B. Medicaid
requires a comprehensive evaluation of the beneficiary's medical condition,
disability, and level of functioning before therapy is initiated. A
comprehensive evaluation must be performed to determine the need for treatment
and, when treatment is indicated, to develop the treatment plan.
1. Medicaid requires the evaluation must be
written and must demonstrate the beneficiary's need for skilled therapy based
on functional diagnosis, prognosis, and positive prognostic
indicators.
2. The evaluation must
form the basis for therapy treatment goals, and the therapist must have an
expectation that the patient can achieve the established goals.
3. Initial evaluations should, at a minimum
contain, the following information:
a)
Beneficiary demographic information,
b) Name of the prescribing
provider,
c) Date of the
evaluation,
d) Diagnosis/functional
condition or limitation being treated and onset date,
e) Applicable medical history including
mechanism of injury, diagnostic imaging/testing, recent hospitalizations
including dates, medications, comorbidities, either complicating or
precautionary information,
f) Prior
therapy history for same diagnosis/condition and response to therapy,
g) Level of function, prior and currenth)
Clinical status including cognitive function, sensation/proprioception, edema,
vision/hearing, posture, active and passive range of motion, strength, pain,
coordination, bed mobility, balance by sitting and standing, transfer ability,
ambulation on level and elevated surfaces, gait analysis, assistive/adaptive
devices which are currently in use or required, activity tolerance, presence of
wounds including description and incision status, assessment of the
beneficiary's ability to perform activities of daily living and potential for
rehabilitation, age appropriate information on all children such as
chronological age/corrected age, motivation for treatment, other significant
physical or mental disabilities/deficiencies that may affect therapy,
i) Special/standardized tests including the
name, scores/results, and dates administered,
j) Social history including effects of the
disability on the beneficiary and the family, architectural/safety
considerations present in the living environment, identification of the primary
caregiver, caregiver's ability/inability to assist with therapy,
k) Discharge plan including requirements to
return to home, school, and/or job,
l) Impression/interpretation of findings,
and
m) Physical therapist's
signature, including name, title, and date of service.
