Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.08-022 - Hospital/Critical Access Hospital/End-Stage Renal Disease Update #139; Rehabilitative Hospital Update #99; Child Health Management Service Update #105; Developmental Day Treatment Clinic Services (DDTCS) Update #107; Occupational, Physical, Speech Therapy Services Update #96; Physician / Independent Lab / CRNA / Radiation Therapy Center Update #155
Current through Register Vol. 49, No. 9, September, 2024
Section II Hospital/Critical Access Hospital (CAH)/End Stage Renal Disease (ESRD)
Tests must be norm referenced, standardized, age appropriate and specific to the therapy provided. The following list of tests is not all-inclusive. When using a test that is not listed below, the provider must include documentation in the evaluation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is selected by Medicaid for review. An explanation of why a test from the approved list could not be used to evaluate the patient must also be included. The Mental Measurement Yearbook (MMY) is the standard reference for determining the reliability and validity of tests administered in an evaluation. Providers should refer to the MMY for additional information regarding specific tests. The following definitions of terms are applied to the lists of accepted tests:
* Standard: Evaluations that are used to determine deficits.
* Supplemental: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.
* Clinical observations: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.
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.
Tests must be norm referenced, standardized, age appropriate and specific to the therapy provided. The following list of tests is not all-inclusive. When using a test that is not listed below, the provider must include documentation in the evaluation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is selected by Medicaid for review. An explanation of why a test from the approved list could not be used to evaluate the patient must also be included. The Mental Measurement Yearbook (MMY) is the standard reference for determining the reliability and validity of tests administered in an evaluation. Providers should refer to the MMY for additional information regarding specific tests. The following definitions of terms are applied to the lists of accepted tests:
* Standard: Evaluations that are used to determine deficits.
* Supplemental: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.
* Clinical observations: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.
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:
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.
In order to determine that speech-language therapy services are medically necessary, an evaluation must contain the following information:
A medical evaluation is a prerequisite for voice therapy.
Progress notes must be legible and must include the following information.
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 that is not listed below, the provider must include documentation in the evaluation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is selected by Medicaid for review. An explanation of why a test from the approved list could not be used to evaluate the child should be included. The Mental Measurement Yearbook (MMY) is the standard reference to determine the reliability and validity of the test(s) administered in the evaluation. Providers should refer to the MMY for additional information regarding specific tests. The following definitions of terms are applied to the lists of accepted tests:
* Standard: Evaluations that are used to determine deficits.
* Supplemental: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.
* Clinical observations: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.
Children receiving language intervention therapy must have cognitive testing once they reach 10 years of age, whether they are in public school or they are home-schooled. Providers must maintain in their records the IQ scores of their patients who are 10 through 20 years of age and receiving language therapy. If a child's IQ score is higher than his or her qualifying language scores, the child qualifies for language therapy; if the IQ score is lower than the qualifying language test scores, the child is deemed to be functioning at or above the expected level. In this case, the child may be denied for language therapy. If a provider determines that therapy is warranted despite the relationship of IQ to language score, the provider must complete and document an in-depth functional profile. However, IQ scores are not required for children under ten (10) years of age.
A provider who chooses to address Apraxia in treatment sessions must submit additional norm-referenced testing to support a coexisting deficit in articulation and/or language. Testing must be administered to examine the beneficiary's receptive and expressive language and articulation skills to determine if there is a coexisting problem. The Kaufman Speech Praxis Test (KSPT) can not stand alone to support the medical necessity of speech therapy. A functional communication profile including a detailed case history and description of the child's communicative abilities, including documentation of any neuromuscular deficits and assessments of the child's oral motor abilities must be included. For older children literacy skills should also be addressed. If possible, a speech sample of the beneficiary's speech should be included. Recommendations and a plan of care for treatment should be included in the documentation submitted.
Section II Rehabilitative Hospital
Tests must be norm referenced, standardized, age appropriate and specific to the therapy provided. The following list of tests is not all-inclusive. When using a test that is not listed below, the provider must include documentation in the evaluation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is selected by Medicaid for review. An explanation of why a test from the approved list could not be used to evaluate the patient must also be included. The Mental Measurement Yearbook (MMY) is the standard reference for determining the reliability and validity of tests administered in an evaluation. Providers should refer to the MMY for additional information regarding specific tests. The following definitions of terms are applied to the lists of accepted tests:
* Standard: Evaluations that are used to determine deficits.
* Supplemental: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.
* Clinical observations: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.
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.
