(A)
Initial
Evaluation. An initial evaluation is an in-depth assessment of a
member's medical condition or disability, or both, and level of functioning to
determine the need for therapy. When therapy is indicated, it is used to
develop a plan of care. The evaluation is conducted by a licensed therapist in
response to the prescribing provider's initial prescription for therapy
services and must occur prior to the start of therapy care. The MassHealth
agency will only pay for one initial evaluation relative to an initial
prescription. Documentation of the therapy initial evaluation must include a
written report for the member's medical record that contains at least the
following information:
(1) the member's name
and address;
(2) the member's
diagnosis (specific and relevant to the medical condition requiring therapy
services);
(3) list of precautions,
if applicable, relevant to the member's illness, injury or disability requiring
therapy services;
(4) a medication
list;
(5) a detailed treatment plan
describing the type, amount, frequency, and duration of therapy and indicating
the diagnosis, prognosis, anticipated goals, and location where therapy will
take place, or the reason treatment is not indicated;
(6) additional health care evaluations, as
indicated;
(7) a description of the
member's psychosocial and health status that includes:
(a) the present effects of the member's
current condition, disability or injury/illness requiring therapy
services;
(b) a brief history, the
date of onset, and any past treatment of the condition, disability, or
injury/illness;
(c) the member's
level of functioning, including physical and functional limitations, both
current and before onset of the current condition, disability or
illness/injury, if applicable;
(d)
any other significant physical or mental disability that may affect
therapy;
(e) sensory and cognitive
status, if applicable; and
(f)
social supports, if applicable.
(8) identification of any current durable
medical equipment (DME) used by the member;
(9) identification of any other
medical/health services concurrently being provided to the member;
(10) a description of any conferences with
the member, member's family, member's clinician, or other interested
persons;
(11) a detailed plan of
care, which must meet the conditions at 130 CMR 432.416(C);
(12) the therapist's signature and the date
of the evaluation; and
(13) for
speech/language therapy only:
(a) assessments
of speech production skills, stimulability, receptive and expressive language
skills, augmentative and alternative communication skills, fluency, voice or
swallowing;
(b) documentation of
the member's cognitive linguistic functioning; and
(c) a description of the member's
communication needs and motivation for therapy.
(B)
Reevaluation. A
reevaluation is an evaluation conducted by a licensed therapist focused on
determining the member's progress toward goals identified in the plan of care,
as well as making a professional judgment about continuing care, modifying
goals and/or treatment, or terminating therapy services. A reevaluation is
needed when there are new clinical findings, a rapid change in the individual's
status, or a member's inability to respond to therapy interventions. Routine,
ongoing progress notes that are part of each therapy visit are not considered
reevaluations.
(C)
Plan
of Care. All therapy services must be provided under a plan of
care established individually for the member. The plan of care must include the
following:
(1) a description of the type of
therapy, location where therapy will take place, anticipated frequency, length
of each visit, and an estimate of the duration of the therapy
services;
(2) documentation of the
diagnosis, prognosis, anticipated goals, functional and measurable short- and
long-term goals, and the reason therapy is needed; and
(3) dated signature of the licensed therapist
who developed the plan of care.
(4)
The plan of care must be reviewed and updated at least every 60 days with the
renewal of the prescription for therapy services, and more frequently as the
member's condition or needs require, including any significant change that may
alter the type, frequency, or duration of therapy services.
