1. © Copyright 2015 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 1 Occupational, Physical, and Speech Therapy Retrospective Review and Billing 101 Presented by Kay Ewalt and Karen Young

2. Retrospective Therapy Review

3. Medicaid Retrospective Therapy Review  Medicaid is contracted with Qsource of Arkansas to perform post-payment audits for Occupational, Physical, and Speech-Language therapy services on children under the age of 21.  Audits are selected randomly each quarter.  A child is only eligible for selection every 12 months.  Audit selection is based on claims billed and paid in the previous quarter.

4. Submitting Requested Charts for Review The following information is included with each quarter’s chart requests:  Therapy Chart Request Reference Sheets (purple sheets).  Master List – Check to ensure you have received all the Therapy Request Cover Sheets listed.  Frequently Asked Questions Reference Sheets.  Charts must be received by Qsource within 30 calendar days, of the “date of record request” found on the Chart Request Sheet.

5. Review Documents Prior to Submitting

6. Annual Update Requirements for Schools An update of progress toward client goals is required annually. For example: Evaluation was completed on 1/5/2015. Then an annual update of progress is due on 1/5/16 and 1/5/17. The therapist can complete these updates independently. They do not have to be completed as part of the Annual Review Conference held each year at the school. Annual Review forms completed by the school at the Annual Review Conference are acceptable if they address progress of the specific type of therapy under review and cover all dates of service under review. Goal pages within the IEP, IFSP and IPP forms are also acceptable for annual updates if each goal is updated quarterly, if the date is documented of when the update occurred and if the dates of service under review are covered.

7. Arkansas Medicaid Provider Criteria: www.medicaid.state.ar.us OT, PT and ST Provider Manual Section II – Contains Medicaid criteria for services

8. DMS-640 Completion  Child’s name and Medicaid number.  Diagnosis to support each type of therapy prescribed.  Minutes per week and duration of services prescribed.  Only public schools can document a duration span. For example: school year (2013-2014) under other information.  Primary Care or Attending Physician must sign and date. Stamped signatures or dates are not accepted.  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.  When printing the DMS-640 form from the online Medicaid Provider Manual, detailed instructions will also print on how to complete the form. Section II – 214.000 E.

9.  OT, PT and ST services require a referral from the beneficiary’s PCP unless the beneficiary is exempt from PCP program requirements, in which case a referral is required from the attending physician.  All referral and prescriptions are required utilizing the DMS-640 form.  Providers of therapy services are responsible for obtaining renewed PCP referrals every six months even if the prescription for therapy is for one year.  When seeing a beneficiary for the first time, the initial referral for evaluation and prescription for treatment must be obtained on separate DMS-640 forms.  Subsequent referrals and prescriptions for continued therapy may be made at the same time using the same DMS-640 form. See Section II – 214.000 A & B Arkansas Medicaid Provider Manual DMS-640 Completion – Cont’d

10. Reconsideration of Denials  Reconsideration information must be received in the Qsource office within 35 calendar days from the date on the initial denial letter.  A copy of the initial denial letter, as well as new or additional information, must be provided.  Reconsideration information must be MAILED to Qsource. Attention: Therapy 124 West Capitol Avenue Suite 900 Little Rock, AR 72201  Only one reconsideration request is allowed per review.

11. Fair Hearings  To request a fair hearing (appeal), you must do so in writing.  You may not request a hearing and a reconsideration at the same time.  Please send your request to: Arkansas Department of Health Medicaid Provider Appeals Office 4815 West Markham Street Slot 31 Little Rock, Arkansas 72205

12. Check the Status of Your Reviews  Go to https://review.qsource-secure.org/provider_home.php.https://review.qsource-secure.org/provider_home.php  Choose Selection Date.  Enter you Provider ID.  Click: Find My Review.  The review status will reflect what determination has been reached to date on any specific review and where the chart is in the review process.  The program will provide one of the following responses:  Chart Not Received  Review in Progress  Approved  Partially Approved  Denied  Recon in Process  Recon Approved  Recon Denied  Recon Partial

13. Doc Upload Tired of copying all that paper? Then consider transmitting your records electronically. If you’re interested, please download and complete the two forms linked below and mail them to the address noted on the documentation. http://qsource.org/arthur/therapy.htm We will process all completed forms and contact you with further information.

