Phonology (CAAP)3. Phonology Awareness Test (PAT)E. Apraxia A provider who chooses to address Apraxia in treatment sessions must submit additional norm-referenced testing to support a coexisting deficit in articulation and/or language. Testing must be administered to examine the beneficiary's receptive and expressive language and articulation skills to determine if there is a coexisting problem. The Kaufman Speech Praxis Test (KSPT) can not stand alone to support the medical necessity of speech therapy. A functional communication profile including a detailed case history and description of the child's communicative abilities, including documentation of any neuromuscular deficits and assessments of the child's oral motor abilities must be included. For older children, literacy skills should also be addressed. If possible, a speech sample of the beneficiary's speech should be included. Recommendations and a plan of care for treatment should be included in the documentation submitted.
1. Kaufman Speech Praxis Test - KSPT - SupplementalF. Voice/Fluency Assessments - Norm Reference 1. Stuttering Severity Instrument for Children and Adults (SSI-3)2. Language Sample - A language sample with an in-depth profile of the percentage of stuttering and type of stuttering that occurs during conversational speech.G. Auditory Processing Assessments - Norm Reference1. Goldman-Fristoe-Woodcock Test of Auditory Discrimination (G-F-WTAD)H. Oral Motor - Supplemental - Norm Reference1. 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)6. Scales of Cognitive Ability for Traumatic Brain Injury (SCATBI)7. Communication Activities of Daily Living, Second Ed. (CADL-2)Section IIChild Health Management Services245.110 Accepted Tests for Occupational Therapy 9-1-08Tests 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 that is not listed below, the provider must include documentation in the evaluation 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 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. The following definitions of terms are applied to the lists of accepted tests:
* STANDARD: Evaluations that are used to determine deficits.
* SUPPLEMENTAL: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.
* CLINICAL OBSERVATIONS: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.
A. Fine Motor Skills - Standard1. 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 - 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 - Supplemental1. Sensory Motor Performance Analysis2. Analysis of Sensory Behavior3. Sensory Integration Inventory4. DeGangi-Berk Test of Sensory IntegrationH. 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. 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 - 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 Scale245.120 Accepted Tests for Physical Therapy 9-1-08Tests 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 that is not listed below, the provider must include documentation in the evaluation 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. The following definitions of terms are applied to the lists of accepted tests:
* STANDARD: Evaluations that are used to determine deficits.
* SUPPLEMENTAL: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.
* CLINICAL OBSERVATIONS: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.
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. 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 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)5. Battelle Developmental Inventory (BDI)C. Physical Therapy Criterion 1. 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
245.210 Accepted Tests for Speech-Language Therapy 9-1-08Tests 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 that is not listed below, the provider must include documentation in the evaluation 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. The following definitions of terms are applied to the lists of accepted tests:
* STANDARD: Evaluations that are used to determine deficits.
* SUPPLEMENTAL: Evaluations that are used to identify deficits and support other results. Supplemental test may not supplant standard tests.
* CLINICAL OBSERVATIONS: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.
A. Speech-Language Tests - Standardized1. 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 Language3. Rossetti Infant-Toddler Language Scale (RITLS)4. Mullen Scales of Early Learning (MSEL)5. Reynell Developmental Language Scales6. 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)9. Kaufman Speech Praxis Test (KSPT)C. Literacy/Comprehension - Supplemental1. The Clinical Assessment of Literacy and Language2. The Literacy Comprehension Test 23. Test of Reading Comprehension 3 (TORC3)D. Written Language/Comprehension - Supplemental 1. Test of Written Language 3 (TWL3)E. Birth to Age 3: 1. (Negative) -1.5 SD (standard score of 77) below the mean in two areas (expressive, receptive) or a (negative) -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.F. Ages 3 to 21: 1. (Negative) -1.5 SD (standard score of 77) below the mean in two areas (expressive, receptive, articulation) or a (negative) -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 age 10 years through 18 years who are receiving language therapy. IQ Scores are not required for children under ten (10) years of age.245.220 Intelligence Quotient (IQ) Testing 9-1-08Children 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 - 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. (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 1. Test of Phonological Awareness (TOPA)2. Clinical Assessment of Articulation and Phonology (CAAP)3. Phonology Awareness Test (PAT)E. Apraxia A provider who chooses to address Apraxia in treatment sessions must submit additional norm referenced testing to support a coexisting deficit in articulation and/or language. Testing must be administered to examine the beneficiary's receptive and expressive language and articulation skills to determine if there is a coexisting problem. The Kaufman Speech Praxis Test (KSPT) can not stand alone to support the medical necessity of speech therapy. A functional communication profile including a detailed case history and description of the child's communicative abilities, including documentation of any neuromuscular deficits and assessments of the child's oral motor abilities must be included. For older children, literacy skills should also be addressed. If possible, a speech sample of the beneficiary's speech should be included. Recommendations and a plan of care for treatment should be included in the documentation submitted.
