016.06.09 Ark. Code R. 019

Current through Register Vol. 49, No. 10, October, 2024

Rule 016.06.09-019 - Occupational, Physical and Speech Therapy Services Provider Manual Update #113, Developmental Day Treatment Clinic Services Provider Manual Update #124, Physician/Independent Lab/CRNA/Radiation Therapy Center Provider Manual Update #170, Nurse Practitione Provider Manual Update Trarismittal-#115, Hospital/Critical Access Hospital/ End Stage Renal Disease Provider Manual Update #157, Child Health Management Services Provider Manual Update #121, Rehabilitative Hospital Provider Manual Update #113

Section II Occupational, Physical, Speech Therapy Services

214.300 Occupational and Physical Therapy Guidelines for Retrospective Review

A. Occupational and physical therapy services are medically prescribed services for the-diagnosis and treatment of movement dysfunction, which-results in functional disabilities,

Occupational and physical 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 considerediunder-accepted-standards oipractice 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 physical or occupational therapist.

3. There must-be-reasonable expectation that-therapy will result in-a-meaningful, improvement or a reasonable expectation that therapy will prevent a worsening of the condition. (See tbe-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 physical and/or occupational therapy includes a comprehensive evaluation of the patient's physical deficits and functional limitations, treatment planned and goals to address each identified problem.

B. Evaluations:

In order to determine that therapy services are medically necessary, an annual evaluation must contain the following information:

1. Date of evaluation.

2. Child's name arid date of birth.

3. Diagnosis applicable to specific therapy.

4. Background information including pertinent medical history; and, if the child is12 months of age or younger, gestational age.

5. 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. The test results should be noted in the evaluation.

6. Objective information describing the child's gross/fine motor abilities/deficits, e.g., range of motion measurements, manual muscle testing, muscle tone or a narrative description of the child's functional mobility skills.

7. Assessment of the results of the evaluation including recommendations for frequency and intensity of treatment.

8. Signature and credentials of the therapist performing the evaluation.

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

10. 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.

C Standardized Testing:

1. Test used must be norm referenced, standardized and specific to theJherapy provided.

2. Test must be age appropriate for the child being tested.

3. Test results must-be reported as-standard seoresrZ-seores, T scores or percentiles. Age-equivalent scores and percentage of delay cannot be used to qualify for services.

4. A score of - 1.50 standard deviations or more from the mean in at least one subtest area or composite score is required to qualify for services.

5. If the child cannot be tested with a norm-referenced, standarddized test, criterion-based testing or a functional description of the child's gross/fine motor deficits may be used. Documentation of the reason a standardized test could not be used must be included in the evaluation.

6. The Mental Measurement Yearbook (MMY) is the standard reference to determine reliability/validity. Refer to sections 214.310 and 214.320 for aiist of standardized tests accepted by Arkansas Medicaid for retrospective reviews.

D. Other Objective Tests and Measures:

1. Range of Motion: A limitation of greater than ten degreesand/or documentation of how a deficit limits function.

2. Muscle Tone: Modified Ashworth Scale.

3. Manual Muscle Test: A deficit is a muscle strength grade of fair (3/5) or below that impedes functional skills. With increased muscle tone, as in cerebral palsy, testing is unreliable.

4. Transfer Skills: Documented as the amount of assistance required to perform transfer, i.e., maximum, moderate, or minimal assistance. A deficit is defined as the inability to perform a transfer safely and independently.

E. Frequency, Intensity and Duration of Physical and/or Occupational Therapy Services:

The frequency, intensity and duration of therapy services should always be medically necessary and realistic for-the age-of the child and the severity-of-the deficit or disorder. Therapy is indicated if improvement will occur as a direct result of these services and if there is a potential for improvement in the form of functional gain.

1. Monitoring: May be used to insure that the child is maintaining a desired skill level or to assess the effectiveness and fit of equipment such as orthotics and other durable medical equipment. Monitoring frequency should be based on a time interval that is reasonable for the complexity of the problem being addressed.

