Include the physician referral and prescription for additional therapy based on clinical records and progress reports furnished by the performing provider 216.310 QIO Extended Therapy Services Review Process1-1-21The following is a step-by-step outline of the extended therapy services review process: A. 8. Since MS affects individuals very differently, with disability progressing over time, the physical therapist is challenged to tailor a unique treatment plan for each person and adjust that plan as needed over the long term. RL Requests must be made in writing and must include additional documentation to substantiate the medical necessity of the SGD evaluation. If it changes, please contact Provider Enrollment.26. 3. HYPERLINK "../../Links/AFMCretroPA.doc"View or print QIO contact information. B. This applies to all patients receiving therapy, even if they require assistance from someone to complete the activity. E. Submit the request to the Division of Medical Services. 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. The qualified therapist or speech-language pathologist must be immediately available to provide assistance and direction throughout the time the service is being performed. 2. 4. Requests for extended therapy services are considered only after a claim is denied because a benefit is exceeded. Individuals With Disabilities Education Act Amendments, 20 USC §1400 (. A request received by the QIO within thirty-five (35) calendar days of a denial will be deemed timely. When -1.5 SD or greater is not indicated by both of these tests, descriptive data from an affect measure and/or accepted clinical procedures can be used to support the medical necessity of services. Subsequent license renewals must be provided when issued. The fee schedule link is located at HYPERLINK "https://medicaid.mmis.arkansas.gov/"https://medicaid.mmis.arkansas.gov/ under the provider manual section. The process of identifying meaningful, achievable functional goals should be a collaborative one between the patient, possibly the patient's family or significant others, and the therapist.3,33 Often the best way to identify patient-centered functional goals is simply to ask the patient, “What are your goals for therapy?” In our experience, patients seldom focus on impairments and rarely say, “I'd like my range of motion to be within normal limits” or “I'd like to have 5/5 strength.” They are likely to respond with a focus on functional limitation or disability: “I want to return to work,” “I need to be able to take care of myself at home,” “I want to play in the game on Saturday,” or “I want to do what the other kids do at my school.” These statements can become the starting point for writing measurable patient-centered functional goals. Regardless of the Program decision the provider will be afforded the opportunity for a conference, if he or she so wishes, for a full explanation of the factors involved and the Program decision. For full access to this pdf, sign in to an existing account, or purchase an annual subscription. If, in the judgment of the clinician reviewer, the documentation supports the medical necessity, the clinician reviewer may approve the request. 1. 6. The QIO will not accept requests sent via electronic facsimile (FAX) or e-mail. 216.305 Documentation Requirements1-1-09A. f. If applicable, test results should be adjusted for prematurity (less than 37 weeks gestation) if the child is 12 months of age or younger, and this should be noted in the evaluation. 1. 14. Limited services providers remain enrolled for one year. Research all inquiries from beneficiaries in response to the Explanation of Medicaid Benefits and 3. The following requirements apply only to Arkansas school districts and education service cooperatives that employ (via a form W-4 relationship) qualified practitioners to provide therapy services. . 2. Their goals focused on presumed components of functional skills, such as maintaining a prone-on-elbows position with the head in midline or righting the head when tipped laterally while sitting on a therapy ball.1 Although therapists may need to address impairments during treatment, there is increasing agreement that the measured goals of therapy should relate to functional limitations and disabilities that are individually meaningful to patients.10,11. HYPERLINK "../../Links/Claims.doc"View or print the Claims Department contact information. The individual provider of speech-language pathology services must be licensed as a speech-language pathology assistant in his or her state. Partial units must not be rounded up and are not reimbursable. In this case, the scaled score is the most appropriate score to consider.PEDIRange of Motion � Functional Performance ImpairmentsROMSensory Processing MeasureSPMSensory Processing Measure-PreschoolSPM-PTest of Infant Motor PerformanceTIMPTest of Gross Motor Development, Second EditionTGMD-2Toddler and Infant Motor Evaluation 214.400 Speech-Language Therapy Guidelines for Review1-1-21A. 7. The team may also include regular and special educators, caregivers and parents, vocational rehabilitation counselors, behavior analysts, and others. Eastern Washington University’s Doctor of Physical Therapy (DPT) Program is dedicated to quality graduate education. The services must be documented and available for review in the beneficiary�s medical record. 