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OUTPATIENT PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY PROVIDER TRAINING MANUAL

EFFECTIVE 07/01/05

175 East Capitol Street Suite 250 Lock Box 13 Jackson, MS 39201

HealthSystems of Mississippi

Provider Manual

Outpatient Physical, Occupational, Speech Therapy Provider Manual

Table of Contents

SECTION I. II. III. IV. V. VI. Introduction Overview of Operations Certification Review Activities Notification of Review Outcome Reconsideration Process Quality Review Activities 1. Quality Review Process Flow Chart 2. Quality Screens (Indicators) VII. VIII. IX. Glossary Precertification Code List Forms and Instructions 1. Precertification Review Request Form 2. Precertification Review Request Form Instructions 3. Place of Service Codes 4. Reconsideration Review Request Form 5. Reconsideration Review Request Form Instructions 6. Quality Re-Review Request Form 7. Quality Re-Review Request Form Instructions 8. Certificate of Medical Necessity Form Effective: 07/01/05 Revised:11/07/06 Outpatient Physical, Occupational and Speech Therapy Table of Contents Page 1 of 1 VII (1-3) VIII (1-3) IX PAGE NUMBER I (1) II (1) III (1-8) IV (1-2) V (1) VI (1-10)

HealthSystems of Mississippi

Provider Manual

9. Certificate of Medical Necessity Form Instructions 10. Occupational Therapy Evaluation Form 11. Physical Therapy Evaluation Form 12. Speech Therapy Evaluation Form 13. Outpatient Therapy Evaluation Form Instructions 14. Occupational Therapy Plan of Care 15. Physical Therapy Plan of Care 16. Speech Therapy Plan of Care 17. Outpatient Therapy Plan of Care Form Instructions

Effective: 07/01/05 Revised:11/07/06

Outpatient Physical, Occupational and Speech Therapy Table of Contents Page 2 of 2

HealthSystems of Mississippi

Provider Manual

Introduction

HealthSystems of Mississippi (HSM) is the Utilization Management and Quality Improvement Organization contracted to perform precertification and quality review for therapy services rendered to Mississippi Medicaid beneficiaries. As DOM's contractor, we will perform precertification and quality review activities for outpatient physical, occupational and speech therapy services. We have been contracted with the Mississippi Division of Medicaid (DOM) providing precertification and quality of care review since 1997. HSM currently performs these functions for Medicaid beneficiaries admitted to the Inpatient acute medical/surgical setting, Acute Psychiatric inpatient setting, Private Duty Nursing care, Swing bed setting, Psychiatric Residential Treatment Facilities, Home Health care, and Durable Medical Equipment. HSM is committed to providing the highest level of service to DOM, and the Medicaid beneficiaries, physicians and providers throughout the state. Mission Statement To improve the quality of health and health care by using information and collaborative relationships to enable change. Core Values We value: the pursuit of innovation integrity in the work we do sharing the responsibility for achieving corporate goals treating people with respect delivering products and services that are valuable to customers an environment of professional growth and fulfillment engaging in work that is socially relevant continuous quality improvement

________________________________________________________________________ Effective: 07/01/05 Outpatient Physical, Occupational and Speech Therapy Revised: 11/08/06 Introduction Page I-1 of 1

HealthSystems of Mississippi

Provider Manual

Overview of Operations

This section contains general information about HealthSystems of Mississippi (HSM's) review program for precertification and quality review of therapy services rendered to Medicaid beneficiaries. For more details regarding how and when review is performed, we strongly encourage you to read through the sections in this manual. The sections contain information about each review type (precertification, concurrent, retrospective, reconsideration and quality sample), review request forms and required documentation that must be submitted to HSM. Our office is located in downtown Jackson at the following address: 175 East Capitol Street Suite 250, Lock Box 13 Jackson, MS. 39201. HSM's hours of operation are as follows: Our business hours are from 8:00 a.m. to 5:00 p.m., Monday through Friday. Our direct office phone number and primary fax number are: Voice Phone: (601) 352-6353 Fax Number: (601) 352-6358

All precertification requests for outpatient therapy services must be faxed or mailed to HSM according to the timelines provided in this manual. Fax outpatient therapy certification requests to: 1- 888-557-1920

There is a help line available for questions regarding certification review decisions and other review processes. This number is: 1-866-740-2221 (Toll-Free) 1-601-360-4949 (Jackson Metropolitan Area) HSM also provides a toll-free hot line through which beneficiaries and providers can report quality concerns and/or complaints. This hot line can be accessed from the hours of 8:00 a.m. through 5:00 p.m. Monday through Friday; the hot line number is: 1-888-204-0221

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HealthSystems of Mississippi Precertification Review Activities

Provider Manual

The Mississippi Division of Medicaid (DOM) requires precertification of outpatient physical and occupational therapy and speech pathology services proposed to be rendered to Mississippi Medicaid beneficiaries. HSM is DOM's precertification review contractor to perform utilization and quality review of outpatient therapy services. Objectives of Precertification Review are to: Ensure medically necessary therapy is provided to beneficiaries Control over utilization of therapy services Ensure appropriateness of services Avoid duplication of services (for areas administered by DOM and across state agencies) Outpatient PT/OT/SLP therapy services include the following: Comprehensive evaluation Individual treatment Group therapy (speech language pathology only) Design, construction and fitting of an adaptive device Outpatient PT/OT/SLP Therapy Review Inclusions Services requiring Precertification by HSM are as follows: Therapy services provided to beneficiaries under age 21 in the office or clinic of a physical therapist, occupational therapist, or speech language pathologist (individual or group practice). Note: Services are not covered in the above settings for beneficiaries age 21 and over. Therapy services provided to beneficiaries (adult and children) in the outpatient department of the hospital. Therapy services provided to beneficiaries under age 21 in a physician's office or clinic (individual or group). This is also applicable to physician assistants and nurse practitioners. Note: Services are not covered in the above settings for beneficiaries age 21 and over. Therapy services provided to beneficiaries under age 21 through the following providers: · Rural Health Clinics (RHC) · Federally Qualified Health Centers (FQHC) · State Department of Health Note: Services are not covered in the above settings for beneficiaries age 21 and over. Therapy services provided to beneficiaries covered under both Medicare and Medicaid if Medicare benefits have been exhausted. Effective 07/01/05 Revised: 11/08/06 Outpatient Physical, Occupational and Speech Therapy Certification Review Activities Page III-1 of 1

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Services are rendered in the following settings: Hospital outpatient School ­ (those services not billed by school provider) Home- (those services not provided through home health agencies) Clinics Individual offices Outpatient PT/OT/SLP Therapy Review Exclusions Precertification of therapy services provided to beneficiaries is not required: Beneficiaries who are residents of a nursing facility regardless of setting. Beneficiaries who are residents of intermediate care/mental retardation facilities (ICF/MR) regardless of setting. Beneficiaries in hospice regardless of setting. Beneficiaries in a Home and Community Based Service (HCBS) waiver program. Therapy Services billed by a school provider. Beneficiaries covered under both Medicare and Medicaid if Medicare benefits have not been exhausted. Staff at HSM HSM's clinical staff, composed of registered nurses, physical and occupational therapists, and speech-language pathologists and physicians make certification review determinations on review requests for outpatient services as described below: Staff Registered Nurses Functions Apply DOM policy Apply explicit medical review criteria Apply quality of care screens Approve services based on policy or criteria, or Refer requests that cannot be approved for physician determination Make determinations based on medical practice standards and his or her clinical experience and judgment Perform reconsideration reviews for any denial decisions Screen the request for completeness of non-clinical information Perform verbal notification of review determination, as appropriate Support all review functions

Therapists

Physician Reviewers

Non-clinical Support Staff

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HealthSystems of Mississippi Overview of the review process (A flow chart of the process is included for your reference).

Provider Manual

Providers submit a request to HSM in accordance with specific timeframes based on the Review Type. (Timeframes are provided in the Review Types and Submission Procedures section of this manual.) HSM will notify the requester when a request is incomplete or if additional administrative information is required and allow specific timeframes for submission of the information. If the requested information is not submitted, HSM will issue a Technical Denial. Upon receipt of a complete precertification request and all required administrative documentation, HSM's registered nurse and therapist reviewers assess the request for completeness of clinical information. If additional clinical information is required, the review request will be pended and the information will be requested from the provider. If the requested information is not submitted, HSM will end (suspend) review of the request. Upon receipt of complete clinical information, HSM's registered nurse and/or therapist reviews the clinical information and determines whether the requested services meet DOM's Policy, whether medical necessity criteria is met, and whether potential quality of care concerns are present. · The nurse or therapist may approve (certify) services that meet DOM policy and medical review criteria. · Request for services that do not meet DOM policy or medical review criteria are referred for physician review. · Every request is screened for quality of care. See the Quality Screening policy and procedure. · Physician reviewers review the requests for service that are referred by registered nurses or therapists. · The physician reviewer may approve (certify) services as requested, may modify the request, or may deny all or part (partial denial--retrospective only) of the requested services. · Prior to making a denial determination, HSM's physician reviewer attempts to contact the prescribing provider to discuss the case. · Written and verbal (if the provider is unable to receive auto-fax) notification of approval review results is sent to providers. Denial determinations are sent to the beneficiary/representative, and providers. · Any party to a denial may request reconsideration of the determination as described in HSM's Reconsideration Process policy and procedure. · If HSM upholds the denial on reconsideration the beneficiary can then request an Administrative Appeal from DOM. (See the Reconsideration Process section of this manual for additional information.)

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HealthSystems of Mississippi

Request for Certification

Provider Manual

Screening for completeness of information

Complete?

No

Request information (Pend)

Information Received

No

Technical Denial

Yes

RN Screens information against criteria

Yes

Information Recevied Re-open

Meets criteria?

No

Physician Review

May contact prescribing provider to ask for additional information Yes

Information Received

No

Technical Denial

Yes

Certification decision

Makes determination

Yes

Services certified?

- Data entry of determination - Number of visits and timeframe assigned - TAN assigned if appropriate (initial review only)

No

Denial

Verbal and written notification

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HealthSystems of Mississippi Submitting a Review Request to HSM

Provider Manual

Prior to submitting a review request to HSM, the provider must verify the beneficiary's eligibility for Medicaid by contacting the Division of Medicaid's fiscal agent. It is the responsibility of the Medicaid provider to verify a Medicaid beneficiary's eligibility each time the beneficiary appears for a service. In addition to verifying the beneficiary's eligibility, the following age specifications need to be verified prior to submitting a request to HSM. Age Specifications Children and adolescents are covered through the last day of the birthday month of the year they reach twenty-one (21). Medicaid covers infants born to a mother who is Medicaid eligible at the time of the baby's birth through the first year of life provided he/she remains in the household of the mother. These requests may be submitted under the mother's Medicaid number with a "K" suffix until the baby is assigned its own number. The baby is covered for one year after birth even if the mother loses her eligibility. Adults (age 21 and older) are eligible for outpatient PT/OT/SLP services when therapy services are determined to be medically necessary and performed in the hospital outpatient setting. Once eligibility and age specifications have been verified, a review request may be submitted to HSM. The following table describes the review types and the procedures to follow for submitting each review type to HSM. Specific timeframes have been established for submission of review requests to HSM. It is imperative that the requesting provider submits the required documentation to HSM at the same time as and along with the completed Certification Request Form.

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Review Types and Submission Procedures Review Type Procedures Submit the following to HSM: Initial precertification request: Outpatient PT/OT/ SLP providers should HSM Medicaid Outpatient PT/OT/SLP submit this type of request at least 3 Precertification Request Form. business days prior to initiation of Certificate of Medical Necessity (CMN) outpatient services and after the evaluation Form visit. HSM Evaluation/Re-Evaluation Form HSM Plan of Care (POC) Form In rare instances where urgent or same day/non-urgent PT/OT/SLP services are provided the following applies: Outpatient PT/OT/SLP providers are required to request certification on the next business day. Business days are defined as Monday through Friday, excluding official state holidays. Concurrent Request: Outpatient Submit the following to HSM: PT/OT/SLP providers should submit this HSM Medicaid Outpatient PT/OT/SLP type of request when prior services have Certification Request Form. been certified and additional services are Current POC (dated within the last 6 needed. The request should be submitted months) Documentation of patient's on or before the last certified day. progress toward achieving goals or modification of goals (this should be reflected in the POC). If a re-evaluation has been performed, submit a completed HSM Evaluation/Reevaluation Form for review and an updated HSM POC form. Therapy notes from the last visits prior to request for concurrent review.

