Arkansas Medicaid conducts retrospective review of
occupational, physical and speech therapy services. The purpose of
retrospective review is to promote effective, efficient and economical delivery
of health care services.
The Quality Improvement Organization (QIO), Arkansas Foundation
for Medical Care, Inc. (AFMC), under contract to the Arkansas Medicaid Program,
performs retrospective reviews of medical records to determine if services
delivered and reimbursed by Medicaid meet medical necessity
requirements.
For the provider's information specific guidelines have been
developed for occupational, physical and speech therapy retrospective reviews.
These guidelines may be found in sections
245.100 through
245.220.
245.100
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 that 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 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 mecf/ca/necess/Yy 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:
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 gestational age.
5. Standardized test results, including all
subtest scores, if applicable. Test results, if applicable, should be adjusted
for prematurity if the child is one year old 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.
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 -1.50
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, 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
245.110 and
245.120 for a list of
standardized tests accepted by the Arkansas Foundation for Medical Care, Inc.
(AFMC) 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 skills. With increased muscle tone, as in cerebral palsy, testing is
unreliable.
4. Transfer Skills:
Documented as amount of assistance 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.
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
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 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.
245.110
Accepted Tests for
Occupational Therapy
Tests used must be norm-referenced, standardized, age
appropriate and specific to the therapy provided. The following list of tests
is not all-inclusive. When using a test not listed here, the provider must
include additional documentation to support the reliability and validity of the
test. This additional information will be used as reference information if the
chart is ever selected by Medicaid for audit review. An explanation of why a
test from the approved list could not be used to evaluate the child must also
be included. The MMYis the standard reference to determine the reliability and
validity of the test(s) administered in an evaluation. Providers should refer
to the MMY for additional information regarding specific tests.
Definitions:
STANDARD: Evaluations that are used to determine
deficits.
SUPPLEMENTAL: Evaluations that are used to justify deficits and
support other results. These should not "stand alone."
CLINICAL OBSERVATIONS?All clinical observations are
supplemental but should be included with every evaluation, especially if
standard scores do not qualify the child for therapy. They will be considered
during reviews for medical necessity.
A. Fine Motor Skills - Standard
1. Peabody Developmental Motor Scales (PDMS,
PDMS2)
2. Toddler and Infant Motor
Evaluation (TIME)
3.
Bruininks-Oseretsky Test of Motor Proficiency (BOMP)
B. Fine Motor Skills - Supplemental
1. Early Learning Accomplishment Profile
(ELAP)
2. Learning Accomplishment
Profile (LAP)
3. Mullen Scales of
Early Learning, Infant/Preschool (MSEL)
4. Miller Assessment for Preschoolers
(MAP)
5. Functional
Profile
6. Hawaii Early Learning
Profile (HELP)
7. Battelle
Developmental Inventory (BDI)
8.
Developmental Assessment of Young Children (DAYC)
9. Brigance Developmental Inventory
(BDI)
C. Visual Motor -
Standard
1. Developmental Test of Visual Motor
Integration (VMI)
2. Test of Visual
Motor Integration (TVMI)
3. Test of
Visual Motor Skills
4. Test of
Visual Motor Skills - R (TVMS)
D. Visual Perception - Standard
1. Motor Free Visual Perceptual
Test
2. Motor Free Visual
Perceptual Test - R (MVPT)
3.
Developmental Test of Visual Perceptual 2/A (DTVP)
4. Test of Visual Perceptual Skills
5. Test of Visual Perceptual Skills (upper
level) (TVPS)
E.
Handwriting - Standard
1. Evaluation Test of
Children's Handwriting (ETCH)
2.
Test of Handwriting Skills (THS)
3.
Children's Handwriting Evaluation Scale
F. Sensory Processing - Standard
1. Sensory Profile for
Infants/Toddlers
2. Sensory Profile
for Preschoolers
3. Sensory Profile
for Adolescents/Adults
4. Sensory
Integration and Praxis Test (SIPT)
5. Sensory Integration Inventory Revised
(SII-R)
G. Sensory
Processing - Supplemental
1. Sensory Motor
Performance Analysis
2. Analysis of
Sensory Behavior
3. Sensory
Integration Inventory
4.