6. FLUENCY: Two tests and/or procedures must be administered, with at least one being a norm-referenced, standardized test with good reliability and validity. When being retrospectively reviewed if the guidelines are met and medical necessity is approved, the nurse reviewer proceeds to the utilization portion of the review. The Mental Measurement Yearbook (MMY) is the standard reference to determine reliability/validity. All subtests, components and scores used for eligibility purposes must be reported. NOTE: This code set is to be used only when all three of the following conditions are in place: 1) The individual receiving services is 3 years old and is not yet 5 years old. B. The request must be received by the QIO within ninety (90) calendar days of the date of the benefits-exceeded denial. Your comment will be reviewed and published at the journal's discretion. Exception: Procedures from this list may be used to analyze data collected and assist in generating an in-depth, functional profile. An electronic signature is accepted provided it is in compliance with Arkansas Code 2531103. Rubber-stamped signatures, those signed by the physician�s nurse or a nurse practitioner and those without a signature date are not considered valid. 10. NO.Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Suzanne Evans-Morris oral-motor assessment procedures 215.000 Speech Generating Device (SGD) Evaluation1-1-21Arkansas Medicaid covers evaluations for speech generating devices (SGDs) under the following conditions. 2. See Section 214.400 D4. (See Section I of this manual.) A qualified speech-language pathologist must: 1. D. The qualified therapist or speech-language pathologist may not be responsible for the supervision of more than 5 individuals. Holds a current Arkansas teaching certificate as a Speech Pathologist II and does not meet any one of the Medicaid federally mandated requirements for a qualified speech-language pathologist. For example, a person with a hip fracture (pathophysiology) may have pain, edema, and loss of muscle force (impairments), cannot get out of bed or walk (functional limitations), and thus cannot manage personal hygiene, work, or participate in leisure activities (disabilities). A. Where applicable, an *Individual Educational Plan (*IEP) established pursuant to Part B of the Individuals with Disabilities Education Act. Overall, writing patient-centered functional goals will help therapists to conform to health policy, to be reimbursed for interventions, to assist in meeting the expectations of the accreditation process and legislation, and ultimately to meet the unique needs of their patients. Physical therapists who incorporate a patient-centered approach to writing functional goals may see a change in how they interact with their patients and the decisions they make regarding patient care. Holds a current Arkansas teaching certificate as a Speech Therapist, 2. Form DMS-671, Request for Extension of Benefits for Clinical, Outpatient, Laboratory, and X-Ray Services, must be utilized for requests for extended therapy services. See Section 262.200 for codes.C. SERVICE FACILITY LOCATION INFORMATIONIf other than home or office, enter the name and street, city, state, and zip code of the facility where services were performed. To determine a patient's desired outcome of physical therapy, a therapist might ask: “What activities that you want to do does this problem keeping you from doing?” Table 1 suggests other questions that could help to elicit information about the patient's desired outcome.34 A patient may express more than one desired outcome of treatment. LANGUAGE: Two language composite or quotient scores (i.e., normed or standalone) in the area of suspected deficit must be reported, with at least one being from a norm-referenced, standardized test with good reliability and validity. NAME OF REFERRING PROVIDER OR OTHER SOURCEPrimary Care Physician (PCP) referral is required for Occupational, Physical, and Speech-Language Therapy Services. The Utilization Review and Office of Medicaid Inspector General shall: 1. HYPERLINK "../../Forms/HP-MFR-001.doc"View or Print the Medicaid Form Request MFR-001. Team members must disclose any financial relationship they have with device manufacturers and must certify that their recommendations are based on a comprehensive evaluation and preferred practice patterns and are not due to any financial or personal incentive. The Canadian Occupational Performance Measure (COPM) was designed for use by occupational therapists, but it can be useful for physical therapists to help patients to identify and rank goals of intervention.30,35 The COPM provides a standardized format for assisting patients to identify goals that are most important to them in the areas of self-care, productivity (work, household management, play/school), and leisure. DIAGNOSIS POINTEREnter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. 214.200 Guidelines for Review of Occupational, Physical, and Speech-Language Therapy Services1-1-21Prior authorization of extension of benefits is required when a physician prescribes more than 90 minutes of therapy per week in one or more therapy discipline(s). 2. k. Signature and credentials of the therapist performing the evaluation. Percentage of phonemes correct 8. A prescription for therapy services is valid for the length of time specified by the prescribing physician, up to one year. Tinel's sign and Phalen's tests can be used to assess for CTS. The goal also is important to his mother, even though she still needs to assist Tom. . The following list of tests … Tell me about your home life. This system automatically generates a notification to the provider that the record(s) has been received. D. School districts or education service cooperatives must have on file all appropriate employment records for qualified therapists, speech-language pathologists and for all therapy or pathology assistants employed by the group. (See Section 214.400, part D, paragraph 8.) Medicaid reimbursement is conditional upon providers� compliance with Medicaid policy as stated in this provider manual, manual update transmittals and official program correspondence. 