2. Maintenance Therapy: Services that are performed primarily to maintain range of motion or to provide positioning services for the patient do not qualify for physical or occupational therapy services. These services can be provided to the child as part of a home program implemented by the child's caregivers and do not necessarily require the skilled services of a physical or occupational therapist to be performed safely and effectively.

3. Duration of Services: Therapy services should be provided as long as reasonable progress is made toward established goals. If reasonable functional progress cannot be expected with continued therapy, servicesshould be discontinue and monitoring or establishment of a home program should be implemented.

F. Progress Notes:

1. Child's name.

2. Date of service.

3. Time in and time out of each therapy session.

4. Objective addressed (should coincide with the plan of care).

5. A description of specific therapy services provided daily and the activities rendered during each therapy session, along with a form measurement.

6. Progress notes must be legible.

7. Therapists must sign each date of entry with a full signature and credentials.

8. Graduate students must have the supervising physical therapist or occupational therapist co-sign progress notes.

214.400 Speech-Language Therapy Guidelines for Retrospective Review

A. Speech - language therapay 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.

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 Giossaryof 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:

1. Date of evaluation.

2. Child's name and date of birth.

3. Diagnosis specific to therapy. »

4. Background information including pertinent medical history; and, if the child is 12 months of age or younger, gestational age.

5. 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 treatment.

7. 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 evaluation;

C. Feeding/Swallowing/Oral Motor:

1. Can be formally or informally assessed.

2. 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 child'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.

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 to voice therapy.

E. Progress Notes:

1. Child's name.

2. Date of service.

3. Time in anytime out of each therapy session.

4. Objectives addressed (should coincide with the plan of care).

5. A description of specific therapyservices provided daijy_and the activities rendered during each therapy session, along with a form of measurement.

6. Progress notes must be legible.

7. Therapists must sign each date of entry with a full signature and credentials.

8. Graduate students must have the supervising speech-language pathologist co-sign progress notes.

SUBJECT: Provider Manual Update Transmittal #124

Section II

Developmental Day Treatment Clinic Services

220.100Occupational and Physical Therapy Guidelines for Retrospective Review

A. Occupational and physical therarpy services are madically prescribed serviees for the diagnosis and treatment of movement dysfunction, which results in functional disabilities.

Occupational and physical therapy services must be medically necessary for 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 byor-under the supervision of a qualified physical or occupational therapist.

3. There must be reasonable expectation that therapy will result in a-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).

B. Evaluations:

In order to determine that therapy services are medically necessary, an annual evaluation must contain the following:

1. Date of evaluation.

2. Childls.name and date of birth.

3. Diagnosis applicable to specific therapy.

4. Background information including pertinent medical history; and, if the child is 12 months of age or younger, gestational age.

7. Assessment of the results of the evaluation, including recommendations for frequency and intensity of treatment.

8. Signature and credentials of the therapist performing the evaluation.

C. Standardized Testing:

1. Tests used must be norm-referenced, standardized tests specific to the therapy provided.

2. Tests must be age appropriate for the child being tested.

3. Test results must be reported as standard scores, Z scores., T-scores or percentiles. Age-equivalent scores and percentage of delay cannot be used to qualify for services.

4. A score of -1.5 standard deviations or more from the mean in at least one subtest area or composite score is required to qualify for services

5.If the chil cannot be tested with a nortm-referenced standardized test, criterion-based testing or a functional description of the child's gross/fine motor deficits may be used. Documentation of the reason why a standardized test could not be used must be included in the evaluation.

6. The Mental Measurement Yearbook (MMY) is the standard reference to determine reliability and validity.

Refer to sections 220.110 and 220.120 for a list of standardized tests accepted by the Arkansas Mediaid program.

D. Other Objective Tests and Measures:

1. Range of Motion: A limitation of greater than ten degrees and/or documentation of how deficit limits function.

2. Muscle Tone: Modified Ashworth Scale.

3. Manual Muscle Test: A deficit is a muscle strength grade of fair (3/5) or below that impedes functional skills. With increased muscle tone, as in cerebral palsy, testing is unreliable.