14. Sign Up for Quarterly eNewsletter Want to stay up-to-date on what is happening? Then sign up for the Qsource Quarterly eNewsletter for the latest information from Qsource and Arkansas Medicaid. http://www.qsource.org/ar/sign-newsletter/

16. Kay Ewalt, RN Case Review Manager kewalt@qsource.org 501-801-6900

17. © Copyright 2015 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 17 Billing Instructions for Therapists HP – Fiscal Agent for the Arkansas Division of Medical Services

18. © Copyright 2015 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 18 Topics for Today Therapy Coverage Exclusions The Review Process Billing Claims Questions

19. © Copyright 2015 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 19 Therapy Coverage

20. © Copyright 2015 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 20 Program Coverage www.medicaid.state.ar.us Occupational, physical and speech services are covered only when: A PCP (or attending physician if the client is PCP exempt) refers the beneficiary for services. A PCP (or attending physician if the client is PCP exempt) writes a prescription for services. Treatment follows a plan of care. The beneficiary is under 21. Only speech therapy is covered for ARKids First-B beneficiaries. Clients over 21 are not eligible for therapy services unless certain conditions are met. (See section 212.000, G of the Therapy provider manual.)

21. © Copyright 2015 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 21 Exclusions

22. © Copyright 2015 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 22 Therapy services for individuals over age 21 are only covered when provided through the following Medicaid programs: Developmental Day Treatment Clinic Services (DDTCS) Hospital/Critical Access Hospital (CAH) Rehabilitative Hospital Home Health Hospice Physician An individual who has been admitted as an inpatient to a hospital or is residing in a nursing care facility is not eligible for occupational therapy, physical therapy and speech-language pathology services under this program. Individuals residing in residential care facilities and supervised living facilities may be eligible for these therapy services when provided on or off site from the facility. Exclusions www.medicaid.state.ar.us

23. © Copyright 2015 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 23 The Review Process

24. © Copyright 2015 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 24 Retrospective Review Occupational, physical and speech services are reviewed by Qsource of Arkansas for effective, efficient and economical delivery of services. Review processes and guidelines are documented in the Therapy provider manual in sections 214.300 and 214.400. www.medicaid.state.ar.us

25. © Copyright 2015 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 25 Billing Claims

26. © Copyright 2015 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 26 Augmentative Communication Device Augmentative communication evaluations are covered under Medicaid with prior approval. Section 231.000 of the Therapy provider manual details the prior authorization process. A PCP or attending physician referral is required to request the prior authorization from the Division of Medical Services, Utilization Review Section. One augmentative communication devices evaluation may be performed every three years based on medical necessity. www.medicaid.state.ar.us

27. © Copyright 2015 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 27 Therapy Benefits Occupational, physical and speech services are limited. Medicaid will reimburse up to four (4) occupational, physical and speech therapy evaluation units (1 unit = 30 minutes) per discipline, per state fiscal year (July 1 through June 30) without authorization. Medicaid will reimburse up to four (4) occupational, physical and speech therapy units (1 unit = 15 minutes) daily, per discipline, without authorization. All requests for extended therapy services must comply with sections 216.300 through 216.315 of the Therapy provider manual. www.medicaid.state.ar.us

28. © Copyright 2015 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 28 Procedure Code Required ModifiersDescription 97003—Evaluation for Occupational Therapy (30-minute unit; maximum of 4 units per state fiscal year, July 1 through June 30) 97530—Individual Occupational Therapy (15-minute unit; maximum of 4 units per day) 97150U2Group Occupational Therapy (15-minute unit; maximum of 4 units per day, maximum of 4 clients per group) 97530UBIndividual Occupational Therapy by Occupational Therapy Assistant (15-minute unit; maximum of 4 units per day) 97150UB, U1Group Occupational Therapy by Occupational Therapy Assistant (15-minute unit; maximum of 4 units per day, maximum of 4 clients per group) Occupational Therapy Codes www.medicaid.state.ar.us