2) The individual is receiving the services under an IEP. 216.315 Administrative Reconsideration 7-1-18A request for administrative reconsideration of the denial of services must be in writing and sent to the QIO within 30 calendar days of the denial. Kenneth E Randall, Irene R McEwen, Writing Patient-Centered Functional Goals, Physical Therapy, Volume 80, Issue 12, 1 December 2000, Pages 1197–1203, https://doi.org/10.1093/ptj/80.12.1197. The nurse reviewer compares the paid claims data to the progress notes submitted. If the documentation submitted supports the billed services, the nurse reviewer approves the utilization portion of the retrospective review. Refer to Section 260.000 of this manual for procedure codes and billing instructions and Section 216.100 of this manual for information regarding extended therapy benefits. A copy of the Clinical Fellowship Year Plan Agreement that is filed with the state licensing board for a license to practice speech-language pathology must be submitted with the provider application and Medicaid contract. . A diagnosis alone is not sufficient documentation to support the medical necessity of therapy. This panel will include one member of the Division of Medical Services, a representative of the provider association and a member of the Department of Human Services Management Staff, who will serve as chairman. The following examples illustrate some ways to develop goals for these types of patients. Date of evaluation. 6. Activities contained in goals relate to the desired outcomes of therapy, and they should be observable and repeatable and have a definite beginning and end.1 “Type on a keyboard,” “retrieve files from overhead cabinets,” and “use the telephone,” for example, are all activities, addressed in separate goals, that might make up a secretary's desired general outcome of “return to work.” Each goal focuses on an activity or activities with similar functional requirements. 231.100 Reconsideration of Prior Authorization Determination1-1-21Reconsideration of a denial may be requested within thirty (30) calendar days of the denial date. INSURED�S OR AUTHORIZED PERSON�S SIGNATUREEnter �Signature on File,� �SOF� or legal signature.14. Check YES or NO.d. 6. 2. This charge must be the usual charge to any client, patient, or other beneficiary of the provider�s services.G. Format: MM/DD/YY. 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. 2. Please note the following diagnosis codes are not specific enough to identify the medical necessity for therapy treatment and may not be used. Item and replica analysis 5. Occupational, Physical, Speech-Language Therapy Services Section II Section II- PAGE 1 A physical therapist should be added to the team if it is determined that there is a need for assistance in the evaluation as it relates to the positioning and seating in utilizing specific SGD equipment. Test results must be reported as standard scores, Z scores, T scores or percentiles. How can 1 help you to be more independent? HYPERLINK "Codes/THERAPY_ProcCodes.doc"View or print the procedure codes for therapy services. One potential goal for extended care or rehabilitation settings: Mr Johnson will dress in 10 minutes, using a stable chair to sit on or for standing support as needed by [date]. Only one reconsideration is allowed per denial. The count begins on the next working day after the date of the Remittance and Status Report (RA) on which the benefits-exceeded denial appears. The letter includes case specific rationale explaining why the services did not meet established criteria. A multidisciplinary team must conduct the SGD evaluation. Required when an auto accident is related to the services. This article defines patient-centered functional goals within the context of the Guide to Physical Therapist Practice and provides a rationale for incorporating functional goals into physical therapy for patients in all areas of practice. B. Percentage of consonants correct 6. Tell me about what you do at work. Refer to Section 262.100 of this manual for procedure codes for all therapy and speech-language pathology services. Ultimately, the “so what?” question is a good way to test each goal: “So what difference does performing this activity mean to the person?” For Mr Johnson, caring for himself and gardening are important and meaningful to him, so working toward these activities should enhance his participation in the intervention.18,30, Many of the goals that therapists write for patients with wounds focus on the wound, not on the individual with the wound. If you have hip pain, you may benefit from physical therapy to help control your symptoms and improve your overall functional mobility. Telephone number is requested but not required.a. Form DMS-640 must be used for the initial referral for evaluation and a separate DMS-640 is required for the prescription. The report must include information about the client�s current speech/language and communication abilities. *The entire volume of the IEP is not required for documentation purposes of retrospective review or audit of a facility�s therapy services. Examples include, but are not limited to, the Fluharty-2, KLST-2, CELF-4 Screen or TTFC. 4. “Leslie will bathe” is one example. For example: C1234C (and 4-digit LEA code)Individuals ages 3 to 5 years who are receiving therapy services under an Individualized Education Program (IEP) through a school district or education service cooperative. Formal or informal