4. Transfer Skills: Documented as amount of assistance required to perform transfer, e.g., maximum, moderate or minimal assistance. A deficit is defined as the inability to perform a transfer safely and independently.

E. Frequency, Intensity and Duration of Physical and/or Occupational Therapy Services:

Frequency, intensity and duration of therapy services should always be medically necessary and realistic for the age of the child and the severity of the deficit or disorder. Therapy is indicated if improvement will occur as a direct result of these services and if there is a potential for improvement in the form of functional gain.

1. Monitoring: May be used to ensure that the child is maintaining a desired skill level or-to-assess the effectiveness and fit of equipment such as orthotics and other durable medical equipment. Monitoring frequency should- be based on a time interval that is reasonable for the complexity of the problem being addressed.

2. Maintenance Therapy: Services performed primarily to maintain range of motion or to provide positioning services for the patient do notT|tialify for physical or occupational therapy services. These services can be provided to the child as part of a home program implemented by the child's caregivers and do not necessarily require the skilled services of a physical or occupational therapist to be safe and effective.

3. Duration of Services: Therapy services should be provided as long as reasonable progress is made toward established goals. If reasonable functional progress cannot be expected with continued therapy, services should be discontinued and monitoring or establishment of a home program should be implemented.

F. Progress Notes:

1. Child's name.

2. Date of service.

3. Time in and time out of each therapy session.

4.Objectives addressed (should coincide with the plan of care).

5. A description of specific therapy services provided daily and the activities rendered during each therapy session ,along with a form measurement.

6. Progress notes must be legible.

7. Therapists rrrast sign each date of entry with a full signature and credentials.

8. Graduate student must have the supervising physical therapist or occupational therapist co-sign progress notes.

220.200Speech-Language Therapy Guidelines for Retrospective Review

A. Speech-language therapy services must be medically necessaryfor the treatment of the individual's illness or injury. To be considered medically necessary, the following conditions must be met:

1. The servicesjnusLbe 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-fesulFin meaningful improvement oral easonable-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 aremedically necessary, an evaluationmust contain the following information:

1. Date of evaluation.

2. Child's name and date of birth.

3. Diagnosis specific to therapy.

4. Background information including pertinent medicalhistoryfand, if the child is 12 months or age or younger, gestational age.

5. Standardized test results, including all subtest scores, if applicable. Test results should be adjusted for prematurity (less than 37 weeks gestation) if the child is age 12 months 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 treatment.

7. 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 evaluation.

C. Feeding/Swallowing/Oral Motor:

1. Can be formally or informally assessed.

2. Must have an in-depth functional profile on oral motor structures and function. This profile is a description of a child's oral motor structure that specifically notes how the structure is impaired 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:

1. Child's name:

2. Date of service.

3. Time in and time out of each therapy session.

4. Objectives-addressed (should coincide with the plan of care).

5. A description of specific therapy services provided daily and the activities rendered during eachiherapy session, along with a form of measurement.

6. Progress notes must be legible.

7. Therapists must sign each date of entry with a full signature and credentials.

8. Graduate students must have the supervising SLP co-sign progress notes.

SUBJECT: Provider Manual Update-Transmittal #170

Section II

Physician/Independent Lab/CRNA/Radiation Therapy Center

227.200Occupational and Physical Therapy Guidelines for Retrospective Review

A. Occupational and physical therapy services are medically prescribed services for the diagnosis and treatment of movement dysfunction, which results in functional- disabilities.

Occupational and physical therapy services must be medically necessaryto the treatment of the individual's illness or injury. To be considered medically neeessary, the following conditons 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 physical or occupational therapist.

3. There must be reasonable expectation that therapy will-result in a meaningful improvement or a reasonable expectation that therapy will prevent a worsening of the condition (See madical necessity definition in the Glossary of this manual.)