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Review Types and Submission Procedures (continued) Review Type Procedures Submit the following to HSM: Retrospective Review: Outpatient HSM Medicaid Outpatient PT/OT/SLP PT/OT/SLP providers should submit this Precertification Request Form. The type of request when the beneficiary was PT/OT/SLP provider must clearly state the not eligible at the time of admission but reason for the retrospective review on the has since received a retroactive eligibility request form. status. A copy of the complete outpatient PT/OT/SLP medical record including HSM will conduct retro review of cases therapy notes. with dates of service older than (1) year ONLY in the following situations: The patient's Medicaid eligibility was retroactively established and the request for certification was received within (1) year of the eligibility determination date. The patient was determined to be retroactively Medicaid eligible at the time of admission and the outpatient PT/OT/SLP provider submits proof that the claim was filed with the fiscal agent in a timely manner by submitting the Transaction Control Number (TCN) assigned to the claim. If all or parts of the requested services are denied during retrospective review, the provider has the right to request a reconsideration of the denied services. NOTE: Cases not meeting the above criteria are not eligible for certification and should not be submitted to HSM for review.

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Provider Manual

The following table depicts the timeframes and documentation requirements for submitting a request for services. Precertification, Concurrent and Retrospective Review Timeframes Activity Timeframes Admission Request must be received at least three (3) working days prior to initiation of service ­after evaluation completed Continued Stay Request must be received on or before the last certified day Retrospective Only done when beneficiary was not Medicaid eligible at the time therapy was provided. Within one (1) year of the retroactive Medicaid eligibility determination Within one (1) business day of HSM's request for additional information Close of business on the working day that the additional information is due and not received (Given one (1) day to submit) Within two (2) business days of receipt of review request and all necessary information Within one (1) business day of verbal notice Within ten (10) business days of receipt HSM's request for additional information

Provider will submit a request to HSM

Length of time provider given to submit additional information HSM will issue a Technical Denial

Within three (3) business days of HSM's request for additional information Close of business on the working day that the additional information is due and not received (Given three (3) days to submit) Within two (2) business days of receipt of review request and all necessary information Within one (1) business day of verbal notice

Close of business on the working day that the additional information is due and not received (Given ten (10) days to submit) Within twenty (20) business days of receipt of all necessary information

Written and verbal (if no auto-fax) notification to provider of review determination Written notification to provider of review determination

Within one (1) business day of verbal notice

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Notices of Review Outcome Written notifications of approval review determinations are sent to outpatient PT/OT/SLP providers. Review determinations involving denials are sent in writing to the beneficiary/ representative, outpatient PT/OT/SLP provider, and the prescribing provider. Note: The beneficiary/representative's notice will not contain the medical basis for the denial. Notices of review outcome include the following information, based upon timing of the review. Type of Review Outcome Approval

Information Date of notice Brief statement of HSM's authority and responsibility for review Reason for determination and/or modification Date(s) of service being approved Type service or procedure certified Number of units certified Total number & type procedures or services certified to date Time span Total time span approved to date Treatment Authorization Number (TAN)

Precert

Concurrent

Retro

Information contained in review denial notifications is contained in the table on the following page.

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Type of Review Outcome Denial

Information Date of notice Brief statement of HSM's authority and responsibility for review Principal reason and clinical rationale for denial Type of procedures or services, number of units, and dates of services being denied Denial start date Total number and time span for previously certified procedures or services Process for requesting a peer-topeer conversation by the prescribing provider or OP PT/OT/SLP provider Process for submitting a reconsideration Reconsideration timeframes May include approved number of days (partial approval)

Precert

Concurrent

Retro

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Outpatient Physical, Occupational and Speech Therapy: Reconsideration Process Objective: To provide the opportunity to request and receive reconsideration of utilization review denial determinations if any of the following parties disagrees with the determination. Beneficiary/representative Outpatient physical, occupational or speech therapy provider Prescribing Provider A request for reconsideration may be submitted to HSM by telephone (601) 360-4875, fax, or mail. The beneficiary/representative may submit any type of written request for reconsideration. HSM has developed a reconsideration form that the provider, or prescribing provider may use to submit a request for reconsideration review. HSM offers two types of reconsiderations, however, only one type of reconsideration of a denial determination is available for each review. Types of Reconsideration requests and timeframes to submit request for review: Expedited Standard Within three (3) business days of denial notice Within thirty (30) calendar days of denial notice

For standard reconsiderations HSM allows ten (10) business days for submission of additional information. Reconsideration review is then performed whether or not additional information was submitted. HSM ensures that the physician reviewer performing the reconsideration review is not the physician reviewer that originally reviewed and denied the request. Timeframe of completion of Reconsideration review by HSM: Expedited Standard Within one (1) business day Within twenty (20) business days

If there is still disagreement with HSM's reconsideration determination, the beneficiary has the right to request an Administrative Appeal through DOM, in writing, within thirty (30) calendar days of HSM's reconsideration review determination notice. The process for requesting an Administrative Appeal is included in the denial notice that is sent to the beneficiary/representative, as well as a statement informing the provider that the beneficiary has the right to request an Administrative Appeal through DOM.

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HealthSystems of Mississippi Quality Review Activities

Provider Manual

The Mississippi Division of Medicaid (DOM) requires review of the quality of care provided to Medicaid beneficiaries receiving outpatient physical, and occupational therapy, and speech-language pathology services. Quality of care review will be conducted during precertification, concurrent, and retrospective review as well as through a randomly selected 5% Quality Sample of cases certified by HSM. Objectives of Quality Review Ensure care provided to Medicaid beneficiaries meets professionally recognized standards of care Ensure that information provided to HSM during certification is substantiated by the complete medical record during sample review Notify healthcare providers of confirmed quality issues identified during the review process Provide a mechanism for providers to request a re-review of confirmed quality issues Work with healthcare providers to remedy identified patterns of quality/utilization problems through education and other interventions. Report suspected fraud and/or abuse to DOM Quality Review Program Components Quality Screening Process 5% Random Quality Sample Quality Re-review Process Quality Intervention Process Criteria for Quality Intervention Committee (QIC) Review Quality Screens/Indicators Note: A flow chart of the quality review process is included for your reference. Quality Review Staff Quality review will be performed during the certification process by registered nurses, physical and occupational therapists, speech language pathologists, and physicians. Registered Nurses (RNs) perform quality review for the 5% Quality Sample. HSM's Quality Intervention Committee (QIC) uses an established process as a means to analyze, identify, and remedy the causes of the confirmed quality issues. The QIC reviews providers with identified patterns of quality and utilization problems through profiling and analysis of confirmed quality issues. This committee works collaboratively with healthcare providers to remedy aberrant practices through education and other interventions to improve patient safety and quality of care.

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HealthSystems of Mississippi Staff Registered Nurses for utilization

Provider Manual Functions Apply quality screens Refer failed quality screens to physicians for review If resolved, will document physician's finding Report suspected fraud and/or abuse to DOM Apply quality screens Determine if information submitted to HSM during the certification process is substantiated by the medical record (5% sample) Refer failed quality screens to physicians for review If a quality issue is confirmed, the physician's findings are documented and a provider notice is generated Process requests for quality re-review and refer to physicians Report suspected fraud and/or abuse to DOM Apply quality screens Determine if potential quality issue(s) is resolved or confirmed If confirmed, will document source of problem, severity level, appropriate action that should have been taken, and rationale for determination Review the request for quality re-review and resolve or reconfirm issues Report suspected fraud and/or abuse to DOM Review medical records for a particular provider identified through the established profiling system Make recommendations for specific interventions Communicate recommended interventions to providers via certified restricted delivery mail Monitor effectiveness of interventions Communicate intervention activities to DOM

Therapists Registered Nurses for 5% Sample

Physician Reviewers

Quality Intervention Committee

Overview of the Quality Screening Process HSM applies quality screens/indicators to all certification review requests submitted by outpatient therapy providers. Quality screens are failed; the review is referred to the physician reviewer. The physician reviewer makes a determination to confirm or resolve the potential quality issue(s). The physician reviewer also applies the quality screens during review to identify any other existing quality issues. The physician reviewer documents the rationale for the determination and, if confirmed, documents the source of problem, severity level, and the appropriate actions that should have been taken. Effective 07/01/05 Revised: 11/08/06 Outpatient Physical, Occupational and Speech Therapy Quality Review Activities Page VI-2 of 2

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Provider Manual

If any issue is confirmed, a quality/utilization issue letter of notification is sent to the identified source of problem. Quality/Utilization Issue Notices contain the following information: · Brief case summary · Description of the quality issue(s) · Source of problem (SOP) · Severity level · Appropriate action that should have been taken · Process for requesting a re-review and timeframes for doing so Overview of the 5% Quality Sample Process HSM issues written requests on the first business day of each month to those providers selected for the random 5% sample review . The request will include an inventory tracking sheet to be returned with the medical record to HSM to identify the review type being submitted Providers must submit copies of the complete medical record requested to HSM within twenty (20) calendar days. HSM will make two (2) attempts to obtain the medical record. HSM will notify DOM of providers who are non-compliant with submitting requested medical records The RN applies the quality screens to the entire medical record and verifies that the medical record substantiates the information submitted during certification review. If the information submitted during certification review is not substantiated by the record, it is documented and later profiled for trends or patterns reportable to DOM. The same process is followed as described above in quality screening if the RN identifies a failed quality screen(s). Overview of Quality Re-Review Process Any provider who receives a quality/utilization notification letter and disagrees with the determination has the opportunity to request and receive a re-review of the determination. The provider must submit in writing a request, which contains the reason the provider disagrees with HSM's determination and any additional information, which might assist in resolving the issue. The request must be submitted within thirty (30) calendar days of HSM's notice via fax or mail. Note: An HSM Quality Re-Review Request Form and instructions are included in this manual for provider use. HSM conducts re-reviews for all timely requests and will make a decision to perform re-review on a case-by-case basis for untimely requests. Re-reviews will be performed whether or not additional information is supplied. Effective 07/01/05 Revised: 11/08/06 Outpatient Physical, Occupational and Speech Therapy Quality Review Activities Page VI-3 of 3

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HSM ensures that the physician reviewer performing the re-review is a different reviewer than the initial reviewer. HSM will render a re-review determination within thirty (30) calendar days of receipt of the request for re-review. HSM issues written notice of the re-review determination to the involved provider within ten (10) business days of the determination date. Written notices for resolved and/or confirmed quality issues will contain the following information: · Brief case summary · Description of the quality issue(s) · Rationale for resolving the issue(s) · Rationale for reconfirming the issue(s) · If reconfirmed also includes: - Source of problem (see glossary) - Severity level (I, II, or III ­ see glossary) - Appropriate action that should have been taken Overview of Quality Intervention and Quality Intervention Committee (QIC) Processes Quarterly profiles are generated and analyzed using the following criteria to determine which providers are to be reviewed at the QIC level for possible intervention. All Severity Level III Cases Frequency of occurrence ­ eight (8) or more issues identified for a source of problem during a quarter period Weighted Severity Level Scoring (WSLS) ­ ten (10) or more points identified for a source of problem during a quarter period. The means of calculating the WSLS: a. Each Severity Level I confirmed issue b. Each Severity Level II confirmed issue c. Each Severity Level III confirmed issue = 1 point = 5 points = 25 points

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HealthSystems of Mississippi For example, for each SOP reported on a quarterly profile: Provider (or Physician) # 000000 3 Level I issues X 1=3 0 Level II issues X 5=0 0 Level III issues X 25=0 Total WSLS for quarter: 3

Provider Manual

Note: A" case" is defined as each certification period for outpatient therapy services. In the instance where a single case has multiple confirmed quality issues for a single source of problem, and they fall into more than one (1) severity level, the issue with the highest severity level is used to calculate the weighted severity level score for that source of problem. Example: If Patient A's outpatient therapy services of 3/20/04 through 4/20/04 had two (2) confirmed quality problems with the same assigned source of problem, one a level II and one a level III, the level III case is used to calculate the weighted severity level score. When the case is reviewed by the QIC, the QIC will consider all confirmed issues, whether used in WSLS calculation or not, when determining the appropriate intervention. Cases that meet the criteria for QIC review are grouped according to the source of problem. These cases are commissioned to physician reviewers for review to identify patterns and trends, review prior interventions, and make recommendations for the most appropriate intervention. Types of interventions include: Educational notices Telephonic consultation Requests for process improvements Requests for corrective action plans Requests for root cause analysis Requests for meeting at HSM with Medical Director and Quality Manager to discuss remedies for identified problem(s) Notification to Division of Medicaid as deemed necessary Focused reviews or studies Providers should submit the requested response to HSM within the timeframe identified in the written notice. The QIC will evaluate the response for appropriateness and notify the provider if approved and/or if modifications or recommendations are made by the QIC. Because quality review is an ongoing process, HSM's QIC will continue to monitor the effectiveness of those interventions.