1. Kaufman Speech Praxis Test - KSPT - SupplementalF. Voice/Fluency Assessments - Norm-Reference 1. Stuttering Severity Instrument for Children and Adults (SSI-3)G. Auditory Processing Assessments - Norm-Reference1. Goldman-Fristoe-Woodcock Test of Auditory Discrimination (G-F-WTAD)H. Oral Motor - Supplemental - Norm-Reference 1. 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 not required
220.110 Accepted Tests for Occupational Therapy 9-1-08Tests 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 below, the provider must include documentation in the evaluation 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 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. The following definitions of terms are applied to the lists of accepted tests:
* STANDARD: Evaluations that are used to determine deficits.
* SUPPLEMENTAL: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.
* CLINICAL OBSERVATIONS: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.
A. Fine Motor Skills - Standard1. 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 - 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 - Supplemental1. Sensory Motor Performance Analysis2. Analysis of Sensory Behavior3. Sensory Integration Inventory4. DeGangi-Berk Test of Sensory IntegrationH. 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. 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) 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 Scale220.120 Accepted Tests for Physical Therapy 9-1-08Tests 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 below, the provider must include documentation in the evaluation 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 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.
The following definitions of terms are applied to the lists of accepted tests:
* Standard: Evaluations that are used to determine deficits.
* Supplemental: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.
* Clinical observations: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.
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. 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 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)5. Battelle Developmental Inventory (BDI)C. Physical Therapy Criterion 1. 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
220.210 Accepted Tests for Speech-Language Therapy 9-1-08Tests 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 below, the provider must include documentation in the evaluation 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 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. The following definitions of terms are applied to the lists of accepted tests:
* Standard: Evaluations that are used to determine deficits.
* Supplemental: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.
* Clinical observations: Clinical observations always have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.
A. Speech-Language Tests - Standardized1. 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 (CADeT)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 Language3. Rossetti Infant-Toddler Language Scale (RITLS)4. Mullen Scales of Early Learning (MSEL)5. Reynell Developmental Language Scales6. 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)9. Kaufman Speech Praxis Test (KSPT)C. Literacy/Comprehension - Supplemental1. The Clinical Assessment of Literacy and Language2. The Literacy Comprehension Test 23. Test of Reading Comprehension 3 (TORC3)D. Written Language/Comprehension - Supplemental1. Test of Written Language 3 (TWL3)E. Birth to Age 3: 1. (Negative) -1.5 SD (standard score of 77) below the mean in two areas (expressive, receptive) or a (negative) -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.F. Ages 3 to 21: 1. (Negative) -1.5 SD (standard score of 77) below the mean in two areas (expressive, receptive, articulation) or a (negative) -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 aged 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 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 on all children who are 10 years through 18 years of age and receiving language therapy. IQ scores are not required for children under ten (10) years of age.220.220 Intelligence Quotient (IQ) Testing 9-1-08Children 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 submitted. 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. 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 Assessments - Supplemental - Norm Reference 1. Test of Phonological Awareness (TOPA)E. Apraxia A provider who chooses to address Apraxia in treatment sessions must submit additional norm-referenced testing to support a coexisting deficit in articulation and/or language. Testing must be administered to examine the beneficiary's receptive and expressive language and articulation skills to determine if there is a coexisting problem. The Kaufman Speech Praxis Test (KSPT) can not stand alone to support the medical necessity of speech therapy. A functional communication profile including a detailed case history and description of the child's communicative abilities, including documentation of any neuromuscular deficits and assessments of the child's oral motor abilities must be included. For older children, literacy skills should also be addressed. If possible, a speech sample of the beneficiary's speech should be included. Recommendations and a plan of care for treatment should be included in the documentation submitted.