B. Evaluations:

In order to determine that therapy services are medically necessary, an annual evaluation must contain the following:

1. Date of evaluation.

2. Child's name and date of birth.

3. Diagnosis applicable to specific therapy.

4. Background information including pertinent medical history; and, if the child is 12 months of age or younger, gestational age.

6. Objective information describing the child's gross/fine motor abilities/deficits, e.Cj., range of motion measurements, manual muscle testing, muscle tone or a narrative description of the child's functional mobility skills.

7. Assessment of the results of the evaluation, including recommendations for frequency and intensity of treatment.

8. Signature and credentials of the therapist performing the evaluation.

C. Standardized Testing:

1. Tests used must be norm-referenced, standardized tests specific to the therapy provided.

2. Tests must be age appropriate for the child being tested.

3. Test results must be reported as standard scores, Z scores., T-scores or percentiles. Age-equivalent scores and percentage of delay cannot be used to qualify for services.

4. A score of -1.5 standard deviations or more from the mean in at least one subtest area or composite score is required to qualify for services

5. If the chil cannot be tested with a nortm-referenced standardized test, criterion-based testing or a functional description of the child's gross/fine motor deficits may be used. Documentation of the reason why a standardized test could not be used must be included in the evaluation.

6. The Mental Measurement Yearbook (MMY) is the standard reference to determine reliability and validity. Refer to sections227.210- and 227.220 for a list of standredized tests recognized by the Quality Improevment Organization (QIO) for retrospective reviews.

D. Other Objective Tests and Measures:

1. Range of Motion: A limitation of greater than ten degrees and/or documentation of how-deficit limits-function.

2. Muscle Tone: Modified Ashworth Scale.

3. Manual Muscle Test: A deficit is a muscle strength grade of fair (3/5) or belowthatimpedes functional skills. With increased muscle tone, as in cerebral-palsy, testing-is unreliable.

4. Transfer Skills: Documentedas amountofassistance required to perform transfer, e.g., maximum, moderate,.or minimal assistance. A deficit is defined as the inability to perform a transfer safely and independently.

E. Frequency, Intensity and Duration of Physical and/or Occupational Therapy Services:

1. Monitoring: May be used to ensure that the child is maintaining a desired- skill level or to assess the effectiveness and fit of equipment such as orthotics and other durable medicaLequipment. Monitoringjfrequency should be based on a time interval that is reasonable for the complexity of the problem being addressed.

2. Maintenance Therapy: Services that are performed primarily to maintain range of motion or to provide positioning services for the patient-do not qualify for physical or occupational therapy services. These services can be provided to the child as part of a home program that can be implemented by the child's caregivers and do not necessarily require the skilled services of a physical or occupational therapist to be performed safely and effectively.

3. Duration of Services: Therapy services should be provided as long as reasonable progress is made toward established goals. If reasonable functional progress cannot be expected with continued therapy, then services should be discontinued and monitoring or establishment of a home program should be implemented.

F. Progress Notes:

1. Child's name.

2. Date of service.

3. Time in and time out of each therapy session.

4. Objectives addressed (should coincide with the plan of care).

5. A description of specific therapy services provided daily and the activities rendered during each therapy session, along with a form measurement.

6. Progress notes must be legible.

7. Therapists must sign each date of entry with a full signature and credentials.

8. Graduate students must have the supervising physical therapist or occupational therapist co-sign progress notes.

227.300Speech - Language Therapy Guidelines for Retrospective Review

A. 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 sucrrtnatthe 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 medical necessity definition in the Glossary of the Arkansas Medicaid manual.)

A diagnosis alone is not sufficient documentation to support the medical necessity of therapy. Assessment for speech-language therapy includes a comprehensive evaluations the patient's speech language deficits and functional limitations, treatment planned and goals to address each identified problem.

B. Evaluations:

In order to deteimirre that speech-language therapy services are medically necessary, an evaluation must contain the following information:

1. Date of evaluation.

2. Child's name and date of birth.

3. Diagnosis specific to therapy.

4. Background information including pertinent medical history and, if the child is 12 months of age or younger, gestational age.