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Provider Manual

Quality of Care Review and Intervention Timeframes Activity Timeframe 5%Sample ­ outpatient therapy providers submit Within 20 days of notification. medical records for cases selected for review. Initial screening of cases for quality or utilization Completed within 20 days of receipt of the medical record. concerns by quality review nurse. PR review to determine if a confirmed problem exists. Send Notice of Quality/Utilization Issue to involved party. Re-review process ­ Involved party requests review of the determination. Within 40 days of receipt of the medical record. Within 10 calendar days of the PR's determination.

Within 30 days of the date of the Notice of Quality/Utilization Issue Re-review of cases by a PR. Completed within 30 days of request Send Notice of Re-review Determination to involved Within 10 calendar days of the party. PR's determination For quality concerns identified by RNs during When a concern is identified precertification or concurrent review, which would impede the authorization process, HSM reviewers flag the case for immediate review by medical director or PR designee. Medical director or PR phones involved party to Determination made within 24 discuss concern and make a determination as to the hours of receipt of complete existence of a problem and regarding authorization information of services. Verbal and written notification of the authorization Within 24 hours of receipt of and quality problem provided to appropriate parties. complete information for certification. Within 10 days of confirmation of the issue by the PR If additional information is required to make a Provider or facility has 24 hours determination, the Medical Director will make the to provide this information request to the appropriate party PR reviews additional information and makes a Within 24 hours of receipt of determination regarding authorization and existence complete information of problem Hotline provided for beneficiaries and providers. Monday through Friday, from 8 a.m. to 5 p.m. Complaint or concern regarding quality or utilization Information to be sent within 10 of care received ­ request all medical information. days of request Case given to quality review nurse to review as See 5% quality sample review outlined in the 5% sample. process Effective 07/01/05 Revised: 11/08/06 Outpatient Physical, Occupational and Speech Therapy Quality Review Activities Page VI-6 of 6

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Quality of Care Review and Intervention Timeframes Activity Timeframe Generate profiles for each prescribing provider, each Every quarter facility, and statewide to include Quality review results and other review results for most recent quarter and cumulative results up to the previous four monitoring quarters. Quality Intervention Committee meets to make Meets monthly, but may determinations regarding who requires intervention teleconference more often if and the appropriate interventions. necessary Once determination made, the quality manager and Within 15 working days of the staff generate letters to all involved parties outlining QIC's determination the QIC's request for action plans. Involved parties submit corrective action plan to Within 30 days of the notification HSM. The QIC reviews the action plans received for Within 15 working days of feedback and approval. Send notice of acceptance approval by the QIC outlining recommended changes. Quality manager performs follow-up monitoring to As often as necessary but at least determine effectiveness of interventions in quarterly remedying aberrant practices. If interventions are ineffective, QIC makes As necessary determinations to modify the intervention and/or submit a written case summary to DOM of the practices including the quality problem, interventions and current practices.

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HealthSystems of Mississippi Quality Review Process

Provider Manual

Registered nurse use quality screens/ indicators to identify potential quality issue during precert, concurrent, retro or 5% quality sample review, or hotline.

PR identifies and confirms a quality issue during precert, concurrent, retro, or 5% quality sample review.

Potential issue identified.

Referred to PR for review

Quality issue confirmed

Yes

Quality issue letter issued to involved party(s)

No

Case filed in medical records as non-quality issue

Case filed as quality issue

DOM receives a report of all confirmed issues. QIC referral depends on quarterly profiling with issue weighting and intervention

No

Request for rereview received

Peer PR reviews request and any additional information

Re-review determination is sent to all involved party(s)

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HealthSystems of Mississippi

Provider Manual

Outpatient Physical, Occupational, and Speech Therapy Quality of Care Screen Indicator Application of Screen OP. 1. There is documentation of Review of required comprehensive evaluation. adequate assessment of a patient Documentation of assessment of rehabilitation before or at time of admission to potential to include physical limitations. determine if the patient meets Description of cognitive functioning and prerequisites for outpatient therapy motivation for treatment. services. Appropriateness of outpatient setting- document if setting is different than in evaluation report. Documentation of status of receptive/expressive language, articulation, voice fluency, oral-motor abilities, feeding/swallowing skills, hearing ability, fined motor skills and vision. Documentation of cognitive/orientation skills as applicable. Documentation of patient's communication needs and motivation for treatment. Documentation of prescribing provider's order on CMN form for consultation of PT/OT/SLP for evaluation. OP. 2. The treatment plan is The length of the individual therapeutic service is appropriate for the diagnosis. reasonable to complete the goals of the therapy Outcome based, measurable goals for the diagnosis. specific to therapy required by the This screen fails if: patient are included in treatment plan. · The therapist provides services that are contraindicated or not indicated for the diagnosis without supporting documentation. · The therapist does not provide indicated services for the diagnosis. Goals must be measurable. Goals must be reasonably achievable for course of treatment. Documentation of problems encountered or changes in treatment plan or goals. OP. 3. Standardized test Examples/accepted measurements: measurements are administered at the Muscle testing beginning of treatment and reRange of motion measured at appropriate intervals Wee FIM or FIM (Functional Independence during course of treatment. Measure) Developmental tests Motor test such as Bruinicks test of motor proficiency Endurance levels Criterion referenced assessments Standardized assessments Modified barium swallow studies as ordered by Effective 07/01/05 Revised: 11/08/06 Outpatient Physical, Occupational and Speech Therapy Quality Review Activities Page VI-9 of 9

HealthSystems of Mississippi

Provider Manual

Outpatient Physical, Occupational, and Speech Therapy Quality of Care Screen Indicator Application of Screen MD. OP. 4. Treatment plan was followed Documentation of therapy must be exactly as as ordered for course of therapy. ordered in prescribing provider's treatment plan prescribing: · type · amount · frequency and duration of therapy · diagnosis and anticipated goals, and · the reason treatment is not indicated. Treatment verified by therapist signature and date Any change in treatment requires prescribing provider's order. Plan of Care approved by prescribing provider before therapy begins and signed within thirty (30) days. Patient's response to treatment is documented. OP. 5. Therapist documents patient Evidence of patient teaching including case and/or parent (caregiver) education conference. Documentation of patient/parent/caregiver response to teaching (i.e. return demonstration). OP. 6. Home Exercise Program Return demonstration of home program by (HEP) includes: patient/caregiver. Home program that models the Determine if there is a need for increased therapy education or change in program through Documentation of instruction and discussion on follow through at home. verbalization of understanding. OP. 7. Orthotics and Prosthetics Example: (O&P) ordered has: Splint/braces should have documentation of need Documentation of reason O&P for use, instruction of proper use and care, plan needed by the patient. for follow up. Treating therapist experienced and Assessment performed by speech/language knowledgeable of O&P. pathologist with input of either OT or PT to Physician order for such O&P. address motor issues. Caregiver/patient trained in proper use of O&P. Augmentative communication assessment performed. Documentation of justification by diagnosis of need for custom fabrication of O&P /supplies. OP. 8. Discharge plan is documented. Therapist documents discharge plans beginning with initial treatment. Therapist documents progress towards discharge. Effective 07/01/05 Revised: 11/08/06 Outpatient Physical, Occupational and Speech Therapy Quality Review Activities Page VI-10 of 10

HealthSystems of Mississippi Glossary

Provider Manual

Appeal: A grievance process for resolving disputes. A beneficiary/ representative may request and obtain an Administrative Appeal of an HSM denial determination that was upheld or modified through HSM'S reconsideration process. Beneficiary: An individual eligible for medical assistance in accordance with state's Medicaid Program and who has been certified as eligible by the appropriate agency and has received services. Certification: Authorization of services by HSM for Medicaid covered services. Concurrent Certification Reviews: A review that is performed after the initial review and during a beneficiary's treatment to determine the medical necessity and appropriateness of continuing the beneficiary's treatment. Comprehensive Evaluation: Before therapy is initiated, an evaluation of the beneficiary's medical condition, disability and level of functioning must be performed to determine the need for treatment. When a need for treatment is determined, a treatment plan must be developed. Criteria: Predetermined elements of health care, developed by health professionals relying on professional expertise, prior experience, and the professional literature, with which aspects of the quality, medical necessity, and appropriateness of a health care service may be compared. Denial Determination: A negative decision by a professional review organization, regarding the medical necessity, quality, or appropriateness of health care services furnished, or proposed to be furnished to a beneficiary. Modification: Any limit or change to a certification request. Pend: Status assigned to a review request by HSM when additional information necessary to complete the review process is required. HSM informs the provider of the need for the information and allows a specific timeframe for submission. Plan of Care: A written plan describing the treatment proposed for each Medicaid beneficiary. Precertification: Authorization of services by HSM prior to the date and or time the services are to begin. Provider: Person, entity, or facility enrolled in the Medicaid program, renders services to Medicaid beneficiaries, and bills Medicaid for services.

Effective 07/01/05 Revised: 11/08/06

Outpatient Physical, Occupational and Speech Therapy Glossary Page VII-1 of 1

HealthSystems of Mississippi

Provider Manual

Quality Assurance Review: An assessment of patient care conducted by HSM for the purpose of improving patient care through peer analysis, intervention, resolution of the problem and follow-up. Quality Re-review ­ due process offered to providers when there is disagreement with any confirmed quality issue identified by HSM. Reconsideration: The review of an adverse determination previously rendered by HSM, requested by a provider or beneficiary/representative. Retrospective Review: A review that is conducted after services are provided to a beneficiary. The review is focused on determining the appropriateness, medical necessity, quality of care, and reasonableness of healthcare services provided. Same Day/Non-Urgent: The delivery of therapy services that do not meet the definition of urgent, but completion of services on the same day as the evaluation significantly impacts the beneficiary's treatment (example: therapeutic activities, such as the use of crutches, on the same day as diagnosis/treatment of leg fracture). Severity Level ­ all confirmed problems are assigned a severity level according to the significant adverse effect to the patient. There are 3 levels: Level I ­ a confirmed quality problem with minimal potential for significant adverse effect to the patient. Level II ­ a confirmed quality problem with the potential for significant adverse effect to the patient. Level III ­ a confirmed quality problem with significant adverse effect to the patient. Significant Adverse Effect ­ unnecessarily prolonged treatment, complications, readmissions, or patient management that results in anatomical or physiological impairment, disability, or death. Source of Problem ­ a provider deemed responsible for a confirmed quality problem (i.e., therapist, physician, physician assistant, nurse practitioner, outpatient facility) Suspend: Act of discontinuation of certification review of a request for services because additional information was not received by HSM in the timeframe allocated. Technical Denial: A denial issued when no medical record or insufficient information to make a determination is provided for review. Treatment Authorization Number (TAN): Approval number that the provider uses to seek payment from the fiscal agent.

Effective 07/01/05 Revised: 11/08/06

Outpatient Physical, Occupational and Speech Therapy Glossary Page VII-2 of 2

HealthSystems of Mississippi

Provider Manual

Urgent Care: The delivery of therapy services resulting from the sudden onset of a medical condition or injury requiring immediate care and manifesting itself by acute symptoms of sufficient severity such that the absence of therapy could result in immediate: hospitalization, moderate impairment to bodily function, serious dysfunction of any bodily organ or part or other serious medical consequences.

Effective 07/01/05 Revised: 11/08/06

Outpatient Physical, Occupational and Speech Therapy Glossary Page VII-3 of 3

HealthSystems of Mississippi THERAPY CERTIFICATION CODE LIST

Provider Manual

These codes require precertification for certain providers for dates of service beginning January 1, 2006.