1. Kaufman Speech Praxis Test - KSPT - SupplementalF. Voice/Fluency Assessments - Norm Reference 1. Stuttering Severity Instrument for Children and Adults (SSI-3)G. Auditory Processing Assessments - Norm Reference1. Goldman-Fristoe-Woodcock Test of Auditory Discrimination (G-F-WTAD)H. Oral Motor - Supplemental - Norm Reference 1. 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)Section IIOccupational, Physical, Speech Therapy Services214.310 Accepted Tests for Occupational Therapy 9-1-08Tests 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 that is not listed below, the provider must include documentation in the evaluation 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 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. The following definitions of terms are applied to the lists of accepted tests:
* STANDARD: Evaluations that are used to determine deficits.
* SUPPLEMENTAL: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.
* CLINICAL OBSERVATIONS: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.
A. Fine Motor Skills - Standard1. 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 - 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 - Supplemental1. Sensory Motor Performance Analysis2. Analysis of Sensory Behavior3. Sensory Integration Inventory4. DeGangi-Berk Test of Sensory IntegrationH. 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. 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 9-1-08Tests 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 that is not listed below, the provider must include documentation in the evaluation 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 Mental Measurement Yearbook (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. The following definitions of terms are applied to the lists of accepted tests:
* STANDARD: Evaluations that are used to determine deficits.
* SUPPLEMENTAL: Evaluations that are used to justify deficits and support other results. Supplemental tests may not supplant standard tests.
* CLINICAL OBSERVATIONS: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justifications of medical necessity.
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. 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 - 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)5. Battelle Developmental Inventory (BDI)C. Physical Therapy Criteria 1. 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
214.410 Accepted Tests for Speech-Language Therapy 9-1-08Tests 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 that is not listed below, the provider must include documentation in the evaluation 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 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. The following definitions of terms are applied to the lists of accepted tests:
* STANDARD: Evaluations that are used to determine deficits.
* SUPPLEMENTAL: Evaluations that are used to justify deficits and support other results. Supplemental tests may not supplant standard tests.
* CLINICAL OBSERVATIONS: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.
A. Speech-Language Tests - Standardized1. 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 Language3. Rossetti Infant-Toddler Language Scale (RITLS)4. Mullen Scales of Early Learning (MSEL)5. Reynell Developmental Language Scales6. 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)9. Kaufman Speech Praxis Test (KSPT)C. Literacy/Comprehension - Supplemental1. The Clinical Assessment of Literacy and Language2. The Literacy Comprehension Test 23. Test of Reading Comprehension 3 (TORC3)D. Written Language/Comprehension - Supplemental 1. Test of Written Language 3 (TWL3)E. Birth to Age 3: 1. (Negative) -1.5 SD (standard score of 77) below the mean in two areas (expressive, receptive) or a (negative) -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.F. Ages 3 to 20: 1. (Negative) -1.5 SD (standard score of 77) below the mean in two areas (expressive, receptive, articulation) or (negative) -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 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. 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 10 years through 18 years of age and receiving language therapy. IQ scores are not required for children under ten (10) years of age.214.420 Intelligence Quotient (IQ) Testing 9-1-08Children 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 1. Test of Phonological Awareness (TOPA)2. Clinical Assessment of Articulation and Phonology (CAAP)3. Phonology Awareness Test (PAT)E. Apraxia A provider who chooses to address Apraxia in treatment sessions must submit additional norm-referenced testing to support a coexisting deficit in articulation and/or language. Testing must be administered to examine the beneficiary's receptive and expressive language and articulation skills to determine if there is a coexisting problem. The Kaufman Speech Praxis Test (KSPT) can not stand alone to support the medical necessity of speech therapy. A functional communication profile including a detailed case history and description of the child's communicative abilities, including documentation of any neuromuscular deficits and assessments of the child's oral motor abilities must be included. For older children, literacy skills should also be addressed. If possible, a speech sample of the beneficiary's speech should be included. Recommendations and a plan of care for treatment should be included in the documentation submitted.
