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Department of Medical Assistance Services PowerPoint Presentation
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Department of Medical Assistance Services

Department of Medical Assistance Services

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Department of Medical Assistance Services

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  1. Department of Medical Assistance Services

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

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

  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

  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

  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

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

  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.

  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.

  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.



  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

  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)

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

  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. 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

  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)

  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!

  21. 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

  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

  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

  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

  25. 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

  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

  27. 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

  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)

  29. 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

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

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

  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

  33. 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

  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

  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

  36. 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

  37. 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)

  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.

  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

  40. Quality ManagementReviewProvider 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.

  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.

  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

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