Procedure Code

64550 92506 92507 92508 92526 92597 92626 92627 92630 92633 92700 95831 95832 95833 95834 95851 95852 97001 97002 97003 97004 97010 97012 97014 97016 97018 97022 97024 97026 97028 97032 97033 97034 97035 97036 97039

Description

Application of surface (transcutaneous) neurostimulator Evaluation of speech, language, voice, communication, and or auditory processing Treatment of speech, language, voice, communication, and/or auditory processing disorder, individual Treatment of speech, language, voice, communication, and/or auditory processing disorder group, 2 or more individuals Treatment of swallowing dysfunction and/or oral function for feeding Evaluation for use and /or fitting of voice prosthetic device to supplement oral speech Evaluation of auditory rehabilitation status, first hour Evaluation of auditory rehabilitation status, each additional 15 minutes (list separately in addition to code for primary procedure) Auditory rehabilitation; pre-lingual hearing loss Auditory rehabilitation; post-lingual hearing loss Unlisted otorhinolaryngological service or procedure Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk Muscle testing, manual (separate procedure) with report; hand, with or without comparison with normal side Muscle testing, manual (separate procedure) with report; total evaluation of body, excluding hand Muscle testing, manual (separate procedure) with report; total evaluation of body, including hand Range of motion measurements and report (separate procedure); each extremity (excluding hand) or each trunk section (spine) Range of motion measurements and report (separate procedure); hand, with or without comparison with normal side Physical therapy evaluation Physical therapy re-evaluation Occupational therapy evaluation Occupational therapy re-evaluation Application of a modality to one or more areas; hot or cold packs Application of a modality to one or more areas; traction, mechanical Application of a modality to one or more areas; electrical stimulation (unattended) Application of a modality to one or more areas; vasopneumatic devices Application of a modality to one or more areas; paraffin bath Application of a modality to one or more areas; whirlpool Application of a modality to one or more areas; diathermy (e.g., microwave) Application of a modality to one or more areas; infrared Application of a modality to one or more areas; ultraviolet Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes Application of a modality to one or more areas; iontophoresis, each 15 minutes Application of a modality to one or more areas; contrasts baths, each 15 minutes Application of a modality to one or more areas; ultrasound, each 15 minutes Application of a modality to one or more areas; Hubbard tank, each 15 minutes Unlisted modality (specify type and time if constant attendance)

Effective 01/01/06 Therapy

Outpatient Physical, Occupational and Speech

Codes Requiring Precertification

Page VIII -1

HealthSystems of Mississippi

Procedure Code Continued

97110 97112

Provider Manual

Description Continued

97113 97116 97124 97139 97140 97150 97530 97532

97533

97542 97750 97760 97761 97762 97799

Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities Therapeutic procedure, one or more areas, each 15 minutes; aquatic therapy with therapeutic exercises Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing) Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) Therapeutic procedure, one or more areas, each 15 minutes; unlisted therapeutic procedure (specify) Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes Therapeutic procedure(s), group (2 or more individuals) Therapeutic activities, direct (one on one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes Development of cognitive skills to improve attention, memory, problem solving, (includes compensatory training), direct (one-on-one) patient contact by the provider, each 15 minutes Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes Wheelchair management (e.g., assessment, fitting, training), each 15 minutes Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s), and/or trunk, each 15 minutes Prosthetic training, upper and/lower extremity(s), each 15 minutes Checkout for orthotic/prosthetic use, established patient, each 15 minutes Unlisted physical medicine/rehabilitation service or procedure

Effective 01/01/06 Therapy

Outpatient Physical, Occupational and Speech

Codes Requiring Precertification

Page VIII -2

HealthSystems of Mississippi 175 E. Capitol Street Suite 250, Lockbox 13 Jackson, MS 39201

Patient's Information Patient/Baby Name: _________________________________ Medicaid #: Date of Birth: Age:

HealthSystems of Mississippi Medicaid Outpatient Physical/Occupational/Speech Therapy Precertification Request Form

I. Beneficiary Information K-Baby Checkbox and Complete Below: K-Baby - Check Here and complete the following: Mother's Name: _______________________________________ Mother's Date of Birth:

Yes

/

Sex:

/

(M or F) No

/ / /

/ /20 /20

Is patient also receiving therapy in any other setting?

Date of Last MD/NP/PA Appointment: Date of next scheduled MD/NP/PA appointment:

If yes, record Place of Service Code:

II. Provider Information Request Date:

/

/20

Record intended Place of Service Code: Referring MD/NP/PA Name: _______________________

MS Medicaid Provider #: Provider/Facility: ______________________________

MS Medicaid #:

Contact/Requestor:____________________________________ Telephone #:(_____) _________ -___________ Ext._________ Fax #: (_____) _________ -_________________ Telephone #: (____) ______-________ Ext. ___________ Services to be provided by:

MD/NP/PA Licensed Therapist PTA/COTA Other (List)_______________________________________ III. Request Type - Select one Concurrent - Attach a copy of current Plan of Care, Reevaluation (if

applicable), notes from last visit and documentation of progress toward goals.

Precertification ­ Attach CMN, Initial Evaluation Form, and

Plan of Care Form

Evaluation Visit Date: Next Planned Visit Date: No Additional Visits Planned

/ /

/20 /20

Existing Certification #: Last Service Date Authorized: Date of Next Planned Visit:

/ /

/20 /20

Urgent Evaluation Visit Date: Next Planned Visit Date:

Same Day/Non-Urgent

Retrospective Review Patient's Medicaid eligibility became effective retroactively during treatment or after discharge. Record TCN (If applicable): _______________________________ Reason for submitting retrospective review:

/ /

/20 /20

No Additional Visits Planned

If patient seen on "urgent" basis prior to precertification by HSM, also provide information about the urgent nature of the care.

_____________________________________________________ _____________________________________________________ _____________________________________________________

______________________________________________ ______________________________________________ __________________________________________________

Complete this form and attach a copy of the complete medical record, including all therapy notes.

Revised: 06/27/06

Page 1 of 2

HealthSystems of Mississippi Medicaid Outpatient Physical/Occupational/Speech Therapy Beneficiary Name: __________________________________ Medicaid #: IV. Requested Therapy Units Type Procedure/ Modality CPT Code Per Visit Frequency Total

(# per week, day, month)

Duration

(# of weeks, days, months)

Dates of Service From Thru

A therapy provider who knowingly or willfully makes, or causes to be made, false statement or representation of a material fact in any application for Medicaid benefits or Medicaid payments may be prosecuted under Federal and State criminal laws and/or may be subject to civil monetary penalties and/or fines. I certify that, as a therapy provider, a Certificate of Medical Necessity for therapy services has been received from the prescribing provider (physician/nurse practitioner/physician assistant) for the above named beneficiary listed in Section I of this Pre-certification Request Form. I certify that the plan of care has been reviewed with and approved by the prescribing provider in Section II of this same form. I certify that the exact therapy services listed above are those approved by the prescribing provider. I understand that therapy services requested on this form are subject to review and approval through the Division of Medicaid's Utilization Management and Quality Improvement Organization. I understand that any falsification, omission, or concealment of material fact may subject me to civil monetary penalties, fines, or criminal prosecution, or may automatically disqualify me as a provider of Medicaid services.

Signature of (Therapy) Provider: __________________________________________ Date: __________________

Mississippi Medicaid Disclaimer Statement HealthSystems of Mississippi's certification determination does not guarantee Medicaid payment for services or the amount of payment for Medicaid services. Eligibility for and payment of Medicaid services are subject to all terms and conditions and limitations of the Medicaid program.

Revised: 06/27/06

Page 2 of 2

Instructions For Completing the HealthSystems of Mississippi Outpatient Physical/Occupational/Speech Therapy Precertification Request Form

Section I

Beneficiary Information

1. Patient Name - Enter the patient's last and first name as it appears on the Mississippi Medicaid ID card. If the beneficiary is a K baby, list baby's name. 2. Medicaid # - Enter the beneficiary's number that appears on the Mississippi Medicaid ID card. 3. Date of Birth ­ Enter the month, date, and year of the patient's birth. 4. Age - Enter the age of the patient at the time service is to be rendered. 5. Sex - Indicate the sex of the patient. 6. K-Baby - Indicate if the patient is a K-baby. 7. Mother's Name - Enter the full name of the K baby's mother. 8. Mother's Date of Birth - Enter the month, date, and year of the mother's birth. 9. Therapy in other setting ­ Indicate either yes or no if the patient is receiving therapy in any other setting. 10. Place of Service Code ­ If the patient is receiving therapy in another setting, indicate the place of service code. 11. Last Physician, Nurse Practitioner, or Physician Assistant's Visit ­ Enter the date of the last visit with the practitioner's. 12. Next Scheduled Physician, Nurse Practitioner, or Physician Assistant's Appointment ­ Enter the date of the next scheduled practitioner's appointment.

Section II

1. 2. 3. 4. 5. 6. 7. 8.

Provider Information

Request Date ­ Record the date of the request. Medicaid # - Enter the provider's Mississippi Medicaid Provider Number. Provider Name - Enter the name of the provider that will provide the care. Contact /Requester - Enter the name of the individual who is primary contact for this case. Telephone # - Enter the contact person's telephone number, including area code and extension. Fax # - Enter the provider's contact fax number, including area code. Intended Place of Service Code ­ Indicate the intended place of service code. Ordering Physician, Nurse Practitioner, or Physician Assistant ­ Indicate the name of the ordering MD/NP/PA. 9. Telephone # - Indicate the telephone number of the ordering MD/NP/PA. 10. Services to be Provided By ­ Indicate the type of provider that will provide therapy services.

Section III

Request Type

1. Precertification - If the request is for precertification, insert the following: A. Date of Evaluation Visit - Enter the date of initial evaluation visit provided to patient. B. Date of Next Planned Visit - Enter date of the next scheduled visit to provide therapy service to patient. C. No Additional Visits Planned ­ Indicate if patient does not qualify for or need additional therapy visits. NOTE: Attach a Copy of the Physician, Nurse Practitioner or Physician Assistant's Order (verbal or written), Initial Evaluation Visit notes and Plan Of Care.

_______________________________________________________________________________________________________ Effective 07/01/2005 Form 1 Instructions Page 1 of 2 Revised: 06/14/06

2. Urgent or Same Day Non-Urgent - Insert the following: A. Date of evaluation Visit - Enter the date of initial evaluation visit provided to the patient. B. Date of Next Planned Visit - Enter date of the next scheduled therapy visit. C. No Additional Visits Planned ­ Indicate if patient does not qualify for or need additional therapy visits. D. Reason for Urgent Services - Indicate reason(s) the urgent services were required. NOTE: This area should be completed for urgent services rendered at any point in the patient's care. Attach a copy of the order, initial evaluation assessment visit notes and plan of care. 3. Concurrent - If the request is for concurrent review (certification for continuing services), complete the following: A. Existing Certification # - Enter existing certification number. B. Date of Last Service Authorized - Enter the date of last service authorized. C. Date of Next Planned Visit - Enter the date of the next scheduled therapy visit. NOTE: Current Physician, Nurse Practitioner, or Physician Assistant's orders, current plan of care, notes from therapist's last visit, and documentation of patient's progress toward achieving goals. 4. Retrospective - Check box for retrospective review and complete the following, if applicable: A. TCN - Transaction Control Number NOTE: A copy of the patient's complete medical record must be attached to this request form.

Section IV.

Diagnoses and ICD-9-CM Codes

1. Medical Diagnoses/ICD-9-CM Codes - Enter the patient's primary and secondary diagnoses for this admission (if applicable) and enter the ICD-9-CM codes that correspond to the diagnoses. 2. Therapy Diagnoses/ICD9-CM Codes ­ Enter the patient's therapy diagnoses for this admission (if applicable) and enter the ICD-9-CM codes that correspond to the diagnoses.

Section V.

1. 2. 3. 4.

Requested Therapy

Therapy Type ­ Indicate if therapy type is physical (PT), occupational (OT) or speech therapy (ST). Narrative Description of Procedure ­ Indicate a narrative description of the CPT code procedure. CPT Code ­ Use a valid CPT code. Frequency ­ Indicate the number of times services are to be rendered per duration, such as 3 times per week for 4 weeks. 5. Units ­ a. Record the number of units requested per visit for each CPT code. b. Record the total number of units requested for each CPT code. 6. Dates of Service ­ Indicate date service will start and the date the service will end. 7. Signature of Provider ­ Indicates that the services listed in Section V of this form are those exact services ordered and certified as medically necessary by the ordering MD/NP/PA specified in Section II of this form for the beneficiary specified in Section I of this form.

