(A)
A clinical
evaluation and assessment of the need for skilled therapy services includes the
following elements:
(1)
A diagnosis of the type and severity of the disorder
or a description of the deficit in physical or sensory
functionality;
(2)
A review of the individual's current physical,
auditory, visual, motor, and cognitive status;
(3)
A case history,
including, when appropriate, family perspectives on the individual's
development and capacity to participate in therapy;
(4)
The outcomes of
standardized tests and any non-standardized tests that use age-appropriate
developmental criteria;
(5)
Other test results and interpretation;
(6)
An evaluation
justifying the provision of skilled therapy services, which may be expressed as
one of two prognoses of the patient's rehabilitative or developmental
potential:
(a)
The patient's functionality is expected to improve within sixty days after the
evaluation because of the delivery of rehabilitative skilled therapy services
or within six months after the evaluation because of the delivery of
developmental skilled therapy services, and the patient is expected to attain
full functionality or make significant progress toward expected developmental
milestones within twelve months; or
(b)
The patient is
not expected to attain full functionality or make significant progress toward
expected developmental milestones within twelve months, but a safe and
effective maintenance program may be established; and
(7)
Any
recommendations for further appraisal, follow-up, or referral.
(B)
A
treatment or maintenance plan for skilled therapy services is based on the
clinical evaluation and assessment. It should be coordinated, when appropriate,
with services provided by non-medicaid providers or programs (e.g., child
welfare, child care, or prevocational or vocational services), and it should
provide a process for involving the patient or the patient's representative in
the provision of services. A complete treatment or maintenance plan includes
the following elements:
(1)
The patient's relevant medical
history;
(2)
Specification of the amount, duration, and frequency
of each skilled therapy service to be rendered; the methods to be used; and the
areas of the body to be treated;
(3)
A statement of
specific functional goals to be achieved, including the level or degree of
improvement expected within the appropriate time period;
(4)
The date of each
treatment;
(5)
The signature of the practitioner responsible for the
treatment plan;
(6)
Documentation of participation by the patient or the
patient's representative in the development of the plan;
(7)
Specific
timelines for reevaluating and updating the plan;
(8)
A statement of
the degree to which the patient has made progress; and
(9)
A recommendation
for one of several courses of action:
(a)
The development
of a new or revised treatment plan;
(b)
The development
of a maintenance plan; or
(c)
The discontinuation of treatment.
Replaces: Part of 5160-34- 01.2