Tests used must be norm referenced, standardized, age appropriate and specific to the therapy provided. The following lists of tests are not all-inclusive. When using a test that is not listed below, the provider must include documentation in the evaluation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is selected by Medicaid for review. An explanation of why a test from the approved list could not be used to evaluate the patient must also be included. The Mental Measurement Yearbook (MMY) is the standard reference for determining the reliability and validity of tests administered in an evaluation. Providers should refer to the MMY for additional information regarding specific tests. The following definitions of terms are applied to the lists of accepted tests:
* Standard: Evaluations that are used to determine deficits.
* Supplemental: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.
* Clinical observations: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.
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:
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.
In order to determine that speech-language therapy services are medically necessary, an evaluation must contain the following information:
A medical evaluation is a prerequisite for voice therapy.
Progress notes must be legible and must include the following information:
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 that is not listed below, the provider must include documentation in the evaluation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is selected by Medicaid for review. An explanation of why a test from the approved list could not be used to evaluate a patient must be included in the documentation. The Mental Measurement Yearbook (MMY) is the standard reference for determining the reliability and validity of test(s) administered in an evaluation. Providers should refer to the MMY for additional information regarding specific tests. The following definitions of terms are applied to the lists of accepted tests:
* Standard: Evaluations that are used to determine deficits.
* Supplemental: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.
* Clinical observations: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.
Two language tests must be reported, with at least one of these being a global, norm-referenced, standardized test with good reliability and validity.
School-aged children who attend public school and whose therapy is provided by the school must have a full evaluation every three years, with an annual update.
If the provider indicates that the patient cannot complete a norm-referenced test, the provider must complete an in-depth functional profile of the patient's functional communication abilities. An in-depth functional profile is a description of a patient's communication behaviors that specifically notes where such communication behaviors are impaired and justifies the medical necessity of therapy.
Children receiving language intervention therapy must have cognitive testing once they reach ten (10) years of age. This also applies to home-schooled children. Providers must maintain in their records the IQ scores of their patients who are 10 through 20 years of age and receiving language therapy. If a child's IQ score is higher than his or her qualifying language score, the child qualifies for language therapy; if the IQ score is lower that the qualifying language test scores, the child is deemed to be functioning at or above the expected level. In this case, the child may be denied for language therapy.
If a provider determines that therapy is warranted despite the relationship of IQ to language score, the provider must complete and document an in-depth functional profile. However, IQ scores are not required for children under ten (10) years of age.
A provider who chooses to address Apraxia in treatment sessions must submit additional norm-referenced testing to support a coexisting deficit in articulation and/or language. Testing must be administered to examine the beneficiary's receptive and expressive language and articulation skills to determine if there is a coexisting problem. The Kaufman Speech Praxis Test (KSPT) can not stand alone to support the medical necessity of speech therapy. A functional communication profile including a detailed case history and description of the child's communicative abilities, including documentation of any neuromuscular deficits and assessments of the child's oral motor abilities must be included. For older children, literacy skills should also be addressed. If possible, a speech sample of the beneficiary's speech should be included. Recommendations and a plan of care for treatment should be included in the documentation submitted.
Section II Child Health Management Services
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 that is not listed below, the provider must include documentation in the evaluation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is selected by Medicaid for audit review. An explanation of why a test from the approved list could not be used to evaluate the child must also be included. The Mental Measurement Yearbook (MMY) is the standard reference to determine the reliability and validity of the test(s) administered in an evaluation. Providers should refer to the MMY for additional information regarding specific tests. The following definitions of terms are applied to the lists of accepted tests:
* STANDARD: Evaluations that are used to determine deficits.
* SUPPLEMENTAL: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.
* CLINICAL OBSERVATIONS: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.
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.
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 that is not listed below, the provider must include documentation in the evaluation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is ever selected by Medicaid for audit review. An explanation of why a test from the approved list could not be used to evaluate a child must also be included. The Mental Measurement Yearbook (MMY) is the standard reference to determine the reliability and validity of the tests administered in an evaluation. Providers should refer to the MMY for additional information regarding specific tests. The following definitions of terms are applied to the lists of accepted tests:
* STANDARD: Evaluations that are used to determine deficits.
* SUPPLEMENTAL: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.
* CLINICAL OBSERVATIONS: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.