_______________________________________________________________________________________________________ Effective 07/01/2005 Form 1 Instructions Page 2 of 2 Revised: 06/14/06

HealthSystems of Mississippi

Provider Manual

Place of Service Codes (To be used when completing the HSM Precertification Review Request Form)

Place of Service Code(s) 01 Place of Service Name Pharmacy Place of Service Description

A facility or location where drugs and other medically related items and services are sold, dispensed, or otherwise provided directly to patients. (Effective 10/1/05) N/A 02 Unassigned A facility whose primary purpose is education. 03 School A facility or location whose primary purpose is to provide temporary 04 Homeless housing to homeless individuals (e.g., emergency shelters, individual Shelter or family shelters). A facility or location owned and operated by the Indian Health 05 Indian Health Service, which provides diagnostic, therapeutic (surgical and nonService Freestanding Facility surgical), and rehabilitation services to American Indians and Alaska Natives who do not require hospitalization. A facility or location, owned and operated by the Indian Health 06 Indian Health Service, which provides diagnostic, therapeutic (surgical and nonService surgical), and rehabilitation services rendered by, or under the Provider-based supervision of, physicians to American Indians and Alaska Natives Facility admitted as inpatients or outpatients. A facility or location owned and operated by a federally recognized 07 Tribal 638 American Indian or Alaska Native tribe or tribal organization under a Free-standing 638 agreement, which provides diagnostic, therapeutic (surgical and Facility non-surgical), and rehabilitation services to tribal members who do not require hospitalization. A facility or location owned and operated by a federally recognized 08 Tribal 638 American Indian of Alaska Native tribe or tribal organization under a Provider-based 638 agreement, which provides diagnostic, therapeutic (surgical and Facility non-surgical), and rehabilitation services to tribal members admitted as inpatients or outpatients. Location, other than a hospital, skilled nursing facility (SNF), 11 Office military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis. Location, other than a hospital or other facility, where the patient 12 Home receives care in a private residence. Congregate residential facility with self-contained living units pro13 Assisted living viding assessment of each resident's needs and on-site support 24 Facility hours a day, 7 days a week, with the capacity to deliver or arrange for services including some health care and other services. (Effective 10/1/03) ____________________________________________________________________________________ Effective 07/01/05 Outpatient Physical, Occupational and Speech Therapy Place of Service Codes Page IX-3-1

HealthSystems of Mississippi Place of Service Place of Name Service Code(s) 14 Group Home

Provider Manual Place of Service Description

15 20

Mobile Unit Urgent Care Facility

21

Inpatient Hospital

22

Outpatient Hospital

23 24 25

Emergency Room - Hospital Ambulatory Surgical Center Birthing Center

26

Military Treatment Facility Skilled Nursing Facility

31

32

Nursing Facility

33

Custodial Care Facility Hospice

34

A residence, with shared living areas, where clients receive supervision and other services such as social and /or behavioral services, custodial service, and minimal services (e.g., medication administration). A facility/unit that moves from place-to-place equipped to provide preventive, screening, diagnostic, and/or treatment services. Location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention. A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions. A portion of a hospital which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided. A freestanding facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis. A facility, other than a hospital's maternity facilities or a physician's office, which provides a setting for labor, delivery, and immediate postpartum care as well as immediate care of newborn infants. A medical facility operated by one or more of the Uniformed Services. Military Treatment Facility (MTF) also refers to certain former U.S Public Health Service (USPHS) facilities now designated as Uniformed Service Treatment Facilities (USTF). A facility which primarily providers inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital. A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals. A facility which provides room, board and other personal assistance services, generally on a long-term basis, and which does not include a medical component. A facility, other than a patient's home, in which palliative and supportive care for terminally ill patients and their families are provided.

____________________________________________________________________________________ Effective 07/01/05 Outpatient Physical, Occupational and Speech Therapy Place of Service Codes Page IX-3-2

HealthSystems of Mississippi Place of Service Place of Name Service Code(s) 41 Ambulance-land 42 49

Provider Manual Place of Service Description

50

51

52

53

54

55

56

A land vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured. An air or water vehicle specifically designed, equipped and staffed Ambulance-Air for lifesaving and transporting the sick or injured. or Water A location, not part of a hospital and not described by any other Place Independent of Service code, that is organized and operated to provide preventive, Clinic diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only. (Effective 10/1/03) A facility located in a medically underserved area that provides Federally Qualified Health Medicare beneficiaries preventive primary medical care under the general direction of a physician. Center A facility that provides inpatient psychiatric services for the diagnosis Inpatient and treatment of mental illness on a 24-hour basis, by or under the Psychiatric supervision of a physician. Facility A facility for the diagnosis and treatment of mental illness that Psychiatric provides a planned therapeutic program for patients who do not Facility-Partial require full time hospitalization, but who need broader programs than Hospitalization are possible from outpatient visits to a hospital-based or hospitalaffiliated facility. A facility that provides the following services: outpatient services, Community including specialized outpatient services for children, the elderly, Mental Health individuals who are chronically ill, and residents of the CMHC's Center mental health services area who have been discarded from inpatient treatment at a mental health facility; 24 hour a day emergency care services; day treatment, other partial hospitalization services, or psychosocial rehabilitation services; screening for patients being considered for admission to State mental health facilities to determine the appropriateness of such admission; and consultation and education services. A facility which primarily provides health-related care and services Intermediate above the level of custodial care to mentally restarted individuals but Care Facility/Mentally does not provide the level of care or treatment available in a hospital of SNF. Retarded A facility, which provides treatment for substance (alcohol and drug) Residential Substance Abuse abuse to live-in residents who do not require acute medical care. Services include individual and group therapy and counseling, family Treatment counseling, laboratory tests, drugs and supplies, psychological Facility testing, and room and board. A facility or distinct part of a facility for psychiatric care which Psychiatric provides a total 24-hour therapeutically planned and professionally Residential staffed group living and learning environment. Treatment Center

____________________________________________________________________________________ Effective 07/01/05 Outpatient Physical, Occupational and Speech Therapy Place of Service Codes Page IX-3-3

HealthSystems of Mississippi Place of Service Place of Name Service Code(s) 57 Non-residential Substance Abuse Treatment Facility 60 Mass Immunization Center

Provider Manual Place of Service Description

61

Comprehensive Inpatient Rehabilitation Facility Comprehensive Outpatient Rehabilitation Facility End-Stage Renal Disease Treatment Facility Public Health Clinic Rural Health Clinic Independent Laboratory Other Place of Service

62

65

A location which provides treatment for substance (alcohol and drug) abuse on an ambulatory basis. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological testing. (effective 10/1/03) A location where providers administer pneumococcal pneumonia and influenza virus vaccinations and submit these services as electronic media claims, paper claim, or using the roster billing method. This generally takes place in a mass immunization setting, such as, a public health center, pharmacy, or mall but may include a physician office setting. A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities. Services include physical therapy, occupational therapy, speech pathology, social or psychological services, and orthotics and prosthetics services. A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities. Services include physical therapy, occupational therapy, and speech pathology services. A facility, other than a hospital, which provides dialysis treatment, maintenance, and/or training to patients or caregivers on an ambulatory or home-care basis. A facility maintained by either State or local health departments that provides ambulatory primary medical care under the general direction of a physician. (effective 10/1/03) A certified facility, which is located in a rural medically underserved area that provides ambulatory primary medical care under the general direction of a physician. A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician's office. Other place of service not identified above.

71

72

81 99

____________________________________________________________________________________ Effective 07/01/05 Outpatient Physical, Occupational and Speech Therapy Place of Service Codes Page IX-3-4

HealthSystems of Mississippi

Outpatient Physical/Occupational/Speech Therapy

Reconsideration Request Form (Page 1 of 1)

I. BENEFICIARY INFORMATION

PATIENT INFORMATION K-BABY -CHECK BOX AND COMPLETE BELOW:

Patient/Baby Name: ______________________________ Medicaid #: Date of Birth: Age:

K-Baby - Check here and complete the following: Mother's Name:_________________________ Mother's Date of Birth:

/

Sex:

/

(M or F)

/

II. PROVIDER INFORMATION

/

Name : ______________________________________ Address:______________________________________ _______________________________________

Medicaid Provider #:

III. RECONSIDERATION REQUESTED BY: Request Date: / / Time Telephone Request Received: _________________ Request Method: Fax Mail Telephone Requested By: Therapist Physician/NP/PA Beneficiary/Representative Requester Name: ____________________________________________________________________ Requester Phone #: (____) _________-__________ Ext. _________ Physician/NP/PA Name: ___________________________ Medicaid Provider #: _________________ Physician/NP/PA Phone #: (____) _________-___________ Ext. _________

IV. RECONSIDERATION INFORMATION

Date of denial issue notification: Service From Date:

/ /

/

Thru Date:

/

/

/

Rationale/medical reason for disagreement: ____________________________________________________

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ________________________________________________________________________________________________

Is additional information being submitted along with this request?

Yes

No

MISSISSIPPI MEDICAID DISCLAIMER STATEMENT HEALTHSYSTEMS OF MISSISSIPPI'S CERTIFICATION DETERMINATION DOES NOT GUARANTEE MEDICAID PAYMENT FOR SERVICES OR THE AMOUNT OF PAYMENT FOR MEDICAID SERVICES. ELIGIBILITY FOR AND PAYMENT OF MEDICAID SERVICES ARE SUBJECT TO ALL TERMS AND CONDITIONS AND LIMITATIONS OF THE MEDICAID PROGRAM.

Effective 7/1/2005

Form 3

Page 1 of 1

Instructions for Completing the HealthSystems of Mississippi Outpatient Physical/Occupational/Speech Therapy Reconsideration Request Form

Section I

Beneficiary Information

1. Patient Name - Enter the patient's last and first name as it appears on the Mississippi Medicaid ID card. If the beneficiary is a K-baby, list baby's name. 2. Medicaid # - Enter the beneficiary's Medicaid number that appears on the Mississippi Medicaid ID card. 3. Date of Birth - Enter the month, date, and year of the patient's birth. 4. Age - Enter the age of the patient at the time service is to be rendered. 5. Sex - Indicate the sex of the patient. 6. K-Baby - Indicate if the patient is a K-baby. 7. Mother's Name - Enter the full name of the K-baby's mother. 8. Mother's Date of Birth - Enter the month, date, and year of the mother's birth.

Section II

Provider Information

1. Provider Name - Enter the name of the provider that will provide the care. 2. Medicaid # - Enter the provider's Mississippi Medicaid Provider Number. 3. Address - Enter the provider's complete mailing address or post office box, including city, state, and zip code.

Section III

1. 2. 3. 4. 5. 6. 8. 9. 10.

Reconsideration Requested By:

Request Date - Record the date of the request. Time Telephone Request Received ­ For HSM use to enter time telephone request received. Request Method ­ Indicate whether request submitted by fax, mail or telephone. Requested By ­ Indicate whether the therapist, physician, nurse practitioner, physician assistant, or beneficiary/representative made the request. Requester Name - Enter the name of the individual who is primary contact for this case. If the patient/beneficiary is the requester, enter the beneficiary/representative name. Requester Phone # - Enter the contact person's telephone number, including area code and extension. If the patient/beneficiary is the requester, enter the beneficiary/representative name. Physician/Nurse Practitioner/Physician Assistant Name - Enter the first and last name of the physician, nurse practitioner or physician assistant who ordered the therapy. Mississippi Medicaid Billing # or Medical License # - Enter the ordering MD/NP/PA Mississippi Medicaid billing number or Mississippi medical license number. Physician/Nurse Practitioner/Physician Assistant Phone # - Enter the MD/NP/PA telephone number, including area code and extension.

Section IV

Reconsideration Information

1. Date of Denial IssueNotification - Enter the date of the provider's Notice of Review Outcome. 2. Service From/Thru Dates: Enter the dates of service certified. 3. Rational/medical reason for disagreement - Enter the rationale/medical reason for disagreement with the review findings. 4. Is additional information being submitted along with this request - Check the appropriate box to indicate whether additional information is attached to the form, (i.e.,copies of medical records, correspondence, etc.)

Effective 07/01/05

Form 3 Instructions

Page 1 of 1

HealthSystems of Mississippi

Outpatient Physical/Occupational/Speech Therapy Quality Re-review Request Form

(Page 1 of 1)

I. BENEFICIARY INFORMATION

PATIENT INFORMATION K-BABY -CHECK BOX AND COMPLETE BELOW:

Patient/Baby Name: ______________________________ Medicaid #: Date of Birth: Age:

K-Baby - Check here and complete the following: Mother's Name:_________________________ Mother's Date of Birth:

/

Sex:

/

(M or F)

/

II. PROVIDER INFORMATION

/

Name : ______________________________________ Address:______________________________________ _______________________________________

Medicaid Provider #:

III. QUALITY RE-REVIEW REQUESTED BY: Request Date: / / Requested By: Therapist Physician Nurse Practitioner Physician Assistant Requester Name: ____________________________________________________________________ Requester Phone #: (____) _________-__________ Ext. _________ Physician/NP/PA Name: ___________________________ Medicaid Provider #: _________________ Physician/NP/PA Phone #: (____) _________-___________ Ext. _________

IV. REREVIEW INFORMATION

Date of quality issue notification: Service From Date:

/ /

/

Thru Date:

/

/

/

Rationale/medical reason for disagreement: ____________________________________________________

___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________

Is additional information being submitted along with this request?