assessment of hearing, articulation and voice skills. G. During administrative reconsideration of an adverse decision, if the extended therapy services original denial was due to lack of proof of medical necessity or the documentation does not allow for approval by the clinician reviewer, the original documentation, reason for the denial and new information submitted will be referred to a different physician adviser for reconsideration. DATE OF CURRENT: ILLNESS (First symptom) ORINJURY (Accident) ORPREGNANCY (LMP)Required when services furnished are related to an accident, whether the accident is recent or in the past. Providers may bill on the same claim detail for two or more sequential dates of service within the same calendar month when the provider furnished equal amounts of the service on each day of the date sequence.B. A copy of the written verification of the receipt of the application packet for the ASHA certificate of clinical competence must accompany the provider application and the Medicaid contract. The fees represent the fee-for-service reimbursement methodology. c. Diagnosis specific to therapy. If the additional information submitted for reconsideration does not support medical necessity or the paid claims (utilization), the case is referred to a physician adviser for final determination. (See the medical necessity definition in the Glossary of this manual.) 262.400 Special Billing Procedures7-1-18Services must be billed according to the care provided and to the extent each procedure is provided. MK Claim payment adjustments, voids, and refunds must follow previously established processes in policy.23. Winton INSURANCE PLAN NAME OR PROGRAM NAMENot required.d. Eligibility for articulation and/or phonological therapy will be based upon standard scores (SS) of -1.5 SD or greater below the mean from two tests. B. The report must include a description of the functional placement of the SGD such as mounting devices, carrying cases, straps, etc. 216.300 Process for Requesting Extended Therapy Services7-1-18A. A general outcome of “clean the house,” for example, has many components, such as doing laundry, sweeping floors, and dusting. Signature and credentials of the therapist performing the evaluation. Where applicable, an Individualized Family Service Plan (IFSP), Individual Program Plan (IPP) or *Individual Educational Plan (*IEP), established pursuant to Part C of the Individuals with Disabilities Education Act. The referral must be made to the DDS First Connections Central Intake Unit, which serves as the State of Arkansas� single point of entry to minimize duplication and expedite service delivery. Background information including pertinent medical history; and, if the child is 12 months of age or younger, gestational age. Retrospectively evaluate medical practice patterns and providers� patterns by comparing each provider�s pattern to norms and limits set by all the providers of the same specialty. 8. 1. Therapists must sign each date of the entry with a full signature and credentials. (Review Section 214.410 � Accepted Tests for Speech-Language Therapy.) The provider must sign, including credentials, and date the request form. Medical Necessity Occupational and physical therapy services must be medically necessary to the treatment of the individual�s illness or injury. Clinical analysis procedures may not replace standardized tests. 3. , Mitchell A, Molloy DW, et al. JL The third word of the goal is the “what,” which is the activity the patient will perform. Changes made to the prescription that alter the type and quantity of services prescribed are invalid unless changes are initialed and dated by the physician. Date of evaluation. Information about the trial period must be documented in the evaluation report. Item 1-C. of the Contract To Participate In The Arkansas Medical Assistance Program Administered By The Division Of Medical Services Title XIX (Medicaid) further requires acceptance of assignment under Title XVIII (Medicare) in order to receive payment under Title XIX (Medicaid) for any applicable deductible or coinsurance that may be due and payable under Title XIX (Medicaid). . What activities do you need help to perform that you would rather do yourself? The subset of approved Condition Codes is found at HYPERLINK "http://www.nucc.org" www.nucc.org under Code Sets.11. When using a test that is not listed below, the provider must include an explanation and justification in the evaluation report to support the use of the chosen test. 3. By doing so, they can assure themselves that the goals are meaningful to patients in their actual surroundings. RA 4. $ CHARGESThe full charge for the service(s) totaled in the detail. C. Evaluation and Report Components 1. 8. D. A completed Request for Prior Authorization and Prescription Form (DMS-679) must be used to request prior authorization. Additional goals may focus on other functional activities important to the individual, such as enhancing mobility, which may ultimately lead to preventing future wounds. The beneficiary�s PCP or the physician specialist must sign the prescription. Tinel's sign involves tapping at the volar wrist while Phalen's test involves maintaining maximum wrist flexion for 60 seconds. 4. Reconsideration review will not be performed if the additional information does not contain substantially different information than that previously submitted. The plan must include goals that are functional, measurable and specific for each individual client. Copies of form DMS-679 can be requested using the Medicaid Form Request, HP-MFR-001. 