2. 1 Department of Medical Assistance Services

3. 2 Special Education Rehabilitation Services October 6, 2009 Presented by: Amy Burkett and Barbara Seymour Health Care Compliance Specialists, II Department of Medical Assistance Services

4. 3 TRAINING OVERVIEW State Plan Clarifications Rehabilitation Service Definitions Rehabilitation Therapists’ Qualifications Documentation Requirements Coordination of Services Quality Management Review

5. 4 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

6. 5 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

7. 6 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

8. 7 STATE PLAN CLARIFICATION Definition Rehabilitation - Medically prescribed treatment for improving or restoring functions which have been impaired by illness/disability or injury

9. 8 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.

10. 9 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.

11. 10 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.

12. 11 STATE PLAN CLARIFICATION Rehabilitation Regain or Restore a skill Demonstrate progress Licensed therapist required Habilitation Gain a new skill Demonstrate progress Licensed therapist required Maintenance Maintain an acquired skill No progress demonstrated Personal care assistant or caregiver or parent

13. 12 REHABILITATION THERAPISTS' QUALIFICATIONS

14. 13 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

15. 14 Therapist Qualifications PT – Virginia Board of Physical Therapy OT – Virginia Board of Medicine SLP – Virginia Board of Audiology & Speech Language Therapy; or CCC’s 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)

16. 15 Therapy Assistants Therapy Assistants (LPTA, COTA, or Speech Assistants) are allowed to provide therapy services under the supervision of a qualified therapist.

17. 16 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

18. 17 DOCUMENTATION REQUIREMENTS

19. 18 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

20. 19 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)

21. 20 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 POC’s is not acceptable!

22. 21 Documentation of Therapist Evaluation NO SPECIFIC DMAS/DOE FORM A comprehensive evaluation must include: Medical Diagnosis History Functional Limitations and Deficits Medical Findings Clinical Signs and Symptoms Therapist Recommendations

23. 22 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

24. 23 Re- Evaluations Re-Evaluations will be reimbursed by DMAS when there is: An interruption in services, or A significant change in the child’s condition NOTE: “program generated” evaluations are not reimbursed by DMAS

25. 24 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

26. 25 PLAN OF CARE MED-8 or IEP Medical Diagnosis (ICD-9 code) The diagnosis identified on the POC should be specific to the medical condition/deficit being treated

27. 26 PLAN OF CARE COMPONENTS Treatment Diagnosis Functional Deficits Summary of previous treatment Long-term goals (LTG’s) Therapy discipline Frequency Treatment interventions/modalities POC implementation date Discharge plan Therapist signature/title/date

28. 27 PLAN OF CARE GOALS The child receiving rehabilitation therapies “drives” the treatment plan The licensed therapist develops the child’s 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

29. 28 PLAN OF CARE LONG TERM GOALS Specific and Individualized Patient Oriented Measurable and functional Realistic Include time frames for goal achievement (month/day/year)

30. 29 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 PLAN OF CARE

31. 30 PLAN OF CARE Specific therapeutic interventions, treatment modalities Plan of care implementation date (month/day/year) Discharge plan

32. 31 PLAN OF CARE SIGNATURES Therapist (licensed practitioner) must sign, title, and fully date the plan of care (MED-8 or IEP)

33. 32 MED-12 PLAN OF CARE ADDENDUM The MED-12 form is used when there are: revisions to the LTG’s (not STG’s) (i.e., changes, additions, and/or deletions) changes in frequency or duration of treatment changes in individual vs group therapy significant changes in the child’s condition

34. 33 MED-9 PROGRESS NOTES Progress notes must be written for each visit provided Services not documented as rendered should not be billed and will not be reimbursed by DMAS

35. 34 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 Child’s response to tx/progress Therapist’s signature, title, and full date

36. 35 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

37. 36 MED-9 PROGRESS NOTE Supervisory 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

38. 37 DISCHARGE SUMMARY/ORDER MED-13 Identify the child’s functional outcome Identify the child’s LTG’s achieved Identify the discharge disposition Therapist signature/title/date (discharge order) Completed within reasonable time frame (30 days)

39. 38 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.

40. 39 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

41. 40 Quality Management Review Provider 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.

42. 41 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.

43. 42 Contact Information For clinical rehab questions call: DMAS Division of Maternal and Child Health Phone: 804-786-6134 MCH Division Fax # 804-612-0043

44. 43 Contact Information The DMAS web site is: www.dmas.virginia.gov For billing questions call the DMAS Provider Helpline at 1-800-552-8627