016.06.07 Ark. Code R. 016

Current through Register Vol. 49, No. 10, October, 2024

Rule 016.06.07-016 - Physician Services Provider Manual Update Transmittal #140; Hospital/Critical Access Hospital (CAH)/End Stage Renal Disease (ESRD) Provider Manual Update #124; Home Health Provider Manual #103

227.210 Accepted Tests for Occupational Therapy

Tests used must be norm referenced, standardized, age appropriate and specific to tine tinerapy provided. The following list of tests is not all-inclusive. When using a test not listed here, the provider must include additional documentation to support the reliability and validity of the test. This additional information will be used as reference information if the chart is ever selected by Medicaid for review. An explanation of why a test from the approved list could not be used to evaluate the child must also be included. The MMY is the standard reference to determine the reliability and validity of the test(s) administered in an evaluation. Providers should refer to the MMY tor additional information regarding specific tests.

DEFINITIONS:

STANDARD: Evaluations that are used to determine deficits.

SUPPLEMENTAL: Evaluations that are used to justify deficits and support other results. These should not "stand alone."

CLINICAL OBSERVATIONS: All clinical observations are supplemental but should be included with every evaluation, especially if standard scores do not qualify the child for therapy. It will be considered when reviewing for medical necessity.

A. Fine Motor Skills - Standard

1. Peabody Developmental Motor Scales (PDMS, PDMS2)

2. Toddler and Infant Motor Evaluation (TIME)

3. Bruininks-Oseretsky Test of Motor Proficiency (BOMP)

4. Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2)

5. Test of Infant Motor Performance (TIMP)

B. Fine Motor Skills - Supplemental

1. Early Learning Accomplishment Profile (FLAP)

2. Learning Accomplishment Profile (LAP)

3. Mullen Scales of Early Learning, Infant/Preschool (MSEL)

4. Miller Assessment for Preschoolers (MAP)

5. Functional Profile

6. Hawaii Early Learning Profile (HELP)

7. Battelle Developmental Inventory (BDI)

8. Developmental Assessment of Young Children (DAYC)

9. Brigance Developmental Inventory (BDI)

C. Visual Motor - Standard

1. Developmental Test of Visual Motor Integration (VMI)

2. Test of Visual Motor Integration (TVMI)

3. Test of Visual Motor Skills

4. Test of Visual Motor Skills - R (TVMS)

D. Visual Perception - Standard

1. Motor Free Visual Perceptual Test

2. Motor Free Visual Perceptual Test - R (MVPT)

3. Developmental Test of Visual Perceptual 2/A (DTVP)

4. Test of Visual Perceptual Skills

5. Test of Visual Perceptual Skills (upper level) (TVPS)

E. Handwriting - Standard

1. Evaluation Test of Children's Handwriting (ETCH)

2. Test of Handwriting Skills (THS)

3. Children's Handwriting Evaluation Scale

F. Sensory Processing - Standard

1. Sensory Profile for Infants/Toddlers

2. Sensory Profile for Preschoolers

3. Sensory Profile for Adolescents/Adults

4. Sensory Integration and Praxis Test (SIPT)

5. Sensory Integration Inventory Revised (SII-R)

G. Sensory Processing - Supplemental

1. Sensory Motor Performance Analysis

2. Analysis of Sensory Behavior

3. Sensory Integration Inventory

4. DeGangi-Berk Test of Sensory Integration

H. Activities of Daily Living/Vocational/Other - Standard

1. Pediatric Evaluation of Disability Inventory (PEDI)

NOTE: The PEDI can also be used for older children whose functional

abilities fall below that expected of a 71/2 year old with no disabilities. If this is the case, the scaled score is the most appropriate score to consider.

2. Adaptive Behavior Scale - School (ABS)

3. Jacobs Pre-vocational Assessment

4. Kohlman Evaluation of Daily Living Skills

5. Milwaukee Evaluation of Daily Living Skills

6. Cognitive Performance Test

7. Purdue Pegboard

8. Functional Independence Measure (FIM) 7 years of age to adult

9. Functional Independence Measure - young version (WeeFIM)

I. Activities of Daily Living/Vocational/Other - Supplemental

1. School Function Assessment (SFA)

2. Bay Area Functional Performance Evaluation

3. Manual Muscle Test

4. Grip and Pinch Strength

5. Jordan Left-Right Reversal Test

6. Erhardy Developmental Prehension

7. Knox Play Scale

8. Social Skills Rating System

9. Goodenough Harris Draw a Person Scale

227.220Accepted Tests for Physical Therapy

A. Norm Reference

1. Adaptive Areas Assessment

2. Test of Gross Motor Development (TGMD-2)

3. Peabody Developmental Motor Scales, Second Ed. (PDMS-2)

4. Bruininks-Oseretsky Test of Motor Proficiency (BOMP)

5. Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2)