1. Kaufman Speech Praxis Test - KSPT - SupplementalF. Voice/Fluency Assessments - Norm-Reference 1. Stuttering Severity Instrument for Children and Adults (SSI-3)G. Auditory Processing Assessments - Norm-Reference1. Goldman-Fristoe-Woodcock Test of Auditory Discrimination (G-F-WTAD)H. Oral Motor - Supplemental - Norm-Reference 1. 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)Section IIPhysician/Independent Lab/CRNA/Radiation Therapy Center227.210 Accepted Tests for Occupational Therapy 9-1-08Tests 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 that is not listed below, the provider must include documentation in the evaluation 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 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. The following definitions of terms are applied to the lists of accepted tests:
* STANDARD: Evaluations that are used to determine deficits.
* SUPPLEMENTAL: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.
* CLINICAL OBSERVATIONS: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justifications of medical necessity.
A. Fine Motor Skills - Standard1. 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 - 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 - Supplemental1. Sensory Motor Performance Analysis2. Analysis of Sensory Behavior3. Sensory Integration Inventory4. DeGangi-Berk Test of Sensory IntegrationH. 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) I. 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 Scale227.220 Accepted Tests for Physical Therapy 9-1-08Tests 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 below, the provider must include documentation in the evaluation 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 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. The following definitions of terms are applied to the lists of accepted tests:
* STANDARD: Evaluations that are used to determine deficits.
* SUPPLEMENTAL: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.
* CLINICAL OBSERVATIONS: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justifications of medical necessity.
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. 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 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)5. Battelle Developmental Inventory (BDI)C. Physical Therapy Criterion 1. 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 1. Assessment of Persons Profoundly or Severely Impaired227.310 Accepted Tests for Speech-Language Therapy 9-1-08Tests 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 that is not listed below, the provider must include documentation in the evaluation 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 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. The following definitions of terms are applied to the lists of accepted tests:
* STANDARD: Evaluations that are used to determine deficits.
* SUPPLEMENTAL: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.
* CLINICAL OBSERVATIONS: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justifications of medical necessity.
A. Speech-Language Tests - Standardized1. 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 (CADeT)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 Language3. Rossetti Infant-Toddler Language Scale (RITLS)4. Mullen Scales of Early Learning (MSEL)5. Reynell Developmental Language Scales6. 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)9. Kaufman Speech Praxis Test (KSPT)C. Literacy/Comprehension - Supplemental1. The Clinical Assessment of Literacy and Language2. The Literacy Comprehension Test 23. Test of Reading Comprehension 3 (TORC3)D. Written Language/Comprehension - Supplemental 1. Test of Written Language 3 (TWL3)E. Birth to Age 3: 1. (Negative) -1.5 SD (standard score of 77) below the mean in two areas (expressive, receptive) or a (negative) -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/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-aged children must be evaluated annually.8. If the provider indicates 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. Child Health Management Services (CHMS) children (birth - 2) must be evaluated every 6 months.F. Ages 3 - 21: 1. (Negative) -1.5 SD (standard score of 77) below the mean in two areas (expressive, receptive, articulation) or a (negative) -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/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 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 on all children who are 10 years through 18 years of age and receiving language therapy. IQ scores will not be required for children under ten (10) years of age.227.320 Intelligence Quotient (IQ) Testing 9-1-08Children 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 Reference 1. Test of Phonological Awareness (TOPA)2. Clinical Assessment of Articulation and Phonology (CAAP)3. Phonology Awareness Test (PAT)E. Apraxia A provider who chooses to address Apraxia in treatment sessions must submit additional norm referenced testing to support a coexisting deficit in articulation and/or language. Testing must be administered to examine the beneficiary's receptive and expressive language and articulation skills to determine if there is a coexisting problem. The Kaufman Speech Praxis Test (KSPT) can not stand alone to support the medical necessity of speech therapy. A functional communication profile, including a detailed case history and description of the child's communicative abilities, including documentation of any neuromuscular deficits and assessments of the child's oral motor abilities must be included. For older children, literacy skills should also be addressed. If possible, a speech sample of the beneficiary's speech should be included. Recommendations and a plan of care for treatment should be included in the documentation submitted.
1. Kaufman Speech Praxis Test - KSPT - SupplementalF. Voice/Fluency Assessments - Norm Reference 1. Stuttering Severity Instrument for Children and Adults (SSI-3)G. Auditory Processing Assessments - Norm Reference1. Goldman-Fristoe-Woodcock Test of Auditory Discrimination (G-F-WTAD)H. Oral Motor - Supplemental - Norm Reference 1. 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)