4. INSURED�S DATE OF BIRTHNot required. Services must be provided in accordance with the treatment plan, with clear documentation of service rendered. h. Oral-peripheral speech mechanism examination, which includes a description of the structure and function of orofacial structures. E. Therapy services providers must use form DMS-640 � �Occupational, Physical and Speech-Language Therapy for Medicaid Eligible Beneficiaries Under Age 21 Prescription/Referral� � to obtain the PCP referral and the written prescription for therapy services for any beneficiary under the age of 21 years. f. If applicable, test results should be adjusted for prematurity (less than 37 weeks gestation) if the child is 12 months of age or younger, and this should be noted in the evaluation. Eligibility for oral-motor/swallowing/feeding therapy will be based upon an in-depth functional profile of oral motor structures and function using a thorough protocol (e.g., checklist, profile) that indicates a moderate or severe deficit or disorder. Dunn If a limited services provider provides services to another Arkansas Medicaid beneficiary during the year of enrollment and bills Medicaid, the enrollment may continue for one year past the most recent claim�s last date of service, if the enrollment file is kept current. 215.100 Speech Generating Devices (SGD) Evaluation Benefit1-1-21One speech generating device (SGD)evaluation may be performed by a speech-language pathologist every three years, based on medical necessity. HYPERLINK "../../Forms/ApplicationPacket.doc"View or print the provider enrollment and contract package (Application Packet). m. Signature and credentials of the therapist performing the evaluation. Sometimes a physical therapist may think that a patient's desired outcome is unreasonable or not achievable. (See Section 202.300 of this manual.) It is a movement based diagnostic system which systematically finds the cause of pain - not just the source - by logically breaking down dysfunctional movement patterns in a structured, repeatable assessment. B. They may be administered by the physical therapist (PT) or occupational therapist (OT). There must be a reasonable expectation that therapy will result in meaningful improvement or a reasonable expectation that therapy will prevent a worsening of the condition. 12. A teenager with severe spastic quadriplegia and profound mental retardation, for example, may seem to have little potential for achieving functional skills. 1. Use the highest level of specificity.22. 202.330 State Licensure Exemptions Under Arkansas Code �17-100-1047-1-18Arkansas Code �17-97-104, as amended, makes it lawful for a person to perform speech-language pathology services without Arkansas licensure as: A. C. In the six bordering states (Louisiana, Mississippi, Missouri, Oklahoma, Tennessee and Texas) an individual provider of speech-language pathology services: 1. Speech Production disorders may involve one, all or a combination of these components of the speech production system. 202.120 Enrollment Criteria for an Occupational Therapy Assistant10-13-03A. The SFMA is our clinical assessment for those who experience pain. Consideration of requests requires correct completion of all fields on this form. l. A description of functional strengths and limitations, a suggested treatment plan and potential goals to address each identified problem. f. If applicable, test results should be adjusted for prematurity (less than 37 weeks gestation) if the child is 12 months of age or younger, and this should be noted in the evaluation. A copy of all certifications and licenses verifying compliance with enrollment criteria for the therapy discipline to be practiced. 2. A written referral for occupational therapy, physical therapy or speech-language pathology services is required from the patient�s primary care physician (PCP) unless the beneficiary is exempt from PCP Managed Care Program requirements. 2. 2. Services are provided only by appropriately licensed individuals who are enrolled as Medicaid providers in keeping with the participation requirements in Section 201.000 of this manual. 214.100 Utilization Review and Office of Medicaid Inspector General1-1-16A. C. The qualified therapist or speech-language pathologist must review and approve all written documentation completed by the individual under his or her supervision prior to the filing of claims for the service provided. Part B of the Individuals with Disabilities Education Act and Section 504 of the Rehabilitation Act of 1973 prohibit a public agency from requiring parents, where they would incur a financial cost, to use insurance proceeds to pay for services that must be provided to a child with disabilities under the �free appropriate public education� requirements of these statutes. The HBAPL houses our clinical entity: … A. 1. 9. If the denial is for medical necessity, the PCP or attending physician and the services provider(s) will be notified in writing of the medical necessity denial. These measures do not replace the use of standardized tests. B. 4. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALSThe provider or designated authorized individual must sign and date the claim certifying that the services were personally rendered by the provider or under the provider�s direction. Physical therapists, family members, and other team members sometimes have difficulty identifying functional goals for people with severe disabilities. For children age three to 21: criterion-referenced tests will not be accepted as a second measure when determining eligibility for language therapy. (See Section 214.400, part D, paragraph 8.) The dates for achievement of goals may change as therapy proceeds.
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