5. Standardized test results, including all subtest scores, if applicable. Test results 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 treatment.

7. The child should be tested in their native language; if not, an explanation must be provided in the evaluation.

8. Signature and credentials of the therapist performing the evaluation.

C. Feeding/Swallowing/Oral Motor:

1. Can be formally or informally assessed.

2. 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 child's oral motor structure.that spedfically notes how such structure is impaired in-its-function and justifies the medical necessity of feeding/swallowing/oral motor therapy service.

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 to voice therapy.

E. Prograss Note:

1. Child's name.

2. Date of service.

3. Time in and time out of each therapy session.

4. Objectives addressed (should coincide with the plan of care).

5. A description of specific therapy services provided daily and the activities rendered during each therapy session, along with a form of measurement.

6. Progress notes must be legible;

7. Therapists must sign each date of entry with a full signature and credentials.

SUBJECT: Provider Manual-Update-Transmittal #115

Section IINurse Practitioner

214.812Speech - Language Therapy Retrospective Review Guidelines

A. 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 sarvice requried can be safely and effectively. performed only by or under the supervision-of a-qualified speech-and language pathologist.

A diagnosis aloneisnot sufficient documentation to support the medical necessity of therapy. Assessment for speech language therapy includes a comprehensive evaluation ofthe 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: |

1. Date of evaluation.

2. Child's name and date of birth.

3. Diagnosis specific to therapy.

4. Background information including pertinent medical history; and, if the child is 12 months of age or younger, gestational age.

5. Standardized test results, including all subtest scores, if applicable. Test results,- if applicable, should be adjusted for prematurity (when less than 37 weeks gestation) if the child is 12 months of age or younger this should be noted in the evaluation.

6. An assessment of the results of the evaluation including recommendations for frequency and intensity of treatment.

7. The child should be tested in theirnative languagerifnot, an explanation must be provided in the evaluation.

8. Signature and credentials of the therapist performing the evaluation.

The mental measurement yearbook is the standard reference to determine good j reliability/validity of the test(s) administered in the evaluation.

C. Birth to Three:

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

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

SUBJECT: Provider Manual Update Transmittal #157

Section II

Hospital/Critical Access Hospital (CAH)/End Stage Renal Disease (ESRD)

218.101Documenting Evaluations

Documentatien of an annual evaluation must contain the following

A. Date-of-evaluation

B. Patient's name and date of birth

C. Diagnosis applicable to specific therapy

D. Background information including pertinent medical history; and, if the child is 12 months of age or younger ,gestational age.

E. Standardized test results, including all subtest scores, when applicable.

F. Test results adjusted for prematurity (less than 37 weeks gestation), when applicable, when the child is 12 months of age or younger.

G. Objective information describing the child's gross/fine motor abilities/deficits, e.g., range of motion measurements, manual muscle testing, muscle tone or a narrative description of the patient's functional mobility skills.

H. Assessment of the results of the evaluation, including recommendations for frequency and intensity of treatment.

I. Signature and credentials ofthe therapist performing the evaluation.

218.200Speech-Language Therapy Guidelines for Retrospective Review for Beneficiaries Under Age 21

A. 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 aspecific and effective treatment for the patient's condition.

3. There must be a reasonable expectation that therapy will result in meaningful improvement or a reasonable expectation thaftherapy 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 ordertu determine that speech-language therapy services are medically necessary, an evaluation must contain the following information:

1. Date of Evaluation.

2. Patient's name and date of birth.

3. Diagnosis specific to therapy.

4. Background information including pertinent medical history, and, if the child-is 12 months of age or younger, gestational age.

5. Standardized test results, including all subtest-seores if applicable. Test -results if applicable, sbauletbszadjusted 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 evaIuation, including recommendations for frequency and intensity of treatment.

7. An explanation why the child was not tested in his or her native language; if not, an explanation must be provided in the envaluation.

8. Signature and credentials of the therapist perfoming the evaluation.

C. 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.

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.