DeGangi-Berk Test of Sensory Integration
H. Activities of Daily
Living/Vocational/Other - Standard
1.
Pediatric Evaluation of Disability Inventory (PEDI)
NOTE: The PEDI can also be used for older children whose
functional abilities fall below that expected of a 71/2 year old with no
disabilities. In this case, the scaled score is the most appropriate score to
consider.
2. Adaptive
Behavior Scale - School (ABS)
3.
Jacobs Pre-vocational Assessment
4.
Kohlman Evaluation of Daily Living Skills
5. Milwaukee Evaluation of Daily Living
Skills
6. Cognitive Performance
Test
7. Purdue Pegboard
8. Functional Independence Measure
(FIM)
9. Functional Independence
Measure - young version (WeeFIM)
I. Activities of Daily
LivingA/ocational/Other- Supplemental
1.
School Function Assessment (SFA)
2.
Bay Area Functional Performance Evaluation
3. Manual Muscle Test
4. Grip and Pinch Strength
5. Jordan Left-Right Reversal Test
6. Erhardy Developmental Prehension
7. Knox Play Scale
8. Social Skills Rating System
9. Goodenough Harris Draw a Person
Scale
245.120
Accepted Tests for Physical Therapy
Tests used must be norm referenced, standardized, age
appropriate and specific to the therapy provided. The following list of tests
is not all-inclusive. When using a test not listed here, the provider must
include additional documentation to support the reliability and validity of the
test. This additional information will be used as reference information if the
chart is ever selected by Medicaid for audit review. An explanation of why a
test from the approved list could not be used to evaluate a child must also be
included. The MMY is the standard reference to determine the
reliability and validity of the tests administered in an evaluation. Providers
should refer to the MMY for additional information regarding specific
tests.
A. Norm Reference
1. Adaptive Areas Assessment
2. Test of Gross Motor Development
(TGMD-2)
3. Peabody Developmental
Motor Scales, Second Ed. (PDMS-2)
4. Bruininks-Oseretsky Test of Motor
Proficiency (BOMP)
5. Pediatric
Evaluation of Disability Inventory (PEDI)
6. Test of Gross Motor Development - 2
(TGMD-2)
7. Peabody Developmental
Motor Scales (PDMS)
8. Alberta
Infant Motor Scales (AIM)
9.
Toddler and Infant Motor Evaluation (TIME)
10. Functional Independence Measure for
Children (WeeFIM)
11. Gross Motor
Function Measure (GMFM)
12.
Adaptive Behavior Scale - School, Second Ed. (AAMR-2)
13. Movement Assessment Battery for Children
(Movement ABC)
B.
Physical Therapy - Supplemental
1. Bayley
Scales of Infant Development, Second Ed. (BSID-2)
2. Neonatal Behavioral Assessment Scale
(NBAS)
C. Physical
Therapy Criterion
1. Developmental assessment
for students with severe disabilities, Second Ed. (DASH-2)
2. Milani-Comparetti Developmental
Examination
D. Physical
Therapy - Traumatic Brain Injury (TBI) - Standardized
1. Comprehensive Trail-Making Test
2. Adaptive Behavior Inventory
E. Physical Therapy - Piloted
Assessment of Persons Profoundly or Severely Impaired
245.200
Speech-Language Therapy Guidelines for Retrospective Review
A. Speech-language 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 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 mecf/ca/necess/Yy 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 gestational age.
5. Standardized test results, including all
subtest scores, if applicable. Test results, if applicable, should be adjusted
for prematurity if the child is one year 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 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.
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.