Assessment of Persons Profoundly or Severely Impaired
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 that is not listed below, the provider must include documentation in the evaluation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is ever selected by Medicaid for audit review. An explanation of why a test from the approved list could not be used to evaluate a child must also be included. The Mental Measurement Yearbook (MMY) is the standard reference to determine the reliability and validity of the test(s) administered in the evaluation. Providers should refer to the MMY for additional information regarding specific tests. The following definitions of terms are applied to the lists of accepted tests:
* STANDARD: Evaluations that are used to determine deficits.
* SUPPLEMENTAL: Evaluations that are used to identify deficits and support other results. Supplemental test may not supplant standard tests.
* CLINICAL OBSERVATIONS: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.
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 provider who chooses to address Apraxia in treatment sessions must submit additional norm referenced testing to support a coexisting deficit in articulation and/or language. Testing must be administered to examine the beneficiary's receptive and expressive language and articulation skills to determine if there is a coexisting problem. The Kaufman Speech Praxis Test (KSPT) can not stand alone to support the medical necessity of speech therapy. A functional communication profile including a detailed case history and description of the child's communicative abilities, including documentation of any neuromuscular deficits and assessments of the child's oral motor abilities must be included. For older children, literacy skills should also be addressed. If possible, a speech sample of the beneficiary's speech should be included. Recommendations and a plan of care for treatment should be included in the documentation submitted.
TOC not required
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 below, the provider must include documentation in the evaluation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is selected by Medicaid for review. An explanation of why a test from the approved list could not be used to evaluate the child must also be included. The Mental Measurement Yearbook (MMY) is the standard reference to determine the reliability and validity of the test(s) administered in an evaluation. Providers should refer to the MMY for additional information regarding specific tests. The following definitions of terms are applied to the lists of accepted tests:
* STANDARD: Evaluations that are used to determine deficits.
* SUPPLEMENTAL: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.
* CLINICAL OBSERVATIONS: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.
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.
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 below, the provider must include documentation in the evaluation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is selected by Medicaid for review. An explanation of why a test from the approved list could not be used to evaluate the child must also be included. The Mental Measurement Yearbook (MMY) is the standard reference to determine the reliability and validity of the test(s) administered in an evaluation. Providers should refer to the MMY for additional information regarding specific tests.
The following definitions of terms are applied to the lists of accepted tests:
* Standard: Evaluations that are used to determine deficits.
* Supplemental: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.
* Clinical observations: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.
Assessment of Persons Profoundly or Severely Impaired
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 below, the provider must include documentation in the evaluation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is selected by Medicaid for review. An explanation of why a test from the approved list could not be used to evaluate the child must also be included. The Mental Measurement Yearbook (MMY) is the standard reference to determine the reliability and validity of the test(s) administered in an evaluation. Providers should refer to the MMY for additional information regarding specific tests. The following definitions of terms are applied to the lists of accepted tests:
* Standard: Evaluations that are used to determine deficits.
* Supplemental: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.
* Clinical observations: Clinical observations always have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.
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 submitted. However, IQ scores are not required for children under ten (10) years of age.
A provider who chooses to address Apraxia in treatment sessions must submit additional norm-referenced testing to support a coexisting deficit in articulation and/or language. Testing must be administered to examine the beneficiary's receptive and expressive language and articulation skills to determine if there is a coexisting problem. The Kaufman Speech Praxis Test (KSPT) can not stand alone to support the medical necessity of speech therapy. A functional communication profile including a detailed case history and description of the child's communicative abilities, including documentation of any neuromuscular deficits and assessments of the child's oral motor abilities must be included. For older children, literacy skills should also be addressed. If possible, a speech sample of the beneficiary's speech should be included. Recommendations and a plan of care for treatment should be included in the documentation submitted.
Section II Occupational, Physical, Speech Therapy Services
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 that is not listed below, the provider must include documentation in the evaluation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is selected by Medicaid for review. An explanation of why a test from the approved list could not be used to evaluate the child should be included. The Mental Measurement Yearbook (MMY) is the standard reference to determine the reliability and validity of the test(s) administered in the evaluation. Providers should refer to the MMY for additional information regarding specific tests. The following definitions of terms are applied to the lists of accepted tests:
* STANDARD: Evaluations that are used to determine deficits.
* SUPPLEMENTAL: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.
* CLINICAL OBSERVATIONS: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.
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.
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 that is not listed below, the provider must include documentation in the evaluation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is selected by Medicaid for review. An explanation of why a test from the approved list could not be used to evaluate a child should be included. The Mental Measurement Yearbook (MMY) is the standard reference to determine the reliability and validity of the tests administered in the evaluation. Providers should refer to the MMY for additional information regarding specific tests. The following definitions of terms are applied to the lists of accepted tests:
* STANDARD: Evaluations that are used to determine deficits.