1. Patient's name.

2 Date of service.

3 Time in and time out of each therapy session.

4. Objectives addressed (should coincide with 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 objectives.

7. Therapist's full signature and credentials for each date of service.

8. The supervising speech and language pathologist's co-signature on graduate students' progress notes.

SUBJECT: Provider Manual Update Transmittal¥121

Section II Child Health Management Services

245.100 Occupational and Physical Therapy Guidelinjes for Retrospective Review

A. Occupational and physical therapy service are madically prescribed-services for the diagnosis andJteatment of movement dysfunction that result in functional disabilities.

Qccupational and physical therapy services-must be-medica!ly necessary for the treatment of the individual's illness or injury. To be considered medically necessary, the following-conditions must be met:

1. The service must be considered under accepted standards of practice to be a specific and effective treatment for the patient's condition.

2. The service 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 physical or occupational therapist.

3. There must be reasonable expectation that therapy will result in a 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.)

Adiagnosis alone is not sufficient documentation to support the medical necessity of therapy. Assessment for-physical and/or-occupational therapy includes-a comprehensive evaluation of the patient's physical deficits and functional limitations, treatment planned and goals to address each identified problem.

B. Evaluations:

In order to determine that therapy services are medically necessary, an annual evaluation must contain the following:

1. Date of evaluation.

2. Child's name and date of birth.

3. Diagnosis applicable to specific therapy.

4. Background information including pertinent medical history; and, if the child is 12 months of age or younger, gestational age.

5. Standardized test results, including all subtest scores, if applicable. Test results, if applicable, should be adjusted for prematurity (less than 37 weeks gestation) if ihe-child is 12 months of age or younger. The test results should be noted in the evaluation.

7. Assessment of the results of the evaluation, including recommendations for frequency and intensity of treatment.

8. Signature and credentials of the therapist performing the evaluation.

C. Standardized Testing:

1. Tests used musfbe norm-referenced, standardized tests specific to the therapy provided.

2. Tests must be age appropriate for the child being tested.

3. Test results must be reported as standard scores, Z scores, T scores-or percentiles. Age equivalent scores and percentage of delay cannot be used to qualify for services.

4. A score of -1.50 standard deviations or more from the mean in at least one subtest area or composite score is required to quaIify for services.

5. if the child cannot be tested with a norm referenced, standardized test criterion-based testing or a functional-deseription-of-the child-s-gross/fine motor deficits may-be used. Documentation of the reason why a standardized test could not be use must-be included IrTthe evaluation.

6. The Mental Measurement Yearbook (MMY) is the standard reference to determine reliability and validity.

Refer of sections 245.110 and 245.120 for a list of standardized tests accepted by the Arkansas Medicaid program for retrospective review.

D. Other Objective Tests and Measures:

1. Range of Motion: A-limitation of-greater than ten degrees and/or documentation of how deficit limits-function.

2. Muscle Tone:, Modified Ashworth Scale.

3. Manual Muscle Test: A deficit is a muscle strength-grade of fair (3/5) or below that impedes functional skillsT With increased muscle tone, as in cerebral palsy, testing is unreliable.

4. Transfer Skills: Documented as amount of assistanee required to perform transfer.i.e., maximum, moderate, minimal assistance. A deficit is defined as the inability to perform a transfer safely and independently.

E. Frequency, Intensity and Duration of Physical and/or Occupational Therapy Services:

Frequency, intensity.and duration of therapy services should always be medically necessary and realistic for the age of the child and the severity of the deficit or disorder. Therapy is indicated if improvement will occur as a direct result of these services and if there is a potential for improvement in the form of functional gain.

1. Monitoring: May be used to ensure that the child is maintaining a desired skill level or to.assess the effectiveness and fit of equipment such as orthotics and other durable medical equipment. MonitoringJrequency should be based on a time interval that is reasonable for the complexity of the problem being addressed.