245.210
List of Accepted Tests
Tests used must be norm referenced, standardized, age
appropriate and specific to the therapy provided. The following list of tests
is not all-inclusive. When using a test not listed here, the provider must
include additional documentation to support the reliability and validity of the
test. This additional information will be used as reference information if the
chart is ever selected by Medicaid for audit review. An explanation of why a
test from the approved list could not be used to evaluate a child must also be
included. The MMY is the standard reference to determine the
reliability and validity of the test(s) administered in the evaluation.
Providers should refer to the MMY for additional information regarding specific
tests.
A. Speech-Language Tests -
Standardized
1. Preschool Language Scale,
Third Ed. (PLS-3)
2. Preschool
Language Scale, Fourth Ed. (PLS-4)
3. Test of Early Language Development, Third
Ed. (TELD-3)
4. Peabody Picture
Vocabulary Test, Third Ed. (PPVT-3)
5. Clinical Evaluation of Language
Fundamentals - Preschool (CELF-P)
6. Clinical Evaluation of Language
Fundamentals, Third Ed. (CELF-3)
7.
Clinical Evaluation of Language Fundamentals, Fourth Ed. (CELF-4)
8. Communication Abilities Diagnostic Test
(CADT)
9. Test of Auditory
Comprehension of Language, Third Ed. (TACL-3)
10. Comprehensive Assessment of Spoken
Language (CASL)
11. Oral and
Written Language Scales (OWLS)
12.
Test of Language Development - Primary, Third Ed. (T0LD-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)
B. Speech
Language Tests - Supplemental
1.
Receptive/Expressive Emergent Language Test, Second Ed. (REEL-2)
2. Nonspeech Test for Receptive/Expressive
Language
3. Rossetti Infant-Toddler
Language Scale (RITLS)
4. Mullen
Scales of Early Learning (MSEL)
5.
Reynell Developmental Language Scales
6. Illinois Test of Psycholinguistic
Abilities, Third Ed. (ITPA-3)
7.
Social Skills Rating System - Preschool & Elementary Level
(SSRS-1)
8. Social Skills Rating
System - Secondary Level (SSRS-2)
C. Birth to Age 3:
1. - (minus)1.5 SD (standard score of 77)
below the mean in two areas (expressive, receptive) or a - (minus) 2.0 SD
(standard score of 70) below the mean in one area to qualify for language
therapy.
2. Two language tests must
be reported, with at least one of these being a global, norm-referenced,
standardized test with good reliability and validity. The second test may be
criterion referenced.
3. All
subtests, components and scores must be reported for all tests.
4. All sound errors must be reported for
articulation including positions and types of errors.
5. If phonological testing is submitted, a
traditional articulation test must also be submitted with a standardized
score.
6. Information regarding the
child's functional hearing ability must be included as a part of the therapy
evaluation report.
7.
Non-school-age children must be evaluated annually.
8. If the provider indicates that the child
cannot complete a norm-referenced test, the provider must submit an in-depth
functional profile of the child's functional communication abilities. An
in-depth functional profile is a description of a child's communication
behaviors that specifically notes where such communication behaviors are
impaired and justifies the medical necessity of therapy. Standardized forms are
available for the completion of an in-depth functional profile, but a
standardized form is not required.
9. Children must be evaluated at least
annually. Children (birth to age 2) in the Child Health Management Services
(CHMS) Program must be evaluated every 6 months.
D. Ages 3 to 21:
1. - (minus)1.5 SD (standard score of 77)
below the mean in two areas (expressive, receptive, articulation) or a -
(minus) 2.0 SD (standard score of 70) below the mean in one area (expressive,
receptive, articulation)
2. Two
language tests must be reported, with at least one of these being a global,
norm-referenced, standardized test with good reliability and validity.
Criterion-referenced tests will not be accepted for this age group.
3. All subtests, components and scores must
be reported for all tests.
4. All
sound errors must be reported for articulation including positions and types of
errors.
5. If phonological testing
is submitted, a traditional articulation test must also be submitted with a
standardized score.
6. Information
regarding child's functional hearing ability must be included as a part of the
therapy evaluation report.
7.
Non-school-age children must be evaluated annually.