Yes

No

MISSISSIPPI MEDICAID DISCLAIMER STATEMENT HEALTHSYSTEMS OF MISSISSIPPI'S CERTIFICATION DETERMINATION DOES NOT GUARANTEE MEDICAID PAYMENT FOR SERVICES OR THE AMOUNT OF PAYMENT FOR MEDICAID SERVICES. ELIGIBILITY FOR AND PAYMENT OF MEDICAID SERVICES ARE SUBJECT TO ALL TERMS AND CONDITIONS AND LIMITATIONS OF THE MEDICAID PROGRAM.

Effective 7/1/2005

Form 4

Page 1 of 1

Instructions for Completing the HealthSystems of Mississippi Outpatient Physical/Occupational/Speech Therapy Quality Re-review Request Form

Section I

Beneficiary Information

1. Patient Name - Enter the patient's last and first name as it appears on the Mississippi Medicaid ID card. If the beneficiary is a K-baby, list baby's name. 2. Medicaid # - Enter the beneficiary's Medicaid number that appears on the Mississippi Medicaid ID card. 3. Date of Birth - Enter the month, date, and year of the patient's birth. 4. Age - Enter the age of the patient at the time service is to be rendered. 5. Sex - Indicate the sex of the patient. 6. K-Baby - Indicate if the patient is a K-baby. 7. Mother's Name - Enter the full name of the K-baby's mother. 8. Mother's Date of Birth - Enter the month, date, and year of the mother's birth.

Section II

Provider Information

1. Provider Name - Enter the name of the outpatient therapy provider that will provide the care. 2. Medicaid # - Enter the provider's Mississippi Medicaid Provider Number. 3. Address - Enter the provider's complete mailing address or post office box, including city, state, and zip code.

Section III

Quality Re-Review Requested By:

1. Request Date - Record the date of the request. 2. Requested By - Check the box(es) to indicate the party(s) requesting the re-review. 3. Requester Name - Enter the name of the individual who is primary contact for this case. 4. Requester Phone # - Enter the contact person's telephone number, including area code and extension. 5. Physician/Nurse Practitioner/Physician Assistant Name - Enter the first and last name of the Physician/Nurse Practitioner/Physician Assistant who ordered the therapy. 6. Mississippi Medicaid Billing # or Medical License # - Enter the ordering MD/NP/PA Mississippi Medicaid billing number or Mississippi medical license number. 7. Physician/Nurse Practitioner/Physician Assistant Phone # - Enter the ordering MD/NP/PA's telephone number, including area code and extension.

Section IV

Quality Re-review Information

1. Date of Quality IssueNotification - Enter the date of the provider's Notice of Quality Issue. 2. Service From/Thru Dates: Enter the dates of service for the patient. 3. Rational/medical reason for disagreement - Enter the rationale/medical reason for disagreement with the review findings. 4. Is additional information being submitted along with this request - Check the appropriate box to indicate whether additional information is attached to the form, (i.e., copies of medical records, correspondence, etc.)

Effective 07/01/2005

Form 4 Instructions

Page 1 of 1

HealthSystems of Mississippi 175 E. Capitol Street Suite 250, Lockbox 13 Jackson, MS 39201

HealthSystems of Mississippi Medicaid Certificate of Medical Necessity Form For Initial Referral/Orders Outpatient Physical/Occupational/Speech Therapy

Section A: Beneficiary and Provider Information

Patient Name: ______________________________ Medicaid #: Date of Birth: Age: Date of last visit:

Ordering MD/NP/PA Name (First and Last): ______________________________________________

/

Sex:

/

(M or F)

Medicaid ID#: Telephone #:

/

/

Diagnoses

-

-

Ext.

Section B: Clinical Information

(THIS SECTION MUST BE COMPLETED BY THE PHYSICIAN/NP/PA.)

ICD-9-CM

Clinical Summary: Record relative history indicating patient's need for each requested therapy service by discipline, i.e., physical, occupational and/or speech therapy.

Physician/Nurse Practitioner/Physician Assistant Order(s):

Section C: Physician//Nurse Practitioner/Physician Assistant Attestation, Signature and Date A physician, nurse practitioner, or physician assistant who attests to the medical necessity of the prescribed services, who knowingly or willfully makes, or causes to be made any false statement or representation of a material fact in any application for Medicaid benefits or Medicaid payments, may be prosecuted under federal and/or state criminal laws and/or may be subject to civil monetary penalties and/or fines. I hereby certify that I am the prescribing physician/nurse practitioner/physician assistant identified in Section A and that I have prescribed the orders listed in Section B of this form. I certify that the medical necessity information in Section B is true, accurate and complete to the best of my knowledge. I understand that any falsification, omission, or concealment of material fact may subject me to civil monetary penalties, fines, or criminal prosecution. _________________________________________________________________ Signature and Title of Prescribing Provider _____________________ Date

Revised: 04/04/06

Page 1 of 1

CMN FORM INSTRUCTIONS

OUTPATIENT PHYSICAL, OCCUPATIONAL, AND SPEECH THERAPY PROGRAM 1

Beneficiary and Provider Information Patient Name: Enter the beneficiary's first and last name as it appears on the Mississippi Medicaid ID card. Date of Birth: Enter the month, date and year of the beneficiary's birth. Age: Enter the age of the beneficiary at the time service is to be rendered. Sex: Indicate the sex of the beneficiary. Date of last visit: Enter the last date that the beneficiary was seen in the office for evaluation of therapy needs. Ordering MD/NP/PA Name (First and Last): Indicate the name of the ordering MD/NP/PA. Medicaid ID#: Enter the ordering MD/NP/PA Mississippi Medicaid Provider Number. Telephone#: Enter the ordering MD/NP/PA telephone number, including area code and extension.

Clinical Information This section is to be completed by the MD/NP/PA Diagnosis and ICD-9-CM-Codes: Enter the beneficiary's primary and secondary diagnoses for this treatment and enter the ICD-9-CM codes that correspond to the diagnoses. Clinical Summary: Record a relative history indicating the beneficiary's need for each requested therapy service by discipline (physical, occupational and/or speech therapy). Physician/Nurse Practitioner/Physician Assistant Order(s): The physician, nurse practitioner, or physician assistant must write an order for therapy services to include the discipline of therapy (PT/OT/SLP) that will need to evaluate the beneficiary. If known, please include specific modalities or treatments that you want carried out during the course of therapy services.

Physician/Nurse Practitioner/Physician Assistant Attestation, Signature And Date: Indicates that the services listed in the clinical summary Section B of this form services ordered as medically necessary by the ordering MD/NP/PA for the beneficiary specified in this form.

HealthSystems of Mississippi 2006

CMN form instructions-4/11/2006

HealthSystems of Mississippi 175 E. Capitol Street Suite 250, Lockbox 13 Jackson, MS 39201

HealthSystems of Mississippi Medicaid Outpatient Occupational Therapy Evaluation/Reevaluation Form

Beneficiary Name: _____________________________________________________ Medicaid#:

Occupational Therapy Evaluation Date:

/

/20

Re-evaluation Date:

/

/20

ICD-9 Codes:

Diagnoses/Conditions being Addressed (Describe specific problems requiring therapy.) Description (e.g.. Medical - CVA, Therapy - paralysis of lower limb) Medical Diagnoses:

Therapy Diagnoses:

History Related to Diagnosis and Therapy:

. . . . / /

I. Date of Onset:

II. Recent Hospitalizations/Dates:

III. Pertinent Medical History: [mechanism of injury, diagnostic imaging/testing, medications, co morbidities (complicating or precautionary

information)]

IV. Prior Therapy History for Same Diagnosis/Condition and Response to Therapy:

V. Social History: (Identify primary caregiver, effects of the disability on the beneficiary and the family, architectural/safety considerations present

in the living environment and caregiver's ability/inability to assist with therapy):

Revised: 06/27/06

Page 1 of 4

HealthSystems of Mississippi 175 E. Capitol Street Suite 250, Lockbox 13 Jackson, MS 39201

HealthSystems of Mississippi Medicaid Outpatient Occupational Therapy Evaluation/Reevaluation Form

Beneficiary Name: ___________________________________________ Medicaid#:

VI. Level of Function: (Initial Evaluation ­ record functional level prior to current condition. For Reevaluation, record the patient's original functional level prior to institution of therapy and current functional level.)

VII. Clinical Status/Impairments: [cognitive function, sensation/proprioception, edema, vision/hearing, posture, AROM, PROM, strength, pain, coordination, bed mobility, balance (sitting and standing), transfer ability, ambulation (level and elevated surfaces), gait analysis, assistive/adaptive devices (currently in use or required), activity, tolerance, presence of wounds (including description and incision status), assessment of the beneficiary's ability to perform ADLs, potential for rehabilitation, age appropriate information on all children (e.g. chronological age/corrected age), motivation for treatment, muscle tone/distribution, neuromotor development, reflex integrity, special/standardized tests including the name, scores/results, and date administered, other significant physical or mental disabilities/deficiencies that may affect therapy.]

Revised: 06/27/06

Page 2 of 4

HealthSystems of Mississippi 175 E. Capitol Street Suite 250, Lockbox 13 Jackson, MS 39201

HealthSystems of Mississippi Medicaid Outpatient Occupational Therapy Evaluation/Reevaluation Form

Beneficiary Name: _______________________________________________ Medicaid#:

VIII. Impression/Interpretation of Findings:

IX. Discharge Plan: (including requirements to return to home, school and/or job)

Attestation Statement: A therapy provider who knowingly or willfully makes, or causes to be made, any false statement of representation of a material fact in any application for Medicaid benefits or Medicaid payments may be prosecuted under Federal and State criminal laws and/or may be subject to civil monetary penalties and/or fines. I certify that I am the therapy provider who performed the therapy evaluation/reevaluation on the Medicaid beneficiary listed on this form. I certify that the information provided on the Evaluation/Reevaluation Form is true, accurate, and complete to the best of my knowledge. I understand that any falsification, omission, or concealment of material fact may subject me to civil monetary penalties, fines, or criminal prosecution, or disqualify me as a provider of Medicaid services.

_________________________________________________________ Signature and Title of Occupational Therapist

_______________________________ Date

Revised: 06/27/06

Page 3 of 4

HealthSystems of Mississippi 175 E. Capitol Street Suite 250, Lockbox 13 Jackson, MS 39201

HealthSystems of Mississippi Medicaid Outpatient Occupational Therapy Evaluation/Reevaluation Form Addendum Page

Beneficiary Name: _______________________________________________ Medicaid#:

Important Notice: When entering information on the Addendum Page, please reference the appropriate section. (For Example: II. Recent Hospitalizations/Dates: ORIF right arm on 07/01/06)

Revised: 06/27/06

Page 4 of 4

HealthSystems of Mississippi 175 E. Capitol Street Suite 250, Lockbox 13 Jackson, MS 39201

HealthSystems of Mississippi Medicaid Outpatient Physical Therapy Evaluation/Reevaluation Form

Beneficiary Name: _____________________________________________________ Medicaid#:

Physical Therapy Evaluation Date:

/

/20

Re-evaluation Date:

/

/20

ICD-9 Codes:

Diagnoses/Conditions being Addressed (Describe specific problems requiring therapy.) Description (e.g.. Medical - CVA, Therapy - paralysis of lower limb) Medical Diagnoses:

Therapy Diagnoses:

History Related to Diagnosis and Therapy:

. . . . / /

I. Date of Onset:

II. Recent Hospitalizations/Dates:

III. Pertinent Medical History: [mechanism of injury, diagnostic imaging/testing, medications, co morbidities (complicating or precautionary

information)]

IV. Prior Therapy History for Same Diagnosis/Condition and Response to Therapy:

V. Social History: (Identify primary caregiver, effects of the disability on the beneficiary and the family, architectural/safety considerations present

in the living environment and caregiver's ability/inability to assist with therapy)

Revised: 06/27/06

Page 1 of 4

HealthSystems of Mississippi 175 E. Capitol Street Suite 250, Lockbox 13 Jackson, MS 39201

HealthSystems of Mississippi Medicaid Outpatient Physical Therapy Evaluation/Reevaluation Form

Beneficiary Name: ___________________________________________________ Medicaid#:

VI. Level of Function: (Initial Evaluation ­ record functional level prior to current condition. For Reevaluation, record the patient's original functional level prior to institution of therapy and current functional level.)

VII. Clinical Status/Impairments: [Motor function, muscle tone/distribution, neuromotor development, reflex integrity, special/ standardized tests including the name, scores/results, and date administered, cognitive function, sensation/proprioception, edema, vision/hearing, posture, AROM, PROM, strength, pain, coordination, bed mobility, balance (sitting and standing), transfer ability, ambulation (level and elevated surfaces), gait analysis, assistive/adaptive devices (currently in use or required), activity, tolerance, presence of wounds (including description and incision status), assessment of the beneficiary's ability to perform ADLs, potential for rehabilitation, age appropriate information on all children (e.g. chronological age/corrected age), motivation for treatment, other significant physical or mental disabilities/deficiencies that may affect therapy.]

