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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 EducationDMAS - Department of Medical Assistance

ServicesCMS - Centers for Medicare & Medicaid

ServicesIEP - Individualized Educational PlanPOC - Plan of CareEPSDT – Early & Periodic Screening, Diagnosis,

and TreatmentQMR – 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

DefinitionMaintenance 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

Rehabilitation

Regain or Restore a skill

Demonstrate progress

Licensed therapist required

HabilitationGain a new skill

Demonstrate progress

Licensed therapist required

Maintenance

Maintain an acquired skill

No progress demonstrated

Personal care assistant or caregiver or parent

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REHABILITATION

THERAPISTS'

QUALIFICATIONS

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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 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)

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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 dateare not reimbursed

Back-dating POC’s is not acceptable!

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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

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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 child’s 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 (LTG’s)• 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 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

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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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•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

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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 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

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MED-9PROGRESS 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

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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

• Child’s response to tx/progress

• Therapist’s 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 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)

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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: 804-786-6134 MCH Division Fax # 804-612-0043

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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