227.100
Guidelines for Retrospective
Review of Occupational, Physical and
Speech Therapy Services
Arkansas Medicaid employed retrospective review of
occupational, physical and speech therapy services for beneficiaries under age
21. The purpose of retrospective review is promotion of 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 by reviewing medical records to determine if
services delivered and reimbursed by Medicaid meet medical necessity
requirements.
Specific guidelines have been developed for occupational,
physical and speech therapy retrospective reviews. These guidelines are
included for information to physicians prescribing and/or providing therapy
services. The guidelines may be found in sections
227.200 through
227.320.
227.200
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 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
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:
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 less. 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 -1.5
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 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
227.210 and
227.220 for a list of
standardized tests recognized by the Arkansas Foundation for Medical Care, Inc.
(AFMC) 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 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 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.
227.210
Accepted Tests for
Occupational Therapy
Tests used must be norm referenced, standardized, age
appropriate and specific to the therapy provided. The following list of tests
is not all-inclusive. When using a test not listed here, the provider must
include additional documentation to support the reliability and validity of the
test. This additional information will be used as reference information if the
chart is ever selected by Medicaid for review. An explanation of why a test
from the approved list could not be used to evaluate the child must also be
included. The 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. It will be considered
when reviewing for medical necessity.
A. Fine Motor Skills - Standard
1. Peabody Developmental Motor Scales (PDMS,
PDMS2)
2. Toddler and Infant Motor
Evaluation (TIME)
3.
Bruininks-Oseretsky Test of Motor Proficiency (BOMP)
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
(Sll-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 TA
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
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 Living/Vocational/Other
- Standard
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
227.220
Accepted Tests for Physical
Therapy
Tests used must be norm referenced, standardized, age
appropriate and specific to the therapy provided. The following list of tests
is not all-inclusive. When using a test not listed here, the provider must
include additional documentation to support the reliability and validity of the
test. This additional information will be used as reference information if the
chart is ever selected by Medicaid for review. An explanation of why a test
from the approved list could not be used to evaluate the child must also be
included. The 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.
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
227.300
Speech-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 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
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 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 should be adjusted for prematurity
if the child is one year old or less, 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 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 to 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.
227.310
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 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.
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
(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-l: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/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.
D. Ages 3-21:
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/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 school age and receiving language therapy. Exception: IQ scores will
not be required for children under ten (10) years of age.
227.320
Intelligence
Quotient (IQ) Testing
Children receiving language intervention therapy must have
cognitive testing once they reach ten (10) years of age. This also applies to
home-schooled children. If the IQ score is higher than the qualifying language
scores, the child qualifies for language therapy; if the IQ score is lower than
the qualifying language test scores, the child would appear to be functioning
at or above the expected level. In this case, the child may be denied for
language therapy. If a provider determines that therapy is warranted, an
in-depth functional profile must be documented. However, IQ scores will not be
required for children under ten (10) years of age.
A. IQ Tests - Traditional
1. Stanford-Binet (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 Reference
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 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)
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)
D. Articulation/Phonological - Supplemental -
Norm Reference Test of Phonological Awareness (TOPA)
E. Voice/Fluency Assessments - Norm Reference
Stuttering Severity Instrument for Children and Adults (SSI-3)
F. Auditory Processing Assessments - Norm
Reference Goldman-Fristoe-Woodcock Test of Auditory Discrimination (G-F-WTAD)
G. Oral Motor - Supplemental -
Norm Reference Screening Test for Developmental Apraxia of Speech, Second Ed.
(STDAS-2) H. Traumatic Brain Injury (TBI) Assessments - Norm Reference
1. Ross Information Processing Assessment -
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)
227.400
Recoupment Process
The Division of Medical Services (DMS), Utilization Review (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 respective 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.