Revised 06/27/06

Page 2 of 4

HealthSystems of Mississippi 175 E. Capitol Street Suite 250, Lockbox 13 Jackson, MS 39201

HealthSystems of Mississippi Medicaid Outpatient Physical Therapy Evaluation/Reevaluation Form

Beneficiary Name: _____________________________________________________ Medicaid#:

VIII. Impression/Interpretation of Findings:

IX: Discharge Plan: (including requirements to return to home, school and/or job)

Attestation Statement: A therapy provider who knowingly or willfully makes, or causes to be made, any false statement of representation of a material fact in any application for Medicaid benefits or Medicaid payments may be prosecuted under Federal and State criminal laws and/or may be subject to civil monetary penalties and/or fines. I certify that I am the therapy provider who performed the therapy evaluation / reevaluation on the Medicaid beneficiary listed on this form. I certify that the information provided on the Evaluation/Reevaluation Form is true, accurate, and complete to the best of my knowledge. I understand that any falsification, omission, or concealment of material fact may subject me to civil monetary penalties, fines, or criminal prosecution, or disqualify me as a provider of Medicaid services.

_________________________________________________________ Signature and Title of Physical Therapist

_______________________________ Date

Revised 06/27/06

Page 3 of 4

HealthSystems of Mississippi 175 E. Capitol Street Suite 250, Lockbox 13 Jackson, MS 39201

HealthSystems of Mississippi Medicaid Outpatient Physical Therapy Evaluation/Reevaluation Form Addendum Page

Beneficiary Name: _______________________________________________ Medicaid#:

Important Notice: When entering information on the Addendum Page, please reference the appropriate section. (For Example: II. Recent Hospitalizations/Dates: ORIF right arm on 07/01/06)

Revised: 06/27/06

Page 4 of 4

HealthSystems of Mississippi 175 E. Capitol Street Suite 250, Lockbox 13 Jackson, MS 39201

HealthSystems of Mississippi Medicaid Outpatient Speech-Language Pathology Evaluation/Reevaluation Form

Beneficiary Name: _____________________________________________________ Medicaid#:

Speech Language Pathology Evaluation Date:

/

/20

Re-evaluation Date:

/

/20

Diagnoses/Conditions being Addressed (Describe specific problems requiring therapy.) Description (e.g.. Medical - CVA, Therapy - paralysis of lower limb) Medical Diagnoses:

ICD-9 Codes:

Therapy Diagnoses:

History Related to Diagnosis and Therapy:

. . . . / /

I. Date of Onset:

II. Recent Hospitalizations/Dates:

III. Pertinent Medical History: [mechanism of injury, diagnostic imaging/testing, medications, co morbidities (complicating or precautionary

information)]

IV. Prior Therapy History for Same Diagnosis/Condition and Response to Therapy:

V. Social History: (Identify primary caregiver, effects of the disability on the beneficiary and the family, architectural/safety considerations present

in the living environment and caregiver's ability/inability to assist with therapy)

Revised 06/27/06

Page 1 of 4

HealthSystems of Mississippi 175 E. Capitol Street Suite 250, Lockbox 13 Jackson, MS 39201

HealthSystems of Mississippi Medicaid Outpatient Speech-Language Pathology Evaluation/Reevaluation Form

Beneficiary Name: ___________________________________________ Medicaid#:

VI. Level of Function: (Initial Evaluation ­ record functional level prior to current condition. For Reevaluation, record the patient's original functional level prior to institution of therapy and current functional level.)

VII. Clinical Status/Impairments: [assistive/adaptive devices (currently used or required), oral motor function, phonation, speech production, articulation, stimulability, voice fluency, receptive and expressive language articulation, feeding/swallowing ability, muscle performance, neuromotor development, pain, reflex integrity, hearing ability, vision and cognitive/orientation skills, assessment of the beneficiary's potential for rehabilitation, sensory integrity, age appropriate information on all children (e.g. chronological age/corrected age), motivation for treatment, special/standardized tests including the name, scores/results, and date administered, other significant physical or mental disabilities/deficiencies]

Revised 06/27/06

Page 2 of 4

HealthSystems of Mississippi 175 E. Capitol Street Suite 250, Lockbox 13 Jackson, MS 39201

HealthSystems of Mississippi Medicaid Outpatient Speech-Language Pathology Evaluation/Reevaluation Form

Beneficiary Name: _______________________________________________ Medicaid#:

VIII. Impression/Interpretation of Findings:

IX. Discharge Plan: (including requirements to return to home, school and/or job)

Attestation Statement: A therapy provider who knowingly or willfully makes, or causes to be made, any false statement of representation of a material fact in any application for Medicaid benefits or Medicaid payments may be prosecuted under Federal and State criminal laws and/or may be subject to civil monetary penalties and/or fines. I certify that I am the therapy provider who performed the therapy evaluation / reevaluation on the Medicaid beneficiary listed on this form. I certify that the information provided on the Evaluation/Reevaluation Form is true, accurate, and complete to the best of my knowledge. I understand that any falsification, omission, or concealment of material fact may subject me to civil monetary penalties, fines, or criminal prosecution, or disqualify me as a provider of Medicaid services.

_________________________________________________________ Signature and Title of Speech Language Pathologist

_______________________________ Date

Revised 06/27/06

Page 3 of 4

HealthSystems of Mississippi 175 E. Capitol Street Suite 250, Lockbox 13 Jackson, MS 39201

HealthSystems of Mississippi Medicaid Outpatient Speech-Language Pathology Evaluation/Reevaluation Form Addendum Page

Beneficiary Name: _______________________________________________ Medicaid#:

Important Notice: When entering information on the Addendum Page, please reference the appropriate section. (For Example: II. Recent Hospitalizations/Dates: ORIF right arm on 07/01/06)

Revised 06/27/06

Page 4 of 4

EVALUATION/RE-EVALUATION FORM INSTRUCTIONS

OUTPATIENT PHYSICAL, OCCUPATIONAL, AND SPEECH THERAPY PROGRAM 1

Beneficiary and Provider Information Patient Name: Enter the beneficiary's first and last name as it appears on the Mississippi Medicaid ID card. Medicaid ID#: Enter the beneficiary's Medicaid ID number Evaluation Date: Enter the date that the beneficiary was seen in the office for evaluation for therapy needs. Reevaluation Date: Enter the date that the beneficiary was seen in the office for a reevaluation for therapy needs.

Clinical Information Medical Diagnosis: Enter the beneficiary's primary and secondary diagnoses for this treatment including ICD-9-CM® codes. Therapy Diagnosis: Enter the beneficiary's therapy diagnosis and ICD-9-CM® (if applicable). Date of Onset: Record the date of onset of the beneficiary's condition that requires therapy evaluation. Recent Hospitalizations/Dates: Enter the dates of any recent hospitalizations and the reason for admission. Pertinent Medical History: Record any medical history that impacts or potentially impacts the need for therapy including mechanism of injury, diagnostic testing/imaging, medications, co-morbidities. Additionally include any complicating or precautionary information. Prior Therapy History: Record any prior therapy that the beneficiary has received for the same diagnosis or condition. Include the type of therapy and response of the beneficiary to that therapy. Social History: Record and identify the primary caregiver, the effects of the disability on the beneficiary and the family, architectural/safety considerations present in the living environment, caregiver's ability/inability to assist with therapy. Level of Function: For the initial evaluation, record the functional level prior to the current treating condition. For the reevaluation, record the beneficiary's original functional level prior to institution of therapy and the current functional level. Clinical Status/Impairments: Ø Motor Function: Level of motor skills and which motor skills can be performed Ø Muscle Tone/Distribution: Describe the type of muscle tone and list involved areas Ø Neuromotor Development: Ability to execute a motor skill and are compensatory movements used Ø Reflex Integrity: Presence or absence of primitive and postural reflexes.

HealthSystems of Mississippi 2006 Evaluation/Reevaluation-4/11/2006

EVALUATION/RE-EVALUATION FORM INSTRUCTIONS

OUTPATIENT PHYSICAL, OCCUPATIONAL, AND SPEECH THERAPY PROGRAM Ø Special/Standardized Tests Including Name, Scores/Results, and Date Administered: Peabody Developmental Motor Scales ­ 2; Locomotion Area: 7 mos. Age equivalent, standard score 8; Preschool Language Scale 3 (PLS-3), Goldman Fristoe Test of Articulation 2 (GFTA-2), Hearing test/screen. Ø Cognitive Function: Level of awareness; ability to follow commands, memory skills that may interfere with learning and retaining new skills; visuospatial and perceptual skills; can include level of retardation. Ø Sensation/Proprioception: Hypersensitivity to movement, lack of body awareness in space. Ø Edema: Location, type and amount. Ø Vision/Hearing: Can be observation; if testing is performed, include results. Ø Posture: Body alignment in static stance. Ø AROM: Specific joint measurements related to area being treated. Ø PROM: Specific joint measurements related to area being treated. Ø Strength: Specific measurement of muscle being addressed. Ø Pain: 0-10 scale for adults and older children; FLACC scale for infants and those unable to communicate. Ø Coordination: Can be manifested through awkward "clumsy" gait; fine motor difficulties with poor spatial perception and poor sequencing. Ø Bed Mobility: Ability to change positions in bed; include amount of assistance required. Ø Balance (Sitting and Standing)" Level of support required to maintain static posture; document level of support required to maintain dynamic posture. Ø Transfer Ability: Level of assistance required, and assistive device used. Ø Ambulation (Level and Elevated Surfaces): Level of assistance required, and assistive device used. Ø Gait Analysis: Gait abnormalities, including posture, stride length, stance time, heel-toe progression. Ø Assistive/Adaptive Devices: Any assistive device used for mobility and used for positioning. For speech: utilization of communication board, sign language, laryngeal prosthetic or any other type of augmentative communication system. Ø Activity Tolerance: Endurance for therapeutic activities. Ø Presence of Wounds (Including Description and Incision Status): Stage of healing, location, size, and depth of wound. Ø Assessment of Beneficiary's ability to Perform ADL's: Amount of assistance required, adaptive equipment or modifications required.

HealthSystems of Mississippi 2006 Evaluation/Reevaluation-4/11/2006

2

EVALUATION/RE-EVALUATION FORM INSTRUCTIONS

OUTPATIENT PHYSICAL, OCCUPATIONAL, AND SPEECH THERAPY PROGRAM Ø Potential for Rehabilitation: Basis for potential. Ø Age Appropriate Information on all Children: Chronological age, age equivalency and corrected age (up to three (3) years of age). Ø Other Significant Physical or Mental Disabilities/Deficiencies That May Affect Therapy: Impression/Interpretation of Findings: Enter the overall assessment/observation for the beneficiary. Discharge Plan: Enter the requirements that will be necessary to complete in order for the beneficiary to return to home, school and/or job. Attestation Statement Therapist Attestation Statement: Therapist must sign (including name and credentials) and date the form. 3

HealthSystems of Mississippi 2006

Evaluation/Reevaluation-4/11/2006

HealthSystems of Mississippi 175 E. Capitol Street Suite 250, Lockbox 13 Jackson, MS 39201

HealthSystems of Mississippi Occupational Therapy Plan of Care

Beneficiary Name: _______________________________________ Medicaid#:

Diagnoses and ICD-9-CM Codes

(Do not complete this section upon precertification) Description (e.g. Medical - CVA, Therapy - paralysis of lower limb) Medical Diagnoses: ICD-9-CM Codes:

Therapy Diagnoses:

. . . .

Units Frequency Total

(# per week, day, month)

Duration

(# of days, weeks, months)

Procedure/Modality:

CPT Code

Per Visit

Projected Period of Treatment (From/Thru)

I. Clinical Updates/Precautions (General summary ­ attendance, general progress, set backs, or changes since last POC):

II. Short Term Goals: (Adult 1 month, Child 1-3 months) [specific, measurable, age appropriate, current status (baseline) for each goal]

III. Long Term Goals: (Adult 4-8 weeks, Child 3-6 months) [specific, measurable, age appropriate, current status (baseline) for each goal]

Revised 06/27/06

Page 1 of 3

HealthSystems of Mississippi 175 E. Capitol Street Suite 250, Lockbox 13 Jackson, MS 39201

HealthSystems of Mississippi Occupational Therapy Plan of Care

Beneficiary Name: _______________________________________ Medicaid#:

IV. Home Program/Caregiver (CG) Response: [Describe Home Exercise Program (HEP), including frequency that HEP is to be performed. Indicate responsible caregiver and his/her response (i.e. ability to perform return demo, verbalization of understanding, and for concurrent review, list frequency that CG performed HEP). If applicable, document reasons explaining CG's inability to participate.]