6. Pediatric Evaluation of Disability Inventory (PEDI)

7. Test of Gross Motor Development - 2 (TGMD-2)

8. Peabody Developmental Motor Scales (PDMS)

9. Alberta Infant Motor Scales (AIM)

10. Toddler and Infant Motor Evaluation (TIME)

11. Functional Independence Measure for Children (WeeFIM)

12. Gross Motor Function Measure (GMFM)

13. Adaptive Behavior Scale - School, Second Ed. (AAMR-2)

14. Movement Assessment Battery for Children (Movement ABC)

15. Test of Infant Motor Performance (TIMP)

16. Functional Independence Measure (FIM) 7 years of age to adult

B. Physical Therapy - Supplemental

1. Bayley Scales of Infant Development, Second Ed. (BSID-2)

2. Neonatal Behavioral Assessment Scale (NBAS)

3. Mullen Scales of Early Learning Profile (MSEL)

4. Hawaii Early Learning Profile (HELP)

C. Physical Therapy Criterion

1. Developmental assessment for students with severe disabilities. Second Ed. (DASH-2)

2. Milani-Comparetti Developmental Examination

D. Physical Therapy - Traumatic Brain Injury (TBI) - Standardized

1. Comprehensive Trail-Making Test

2. Adaptive Behavior Inventory

E. Physical Therapy - Piloted

Assessment of Persons Profoundly or Severely Impaired

227.310Accepted Tests for Speech-Language Therapy

A. Speech-Language Tests - Standardized

1. Preschool Language Scale, Third Ed. (PLS-3)

2. Preschool Language Scale, Fourth Ed. (PLS-4)

3. Test of Early Language Development, Third Ed. (TELD-3)

4. Peabody Picture Vocabulary Test, Third Ed. (PPVT-3)

5. Clinical Evaluation of Language Fundamentals - Preschool (CELF-P)

6. Clinical Evaluation of Language Fundamentals, Third Ed. (CELF-3)

7. Clinical Evaluation of Language Fundamentals, Fourth Ed. (CELF-4)

8. Communication Abilities Diagnostic Test (CADeT)

9. Test of Auditory Comprehension of Language, Third Ed. (TACL-3)

10. Comprehensive Assessment of Spoken Language (CASL)

11. Oral and Written Language Scales (OWLS)

12. Test of Language Development - Primary, Third Ed. (T0LD-P:3)

13. Test of Word Finding, Second Ed. (TWF-2)

14. Test of Auditory Perceptual Skills, Revised (TAPS-R)

15. Language Processing Test, Revised (LPT-R)

16. Test of Pragmatic Language (TOPL)

17. Test of Language Competence, Expanded Ed. (TLC-E)

18. Test of Language Development - Intermediate, Third Ed. (T0LD-I:3)

19. Fullerton Language Test for Adolescents, Second Ed. (FLTA)

20. Test of Adolescent and Adult Language, Third Ed. (TOAL-3)

21. Receptive One-Word Picture Vocabulary Test, Second Ed. (ROWPVT-2)

22. Expressive One-Word Picture Vocabulary Test, 2000 Ed. (EOWPVT)

23. Comprehensive Receptive and Expressive Vocabulary Test, Second Ed. (CREVT-2)

24. Kaufman Assessment Battery for Children (KABC)

25. Receptive/Expressive Emergent Language Test, Third Edition (REEL-3)

B. Speech Language Tests - Supplemental

1. Receptive/Expressive Emergent Language Test, Second Ed. (REEL-2)

2. Nonspeech Test for Receptive/Expressive Language

3. Rossetti Infant-Toddler Language Scale (RITLS)

4. Mullen Scales of Early Learning (MSEL)

5. Reynell Developmental Language Scales

6. Illinois Test of Psycholinguistic Abilities, Third Ed. (ITPA-3)

7. Social Skills Rating System - Preschool & Elementary Level (SSRS-1)

8. Social Skills Rating System - Secondary Level (SSRS-2)

C. Birth to Age 3:

1. -(minus)1.5 SD (standard score of 77) below the mean in two areas (expressive, receptive) or a -(minus) 2.0 SD (standard score of 70) below the mean in one area to qualify for language therapy.

2. Two language tests must be reported with at least one of these being a global norm-referenced standardized test with good reliability/validity. The second test may be criterion referenced.

3. All subtests, components, and scores must be reported for all tests.

4. All sound errors must be reported for articulation, including positions and types of errors.

5. If phonological testing is submitted, a traditional articulation test must also be submitted with a standardized score.

6. Information regarding the child's functional hearing ability must be included as a part of the therapy evaluation report.

7. Non-school-aged children must be evaluated annually.

8. If the provider indicates the child cannot complete a norm-referenced test, the provider must submit an in-depth functional profile of the child's functional communication abilities. An in-depth functional profile is a description of a child's communication behaviors that specifically notes where such communication behaviors are impaired and justifies the medical necessity of therapy. Standardized forms are available for the completion of an in-depth functional profile, but a standardized form is not required.

9. Children must be evaluated at least annually. Child Health Management Services (CHMS) children (birth - 2) must be evaluated every 6 months.

D. Ages 3 - 21:

1. -(minus)1.5 SD (standard score of 77) below the mean in two areas (expressive, receptive, articulation) or a -(minus) 2.0 SD (standard score of 70) below the mean in one area (expressive, receptive, articulation).

2. Two language tests must be reported with at least one of these being a global norm-referenced standardized test with good reliability/validity. Criterion-referenced tests will not be accepted for this age group.

3. All subtests, components and scores must be reported for all tests.

4. All sound errors must be reported for articulation, including positions and types of errors.

5. If phonological testing is submitted, a traditional articulation test must also be submitted with a standardized score.

6. Information regarding child's functional hearing ability must be included as a part of the therapy evaluation report.

7. Non-school-age children must be evaluated annually.

8. School-age children must have a full evaluation every three years (a yearly update is required) if therapy is school related; outside of school, annual evaluations are required. "School related" means the child is of school age, attends public school and receives therapy provided by the school.

9. If the provider indicates the child cannot complete a norm-referenced test, the provider must submit an in-depth functional profile of the child's functional communication abilities. An in-depth functional profile is a description of a child's communication behaviors that specifically notes where such communication behaviors are impaired and justifies the medical necessity of therapy. Standardized forms are available for the completion of an in-depth functional profile, but a standardized form is not required.

10. IQ scores are required on all children who are school age and receiving language therapy. Exception: IQ scores will not be required for children under ten (10) years of age.

016.06.07 Ark. Code R. 016

9/10/2007