2. Maintenance Therapy: Services that are performed primarily to maintain range of motion or to provide positioning services for the patient do not qualify for physical or occupational therapy services. These services can be provided to the child as part of a home program that can be implemented by the child's caregivers and do not necessarily require the skilled services of a physical or occupational therapist to perform safely and effectively.

3. Duration of Services: Therapy services should be provided as long as reasonable progress is made toward established goals. If reasonable functional progress cannot be expected with continued therapy, then services should be discontinued and monitoring or establishment of a home program should be implemented.

F. Progress Notes:

1. Child's name.

2. Date of service.

3 Time in-ahd time out of each therapy session.

4. Objectives addressed (should coincide with the plan of care).

5. A description of specific therapy services provided daily and the activities rendered during each therapy session, along with a form measurement.

6. Progress notes must be legible.

7. Therapists must sign each date of entry with a full signature and credentials.

8. Graduate students-must-bave the supervising physical-therapist or occupational therapist co-sign progress notes.

245.200Speech-Language Therapy Guidelines for Retrospective Review

A Speech-language therapy serviees must be medJGalJy-necessary-for4he 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 suchrthatthe services required carrbe safely and effectively performed only by or under the supervision of a qualified speech and language pathologist.

3 Theremust be reasonable expBctatiorLthat-therapy-will result-in meaningful improvement or a reasonable expectation the therapy wilLprevent 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:

1. Date of evaluation.

2. Child's name and date of birth.

3. Diagnosis specific to therapy

4. Background information including-pertinent medical history; and, if the child is 12 months of age or younger, gestational age.

5. 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 old 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 treatment.

7. 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 evaluation.

C. Feeding/Swallowing/Oral Motor:

1. Can be formally or informally assessed.

2. Must have 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 child's oral motor structure that specifically notes how such structure is impaired in its function and justifie the medica necessity of feeding/swallowing/oral motor therapy services.

D. Voice

A medical evaluation is a prerequisite for voice therapy.

E. Progress Notes

1. Child's name.

2. Date of service.

3. Time in and time out of each therapy session

4. Objectives addressed (should coincide with-the plan of care).

5. A description of specific therapy services provided daily and the activities rendered during each therapy session, along with a form of measurement.

6. Progress notes must be legible.

7. Therapists must sign each date of entry with a full signature and credentials.

8. Graduate students-must-have the supervising speech-language pathologist co-sign progress notes.

SUBJECT: Provider Manual-Update.Transmittal #113.

Section IIRehabilitative Hospital

216.101Documenting Evaluations

Documentation-of an annual evaluation must contain the foirow|ng:

A. Date of evaluation

B. Patient's name and date of birth

C. Diagnosis applicable to specific therapy

D. Background information including pertinent medical history; and, if the child is 12 months of age or .younger gestational age.

E Standardized test results, including all subtest scores, when application.

F., Test results adjusted for prematurity (less than 37 weeks gestation), when applicable, when the child is less than 12 months of age or younger

G. Objective information describing the child's gross/fine motor abilities/deficits, e.g., range of motion measurements, manual muscle testing, muscle tone or a narrative, description of the patient's functional mobility skills.

H. Assessment of the results of the evaluation, including recommendations for frequency and intensity of treatment.

I. Signature and credentials of the therapist performing the evaluation.

216.200Speech-Language Therapy Guidelines for Retrospective ReviewTor Beneficiaries Under Age 21

A. 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:

1. Date of evaluation.

2. Child's name and date of birth.

3. Diagnosis specific to therapy.

4. Background information including pertinent medical history; and if the child is 12 months of age or younger, gestational age.

5. 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 treatment.

7. 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 evaluation.

C. 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/swalldwiffg/oral motor therapy services.

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:

1. Patient's name.

2. Date of service.

3. Time in and time out of each therapy session.

4. Objectives addressed (should coincide with 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 objectives.

7. Therapist's must sign each date of entry with a full signature and credentials,

8. The supervising speech and language pathologist's co-signature on graduate, students'progress notes.

016.06.09 Ark. Code R. 019

7/7/2009