29. © Copyright 2015 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 29 Procedure CodeRequired ModifierDescription 97001—Evaluation for Physical Therapy (30-minute unit; maximum of 4 units per state fiscal year, July 1 through June 30) 97110—Individual Physical Therapy (15-minute unit; maximum of 4 units per day) 97150—Group Physical Therapy (15-minute unit; maximum of 4 units per day, maximum of 4 clients per group) 97110UBIndividual Physical Therapy by Physical Therapy Assistant (15-minute unit; maximum of 4 units per day) 97150UBGroup Physical Therapy by Physical Therapy Assistant (15-minute unit; maximum of 4 units per day, maximum of 4 clients per group) Physical Therapy Codes www.medicaid.state.ar.us

30. © Copyright 2015 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 30 92507—Individual Speech Session (15-minute unit; maximum of 4 units per day) 92508—Group Speech Session (15-minute unit; maximum of 4 units per day, maximum of 4 clients per group) 92507UBIndividual Speech Therapy by Speech-Language Pathology Assistant (15-minute unit; maximum of 4 units per day) 92508UBGroup Speech Therapy by Speech-Language Pathology Assistant (15-minute unit; maximum of 4 units per day, maximum of 4 clients per group) 92521UA  (Evaluation of speech fluency (e.g. stuttering, cluttering) (30- minute unit; maximum of 4 units per state fiscal year, July 1 through June 30) 92522UA  (Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria) (30-minute unit; maximum of 4 units per state fiscal year, July 1 through June 30) 92523UA  (Evaluation of speech production (e.g., articulation, phonological process, apraxia, dysarthria) with evaluation of language comprehension and expression (e.g., receptive and expressive language) (30-minute unit; maximum of 4 units per state fiscal year, July 1 through June 30) 92524UA  (Behavioral and qualitative analysis of voice and resonance (30-minute unit; maximum of 4 units per state fiscal year, July 1 through June 30) Speech Language Pathology www.medicaid.state.ar.us

31. © Copyright 2015 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 31 When evaluating for Oral Motor/Feeding/Swallowing only – Provider should use code 92522 UA When evaluating for Oral Motor/Feeding/Swallowing AND language – Provider should use code 92523 UA For detailed information concerning how to use and bill for these codes, please go to: http://www.asha.org/Practice/reimbursement/coding/NEW-CPT-Evaluation-Codes-for- SLPs/http://www.asha.org/Practice/reimbursement/coding/NEW-CPT-Evaluation-Codes-for- SLPs/. Speech Language Pathology www.medicaid.state.ar.us

32. © Copyright 2015 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 32 Procedure CodeDescription 92607 92608 Augmentative Communication Device Evaluation ACD Evaluation www.medicaid.state.ar.us

33. © Copyright 2015 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 33 Place of ServicePlace of Service Code Doctor’s Office11 Patient’s Home12 Day Care Facility52 Night Care Facility52 Other Locations99 Residential56 Place of Service Codes www.medicaid.state.ar.us

34. © Copyright 2015 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 34 LEA CodeDescription AIndividuals from birth through 2 years (but not 3 years old before September 15 of the current school year) who are receiving therapy services under an Individualized Family Services Plan (IFSP) through the Division of Developmental Disabilities Services. BIndividuals ages 0 through 5 years (if individual has not reached age 5 by September 15) who are receiving therapy services under an Individualized Plan (IP) through the Division of Developmental Disabilities Services. CIndividuals ages 3 through 5 years (if individual has not reached age 5 by September 15) who are receiving therapy services under an Individualized Education Program (IEP) through an education service cooperative. DIndividuals ages 5 (by September 15) to 21 years who are receiving therapy services under an IEP through a school district. EIndividuals ages 18 through 20 years who are receiving therapy services through the Division of Developmental Disabilities Services. FIndividuals ages 18 through 20 years who are receiving therapy services from individual or group providers not included in any of the previous categories (A-E). GIndividuals ages birth through 17 years who are receiving therapy/pathology services from individual or group providers not included in any of the previous categories (A-F). Billing for School Districts School districts billing for therapy services must use the appropriate Therapy Service Indicator and 4-digit School District LEA code. www.medicaid.state.ar.us

35. © Copyright 2012 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Questions?

36. © Copyright 2015 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 36 Thank You