8. School-age children must have a full
evaluation every three years (a yearly update is required) if therapy is school
related; outside of school annual evaluations are required. "School related"
means the child is of school age, attends public school and receives therapy
provided by the school.
9. If the
provider indicates that the child cannot complete a norm-referenced test, the
provider must submit an in-depth functional profile of the child's functional
communication abilities. An in-depth functional profile is a description of a
child's communication behaviors that specifically notes where such
communication behaviors are impaired and justifies the medical necessity of
therapy. Standardized forms are available for the completion of an in-depth
functional profile, but a standardized form is not required.
10. IQ scores are required for all children
who are school age and receiving language therapy. Exception: IQ scores
are not required for children under ten (10) years of age.
245.220
Intelligence Quotient (IQ) Testing
Children receiving language intervention therapy must have
cognitive testing once they reach ten (10) years of age. This also applies to
home-schooled children. If the IQ score is higher than the qualifying language
scores, then the child qualifies for language therapy; if the IQ score is lower
than the qualifying language test scores, the child would appear to be
functioning at or above expected level. In this case, the child may be denied
for language therapy. If a provider determines that therapy is warranted, an
in-depth functional profile must be submitted. However, IQ scores are not
required for children under ten (10) years of age.
A. IQ Tests - Traditional
1. Stanford-Benet (S-B)
2. The Wechsler Preschool & Primary
Scales of Intelligence, Revised (WPPSI-R)
3. Slosson
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)
B.
Severe & Profound IQ Test/Non-Traditional - Supplemental - Norm-Referenced
1. Comprehensive Test of Nonverbal
Intelligence (CTONI)
2. Test of
Nonverbal Intelligence (TONI-3) - 1997
3. Functional Linguistic Communication
Inventory (FLCI)
C.
Articulation/Phonological Assessments - Norm-Referenced
1. Arizona Articulation Proficiency Scale,
Third Ed. (Arizona-3)
2.
Goldman-Fristoe Test of Articulation (GFTA)
3. Goldman-Fristoe Test of Articulation,
Second Ed. (GFTA-2)
4. Khan-Lewis
Phonological Analysis (KLPA)
5.
Slosson Articulation Language Test with Phonology (SALT-P)
6. Bernthal-Bankson Test of Phonology
(BBTOP)
7. Smit-Hand Articulation
and Phonology Evaluation (SHAPE)
8.
Comprehensive Test of Phonological Processing (CTOPP)
9. Assessment of Intelligibility of
Dysarthric Speech (AIDS)
10. Weiss
Comprehensive Articulation Test (WCAT)
11. Assessment of Phonological Processes - R
(APPS-R)
12. Photo Articulation
Test, Third Ed. (PAT-3)
D. Articulation/Phonological Assessments -
Supplemental - Norm-Referenced
Test of Phonological Awareness (TOPA)
E. Voice/Fluency Assessments -
Norm-Referenced
Stuttering Severity Instrument for Children and Adults
(SSI-3)
F. Auditory
Processing Assessments - Norm-Referenced
Goldman-Fristoe-Woodcock Test of Auditory Discrimination
(G-F-WTAD)
G. Oral Motor -
Supplemental - Norm-Referenced
Screening Test for Developmental Apraxia of Speech, Second Ed.
(STDAS-2) H. Traumatic Brain Injury (TBI) Assessments - Norm-Referenced
1. Ross Information Processing Assessment -
Primary
2. 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)
245.300
Recoupment Process
The Division of IVIedical Services (DIVIS), Utilization Review
Section (UR) is required to initiate the recoupment process for all claims that
Arkansas Foundation for Medical Care, Inc. (AFMC), Arkansas' only Quality
Improvement Organization (QIO), has denied for not meeting the medical
necessity requirement. Based on QIO findings during retrospective reviews, UR
will initiate recoupments as appropriate.
Medicaid will send the provider an Explanation of Recoupment
Notice that will include the claim date of service, Medicaid beneficiary name
and ID number, service provided, amount paid by Medicaid, amount to be
recouped, and the reason the claim has been denied.
