Department of Medical Assistance Services

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Department of Medical Assistance Services
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Special Education Rehabilitation
Services October 6, 2009 Presented by Amy
Burkett and Barbara Seymour Health Care
Compliance Specialists, IIDepartment of Medical
Assistance Services
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TRAINING OVERVIEW

• State Plan Clarifications
• Rehabilitation Service Definitions
• Rehabilitation Therapists Qualifications
• Documentation Requirements
• Coordination of Services
• Quality Management Review

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COMMONLY USED ACRONYMS

• DOE - Department of Education
• DMAS - Department of Medical Assistance
  Services
• CMS - Centers for Medicare Medicaid
  Services
• IEP - Individualized Educational Plan
• POC - Plan of Care
• EPSDT Early Periodic Screening, Diagnosis,
  and Treatment
• QMR Quality Management Review

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Medical Necessity

• Determined by licensed practitioner of healing
  arts and IEP team
• Defines the medical justification of services
  which are provided to treat or correct identified
  health problems
• Treatment prescribed is in accordance with
  standards of medical practice

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STATE PLAN CLARIFICATION

• Since 7/1/06, school services, including
  rehabilitation, are located in the EPSDT state
  plan regulations (42 CFR 440.40)
• EPSDT regulations provide for coverage of
  rehabilitation and habilitation for children
  under the age of 21

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STATE PLAN CLARIFICATION

• Definition
• Rehabilitation - Medically prescribed treatment
  for improving or restoring functions which have
  been impaired by illness/disability or injury

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STATE PLAN CLARIFICATION

• Definition
• Habilitation - Medically prescribed treatment
  for acquiring a skill a child never had or to
  gain a new skill, or to prevent disease
  progression. For example, a child that has been
  tube fed since birth and is able to start oral
  feedings, or a child who was never able to
  ambulate and now has gained the ability to
  ambulate.

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STATE PLAN CLARIFICATION

• Definition
• Maintenance Therapy Services to assist a child
  from losing/maintaining an acquired skill, or to
  correct or ameliorate a health condition for
  children under the age of 21. This service does
  not require the skills of a licensed therapist
  and can be carried out by a personal care
  assistant or a caregiver/parent.

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STATE PLAN CLARIFICATION

• Rehabilitation to regain or restore, must
  demonstrate progress, and must require the skills
  of a licensed therapist (PT/OTR/SLP).
• Habilitation to gain a new skill, must
  demonstrate progress, and must require the skills
  of a licensed therapist (PT/OTR/SLP).
• Maintenance to maintain an acquired skill, no
  progress is demonstrated, and does not require
  the skills of a licensed therapist. Is performed
  by a personal care assistant or caregiver/parent.

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STATE PLAN CLARIFICATION
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Therapist Practice Requirements

• DMAS refers to the Virginia Department of Health
  Professions (DHP) licensure qualifications
  section to verify that therapists meet DMAS
  requirements
• Therapists have requirements within their
  licensure boards, practices, and/or associations
  that must be followed. These are not DMAS
  requirements

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Therapist Qualifications

• PT Virginia Board of Physical Therapy
• OT Virginia Board of Medicine
• SLP Virginia Board of Audiology Speech
  Language Therapy or CCCs from ASHA or licensed
  by the VA Board of Education with an endorsement
  in speech language disorders, pre-K-12 and a
  Masters degree in SLP (without exam from the BOA
  SLP)

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Therapy Assistants

• Therapy Assistants (LPTA, COTA, or Speech
  Assistants) are allowed to provide therapy
  services under the supervision of a qualified
  therapist.

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PT/OT/SLP-Qualifications

• Physical Therapist LPT, LPTA
• Occupational Therapist OTR, COTA
• Speech-Language Pathologist CCC/SLP, SLP,
  CFY/SLP, SLP with licensure by Board of
  Education/ Board of Audiology and SLP, and
  speech-language assistants

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DOCUMENTATION REQUIREMENTS
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Points to Remember!

• DMAS allows the use of either the IEP or the POC
  (MED-8) as the plan of care
• If the IEP is used as the POC, it must include
  all the POC required components of the MED-8
• Therapists must always follow their licensure
  practice requirements regarding referrals and
  physician orders

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Licensed Practitioner

• The licensed practitioner/therapist is required
  to
• Order the evaluation (MED-6)
• Complete the evaluation (no form)
• Complete the POC (MED-8 or IEP)
• Complete progress notes (MED-9)
• Complete POC Addendum(s) (MED-12)
• Complete Discharge Summary/Order (MED-13)

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Licensed Practitioner Orders

• If the 21 day POC signature requirement is not
  met
• DMAS will only reimburse for the provision of
  services provided after the therapist signature
  date
• Services provided prior to the therapist
  signature date
• are not reimbursed
• Back-dating POCs is not acceptable!