V. Discharge Plan:

Therapist Section

Documentation of Prescribing Provider's Verbal Order. This Plan of Care must be reviewed and agreed to by the prescribing provider before treatment is begun. Verbal order from ________________________________, Title _____________________ Taken by _______________________________________, Title _____________________ Date________________

A therapy provider who knowingly or willfully makes, or causes to be made, any false statement of representation of a material fact in any application for Medicaid benefits or Medicaid payments may be prosecuted under Federal and State criminal laws and/or may be subject to civil monetary penalties and/or fines. I certify that I am the therapy provider who developed this plan of care. I certify that the information provided on the Plan of Care form is true, accurate, and complete to the best of my knowledge. I understand that any falsification, omission, or concealment of material fact may subject me to civil monetary penalties, fines, or criminal prosecution, or disqualify me as a provider of Medicaid services.

_____________________________________________________________ Signature and Title of Occupational Therapist

___________________________ Date

Prescribing Provider Section

Prescribing Provider Attestation, Signature and Date (Note: Must be completed before initiation of treatment or within thirty (30) calendar

days of the verbal order approving the treatment plan.) A physician, nurse practitioner, or physician assistant who attests to the medical necessity of the prescribed services, who knowingly or willfully makes, or causes to be made, any false statement or representation of a material fact in any application for Medicaid benefits or Medicaid payments, may be prosecuted under federal and/or state criminal laws and/or may be subject to monetary penalties and/or fines. I hereby certify that I have reviewed and approved this plan of care for the therapy provider and that I deem it to be medically necessary for the patient listed on this Plan of Care form. I understand that any falsification, omission or concealment of material fact may subject me to civil monetary penalties, fines, or criminal prosecution.

________________________________________________________________________

Signature and Title of Prescribing Provider

____________________________ Date

Revised 06/27/06

Page 2 of 3

HealthSystems of Mississippi 175 E. Capitol Street Suite 250, Lockbox 13 Jackson, MS 39201

HealthSystems of Mississippi Occupational Therapy Plan of Care Addendum Page

Beneficiary Name: ___________________________________ Medicaid#:

Important Notice: When entering information on the Addendum Page, please reference the appropriate section. (For Example: II. Recent Hospitalizations/Dates: ORIF right arm on 07/01/06)

Revised 06/27/06

Page 3 of 3

HealthSystems of Mississippi 175 E. Capitol Street Suite 250, Lockbox 13 Jackson, MS 39201

HealthSystems of Mississippi Physical Therapy Plan of Care

Beneficiary Name: _______________________________________ Medicaid#:

Diagnoses and ICD-9-CM Codes

(Do not complete this section upon precertification) Description (e.g. Medical - CVA, Therapy - paralysis of lower limb) Medical Diagnoses: ICD-9-CM Codes:

Therapy Diagnoses:

. . . .

Units Frequency Total

(# per week, day, month)

Duration

(# of days, weeks, months)

Procedure/Modality:

CPT Code

Per Visit

Projected Period of Treatment (From/Thru)

I. Clinical Updates/Precautions (General summary ­ attendance, general progress, set backs, or changes since last POC):

II. Short Term Goals: (Adult 1 month, Child 1-3 months) [specific, measurable, age appropriate, current status (baseline) for each goal]

III. Long Term Goals: (Adult 4-8 weeks, Child 3-6 months) [specific, measurable, age appropriate, current status (baseline) for each goal]

Revised 06/27/06

Page 1 of 3

HealthSystems of Mississippi 175 E. Capitol Street Suite 250, Lockbox 13 Jackson, MS 39201

HealthSystems of Mississippi Physical Therapy Plan of Care

Beneficiary Name: _______________________________________ Medicaid#:

IV. Home Program/Caregiver (CG) Response: [Describe Home Exercise Program (HEP), including frequency that HEP is to be performed. Indicate responsible caregiver and his/her response (i.e. ability to perform return demo, verbalization of understanding, and for concurrent review, list frequency that CG performed HEP). If applicable, document reasons explaining CG's inability to participate.]

V. Discharge Plan:

Therapist Section

Documentation of Prescribing Provider's Verbal Order. This Plan of Care must be reviewed and agreed to by the prescribing provider before treatment is begun. Verbal order from ________________________________, Title _____________________ Taken by _______________________________________, Title _____________________ Date________________

A therapy provider who knowingly or willfully makes, or causes to be made, any false statement of representation of a material fact in any application for Medicaid benefits or Medicaid payments may be prosecuted under Federal and State criminal laws and/or may be subject to civil monetary penalties and/or fines. I certify that I am the therapy provider who developed this plan of care. I certify that the information provided on the Plan of Care form is true, accurate, and complete to the best of my knowledge. I understand that any falsification, omission, or concealment of material fact may subject me to civil monetary penalties, fines, or criminal prosecution, or disqualify me as a provider of Medicaid services.

_____________________________________________________________ Signature and Title of Physical Therapist

___________________________ Date

Prescribing Provider Section

Prescribing Provider Attestation, Signature and Date. (Note: Must be completed before initiation of treatment or within thirty (30) calendar

days of the verbal order approving the treatment plan.)

A physician, nurse practitioner, or physician assistant who attests to the medical necessity of the prescribed services, who knowingly or willfully makes, or causes to be made, any false statement or representation of a material fact in any application for Medicaid benefits or Medicaid payments, may be prosecuted under federal and/or state criminal laws and/or may be subject to monetary penalties and/or fines. I hereby certify that I have reviewed and approved this plan of care for the therapy provider and that I deem it to be medically necessary for the patient listed on this Plan of Care form. I understand that any falsification, omission or concealment of material fact may subject me to civil monetary penalties, fines, or criminal prosecution.

________________________________________________________________________

Signature and Title of Prescribing Provider

____________________________ Date

Revised 06/27/06

Page 2 of 3

HealthSystems of Mississippi 175 E. Capitol Street Suite 250, Lockbox 13 Jackson, MS 39201

HealthSystems of Mississippi Physical Therapy Plan of Care Addendum Page

Beneficiary Name: ___________________________________ Medicaid#:

Important Notice: When entering information on the Addendum Page, please reference the appropriate section. (For Example: II. Recent Hospitalizations/Dates: ORIF right arm on 07/01/06)

Revised 06/27/06

Page 3 of 3

HealthSystems of Mississippi 175 E. Capitol Street Suite 250, Lockbox 13 Jackson, MS 39201

HealthSystems of Mississippi Speech Language Pathology Plan of Care

Beneficiary Name: _______________________________________ Medicaid#:

Diagnoses and ICD-9-CM Codes

(Do not complete this section upon precertification) Description (e.g. Medical - CVA, Therapy - paralysis of lower limb) Medical Diagnoses: ICD-9-CM Codes:

Therapy Diagnoses:

. . . .

Units Frequency Total

(# per week, day, month)

Duration

(# of days, weeks, months)

Procedure/Modality:

CPT Code

Per Visit

Projected Period of Treatment (From/Thru)

I. Clinical Updates/Precautions (General summary ­ attendance, general progress, set backs, or changes since last POC):

II. Short Term Goals: (Adult 1 month, Child 1-3 months) [specific, measurable, age appropriate, current status (baseline) for each goal]

III. Long Term Goals: (Adult 4-8 weeks, Child 3-6 months) [specific, measurable, age appropriate, current status (baseline) for each goal]

Revised 06/27/06

Page 1 of 3

HealthSystems of Mississippi 175 E. Capitol Street Suite 250, Lockbox 13 Jackson, MS 39201

HealthSystems of Mississippi Speech Language Pathology Plan of Care

Beneficiary Name: _______________________________________ Medicaid#:

IV. Home Program/Caregiver (CG) Response: [Describe Home Exercise Program (HEP), including frequency that HEP is to be performed. Indicate responsible caregiver and his/her response (i.e. ability to perform return demo, verbalization of understanding, and for concurrent review, list frequency that CG performed HEP). If applicable, document reasons explaining CG's inability to participate.]

V. Discharge Plan:

Therapist Section

Documentation of Prescribing Provider's Verbal Order. This Plan of Care must be reviewed and agreed to by the prescribing provider before treatment is begun. Verbal order from ________________________________, Title _____________________ Taken by _______________________________________, Title _____________________ Date________________

A therapy provider who knowingly or willfully makes, or causes to be made, any false statement of representation of a material fact in any application for Medicaid benefits or Medicaid payments may be prosecuted under Federal and State criminal laws and/or may be subject to civil monetary penalties and/or fines. I certify that I am the therapy provider who developed this plan of care. I certify that the information provided on the Plan of Care form is true, accurate, and complete to the best of my knowledge. I understand that any falsification, omission, or concealment of material fact may subject me to civil monetary penalties, fines, or criminal prosecution, or disqualify me as a provider of Medicaid services.

_____________________________________________________________ Signature and Title of Speech Language Pathologist

___________________________ Date

Prescribing Provider Section

Prescribing Provider Attestation, Signature and Date (Note: Must be completed before initiation of treatment or within thirty (30) calendar

days of the verbal order approving the treatment plan.)

A physician, nurse practitioner, or physician assistant who attests to the medical necessity of the prescribed services, who knowingly or willfully makes, or causes to be made, any false statement or representation of a material fact in any application for Medicaid benefits or Medicaid payments, may be prosecuted under federal and/or state criminal laws and/or may be subject to monetary penalties and/or fines. I hereby certify that I have reviewed and approved this plan of care for the therapy provider and that I deem it to be medically necessary for the patient listed on this Plan of Care form. I understand that any falsification, omission or concealment of material fact may subject me to civil monetary penalties, fines, or criminal prosecution.

________________________________________________________________________

Signature and Title of Prescribing Provider

____________________________ Date

Revised 06/27/06

Page 2 of 3

HealthSystems of Mississippi 175 E. Capitol Street Suite 250, Lockbox 13 Jackson, MS 39201

HealthSystems of Mississippi Speech Language Pathology Plan of Care Addendum Page

Beneficiary Name: ___________________________________ Medicaid#:

Important Notice: When entering information on the Addendum Page, please reference the appropriate section. (For Example: II. Recent Hospitalizations/Dates: ORIF right arm on 07/01/06)

Revised 06/27/06

Page 3 of 3

PLAN OF CARE FORM INSTRUCTIONS

OUTPATIENT PHYSICAL, OCCUPATIONAL, AND SPEECH THERAPY PROGRAM

1

Patient Name: Enter the beneficiary's first and last name as it appears on the Mississippi Medicaid ID card. Medicaid ID#: Enter the beneficiary's Medicaid ID number. Diagnosis and ICD-9-CM-Codes: Enter the beneficiary's primary and secondary diagnoses for this treatment and enter the ICD-9-CM codes that correspond to the diagnoses. Therapy Diagnosis: Enter the beneficiary's therapy diagnosis and ICD-9-CM® (if applicable). Procedure/Modality: Indicate a description of the CPT code procedure/modality. CPT Code: Use a valid CPT code. Units: Indicate the number of units for each visit, and the total number of units requested. Frequency: Indicate the number of times services are to be rendered per week, day or month. Duration: Indicate the number of days; weeks or months services are to be rendered. Dates of Service: Indicate date service will start and the date service will end. Clinical Update/Precautions: General summary ­ attendance, general progress, set backs, or changes since last POC. Safety concerns that are identified in the evaluation should be addressed (e.g. spinal precautions, weight bearing status, etc). Short Term Goals (Adult 1 month, Child 1-3 months): Should be specific, measurable and age appropriate. Record the current status (baseline) for each goal. Long Term Goals (Adult 4-8 weeks, Child 3-6 months): Should be specific, measurable and age appropriate. Record the current status (baseline) for each goal. Home Program/Caregiver Response: Specific exercises or tools should be listed and discussed with each beneficiary during each therapy session. Indicate responsible caregiver and his/her response (i.e. ability to perform return demo, verbalization of understanding, and for concurrent review, list frequency that CG performed HEP). If applicable, document the reasons explaining the caregiver's inability to participate. Discharge Plan: Including requirements to return to home, school, and/or job. Documentation of the Prescribing Provider's Verbal Order: If a verbal order was received to initiate the plan of care, the therapist should document from whom the verbal order was obtained from and document who received the order. Therapist Attestation Statement: Therapist must sign (including name and credentials) and date the form. Prescribing Provider Attestation, Signature and Date: Note: Must be completed within thirty (30) calendar days of the initiation of therapy.

HealthSystems of Mississippi

POC form instructions.doc-6/29/2006

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OP TOC.doc

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