* SUPPLEMENTAL: Evaluations that are used to justify deficits and support other results. Supplemental tests may not supplant standard tests.
* CLINICAL OBSERVATIONS: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justifications of medical necessity.
Assessment of Persons Profoundly or Severely Impaired
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 that is not listed below, the provider must include documentation in the evaluation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is selected by Medicaid for review. An explanation of why a test from the approved list could not be used to evaluate the child should be included. The Mental Measurement Yearbook (MMY) is the standard reference to determine the reliability and validity of the test(s) administered in the evaluation. Providers should refer to the MMY for additional information regarding specific tests. The following definitions of terms are applied to the lists of accepted tests:
* STANDARD: Evaluations that are used to determine deficits.
* SUPPLEMENTAL: Evaluations that are used to justify deficits and support other results. Supplemental tests may not supplant standard tests.
* CLINICAL OBSERVATIONS: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justification of medical necessity.
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 are not required for children under ten (10) years of age.
A provider who chooses to address Apraxia in treatment sessions must submit additional norm-referenced testing to support a coexisting deficit in articulation and/or language. Testing must be administered to examine the beneficiary's receptive and expressive language and articulation skills to determine if there is a coexisting problem. The Kaufman Speech Praxis Test (KSPT) can not stand alone to support the medical necessity of speech therapy. A functional communication profile including a detailed case history and description of the child's communicative abilities, including documentation of any neuromuscular deficits and assessments of the child's oral motor abilities must be included. For older children, literacy skills should also be addressed. If possible, a speech sample of the beneficiary's speech should be included. Recommendations and a plan of care for treatment should be included in the documentation submitted.
Section II Physician/Independent Lab/CRNA/Radiation Therapy Center
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 that is not listed below, the provider must include documentation in the evaluation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is selected by Medicaid for review. An explanation of why a test from the approved list could not be used to evaluate the child must also be included. The Mental Measurement Yearbook (MMY) is the standard reference to determine the reliability and validity of the test(s) administered in an evaluation. Providers should refer to the MMY for additional information regarding specific tests. The following definitions of terms are applied to the lists of accepted tests:
* STANDARD: Evaluations that are used to determine deficits.
* SUPPLEMENTAL: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.
* CLINICAL OBSERVATIONS: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justifications of medical necessity.
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. If this is the case, the scaled score is the most appropriate score to consider.
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 below, the provider must include documentation in the evaluation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is selected by Medicaid for review. An explanation of why a test from the approved list could not be used to evaluate the child must also be included. The Mental Measurement Yearbook (MMY) is the standard reference to determine the reliability and validity of the test(s) administered in an evaluation. Providers should refer to the MMY for additional information regarding specific tests. The following definitions of terms are applied to the lists of accepted tests:
* STANDARD: Evaluations that are used to determine deficits.
* SUPPLEMENTAL: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.
* CLINICAL OBSERVATIONS: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justifications of medical necessity.
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 that is not listed below, the provider must include documentation in the evaluation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is selected by Medicaid for review. An explanation of why a test from the approved list could not be used to evaluate the child must also be included. The Mental Measurement Yearbook (MMY) is the standard reference to determine the reliability and validity of the test(s) administered in an evaluation. Providers should refer to the MMY for additional information regarding specific tests. The following definitions of terms are applied to the lists of accepted tests:
* STANDARD: Evaluations that are used to determine deficits.
* SUPPLEMENTAL: Evaluations that are used to identify deficits and support other results. Supplemental tests may not supplant standard tests.
* CLINICAL OBSERVATIONS: Clinical observations have a supplemental role in the evaluation and should always be included. Detail, precision and comprehensiveness of clinical observations are especially important when standard scores do not qualify the patient for therapy and the clinical notes constitute the primary justifications of medical necessity.
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 provider who chooses to address Apraxia in treatment sessions must submit additional norm referenced testing to support a coexisting deficit in articulation and/or language. Testing must be administered to examine the beneficiary's receptive and expressive language and articulation skills to determine if there is a coexisting problem. The Kaufman Speech Praxis Test (KSPT) can not stand alone to support the medical necessity of speech therapy. A functional communication profile, including a detailed case history and description of the child's communicative abilities, including documentation of any neuromuscular deficits and assessments of the child's oral motor abilities must be included. For older children, literacy skills should also be addressed. If possible, a speech sample of the beneficiary's speech should be included. Recommendations and a plan of care for treatment should be included in the documentation submitted.