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Documentation of Therapist EvaluationNO
SPECIFIC DMAS/DOE FORM

• A comprehensive evaluation must include
• Medical Diagnosis
• History
• Functional Limitations and Deficits
• Medical Findings
• Clinical Signs and Symptoms
• Therapist Recommendations

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Evaluations

• Medicaid reimbursement will be made for
  evaluations when
• Licensed practitioner/therapist orders the
  initial evaluation (MED-6), or
• A child has been discharged from therapy services
  and needs to be re-admitted for continued
  treatment

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Re- Evaluations

• Re-Evaluations will be reimbursed by DMAS when
  there is
• An interruption in services, or
• A significant change in the childs condition
• NOTE program generated evaluations are not
  reimbursed by DMAS

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Transfer of Services

• When a child is transferred to another school
  division, services should not be interrupted
• re-evaluation may be performed but billed as a
  visit
• revision to the plan of care, if needed

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PLAN OF CAREMED-8 or IEP

• Medical Diagnosis (ICD-9 code)
• The diagnosis identified on the POC should be
  specific to the medical condition/deficit being
  treated

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PLAN OF CARE COMPONENTS

• Treatment Diagnosis
• Functional Deficits
• Summary of previous treatment
• Long-term goals (LTGs)
• Therapy discipline
• Frequency
• Treatment interventions/modalities
• POC implementation date
• Discharge plan
• Therapist signature/title/date

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PLAN OF CAREGOALS

• The child receiving rehabilitation therapies
  drives the treatment plan
• The licensed therapist develops the childs long
  term goals based on the results of the initial
  evaluation
• All long term goals with achievement dates must
  be documented on the plan of care

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PLAN OF CARE LONG TERM GOALS

• Specific and Individualized
• Patient Oriented
• Measurable and functional
• Realistic
• Include time frames for goal achievement
  (month/day/year)

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PLAN OF CARE

• Discipline (PT/OT/SLP)
• Frequency (i.e. 2x/wk, 1-2x/wk)
• individual and /or group therapy
• Maximum of 6 children in group therapy regardless
  of payer source

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PLAN OF CARE

• Specific therapeutic interventions,
  treatment modalities
• Plan of care implementation date (month/day/year)
• Discharge plan

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PLAN OF CARESIGNATURES

• Therapist (licensed practitioner) must sign,
  title, and fully date the plan of care (MED-8 or
  IEP)

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MED-12 PLAN OF CARE ADDENDUM

• The MED-12 form is used when there are
• revisions to the LTGs (not STGs)
• (i.e., changes, additions, and/or deletions)
• changes in frequency or duration of treatment
• changes in individual vs group
• therapy
• significant changes in the childs condition

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MED-9PROGRESS NOTES

• Progress notes must be written for each visit
  providedServices not documented as rendered
  should not be billed and will not be reimbursed
  by DMAS

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MED- 9 PROGRESS NOTE COMPONENTS

• Document therapy participation
• Short term goals/objectives/time frames for goal
  achievement
• Short term goal revisions as needed throughout
  the school year
• Therapeutic activities/procedures
• Childs response to tx/progress
• Therapists signature, title, and full date

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MED-9 PROGRESS NOTE

• Therapy assistants may only document progress
  notes on the MED-9
• Therapy assistants cannot develop the evaluation,
  POC/IEP, POC addendum, or the discharge summary

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MED-9 PROGRESS NOTESupervisory Requirements

• Supervisory 30 day review of all therapy
  assistants
• The supervisory visit must be performed and
  documented by the licensed therapist
• The monthly supervision section of the revised
  MED-9 must be fully completed, signed, titled,
  and dated by both the licensed therapist and the
  therapy assistant

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DISCHARGE SUMMARY/ORDERMED-13

• Identify the childs functional outcome
• Identify the childs LTGs achieved
• Identify the discharge disposition
• Therapist signature/title/date (discharge order)
• Completed within reasonable time frame (30 days)

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Coordination of Services

• The purpose of coordination of services is to
  maximize therapy benefits for the child.
• Occurs when a child has an overlap of services
  between school and community therapy due to a
  medical need. Therapists should communicate on
  an ongoing basis and document.

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Quality Management Review (QMR)

• The purpose of QMR is to ensure
• Health, safety, and welfare
• Clinical aspects of the individual
• Meeting regulations and documentation standards

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Quality Management ReviewProvider
Responsibility

• Rehab services are to be terminated when any of
  these conditions exist
• Further progress toward the established goals is
  unlikely, and/or
• The services (i.e., home program) can be
  provided by a trained personal care assistant
  or parent/caretaker, and/or
• No longer requires the skills of a qualified
  therapist.

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QUALITY MANAGEMENT REVIEW APPEAL PROCESS

• Following DMAS audits, a QMR letter will be sent
  which will include the audit results and provider
  appeal rights information.

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Contact Information

• For clinical rehab questions call
• DMAS Division of Maternal and Child Health
• Phone [phone]
• MCH Division Fax [phone]

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Contact Information

• The DMAS web site is
• www.dmas.virginia.gov
• For billing questions call the DMAS Provider
  Helpline at 1-800-552-8627