1. The services must be considered under accepted standards of practice to be a specific and effective treatment for the patient's condition;

2. The services must be of such a level of complexity, or the patient's condition must be such that the services required can be safely and effectively performed only by or under the supervision of a qualified physical or occupational therapist; and

3. There must be reasonable expectation that therapy will result in a meaningful improvement or a reasonable expectation that therapy will prevent a worsening of the condition. (See the medical necessity definition in the Glossary of this manual.)

1. Date of evaluation;

2. Child's name and date of birth;

3. Diagnosis specific to therapy;

4. Background information including pertinent medical history; and, if the child is twelve (12) months of age or younger, gestational age. The child should be tested in the child's dominant language; if not, an explanation must be provided in the evaluation.

5. Standardized test results, including all subtest scores, if applicable. Test results must be reported as standard scores, Z scores, T scores, or percentiles. Age-equivalent scores and percentage of delay cannot be used to qualify for services;

6. If applicable, test results should be adjusted for prematurity (less than thirty-seven (37) weeks gestation) if the child is twelve (12) months of age or younger, and this should be noted in the evaluation;

7. Objective information describing the child's gross/fine motor abilities/deficits, e.g., range of motion measurements, manual muscle testing, muscle tone, or a narrative description of the child's functional mobility skills (strengths and weaknesses);

8. An interpretation of the results of the evaluation including recommendations for therapy/minutes per week;

9. A description of functional strengths and limitations, a suggested treatment plan, and potential goals to address each identified problem; and

10. Signature and credentials of the therapist performing the evaluation.

1. Tests used must be norm-referenced, standardized, and specific to the therapy provided.

2. Tests must be age appropriate for the child being tested.

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

4. Eligibility for therapy will be based upon a score of -1.5 standard deviations (SD) below the mean or greater in at least one (1) subtest area or composite score on a norm-referenced, standardized test. When a -1.5 SD or greater is not indicated by the test, a criterion-referenced test along with informed clinical opinion must be included to support the medical necessity of services.

5. If the child cannot be tested with a norm-referenced standardized test, criterion-based testing or a functional description of the child's gross/fine motor deficits may be used. Documentation of the reason a standardized test could not be used must be included in the evaluation.

6. The Mental Measurement Yearbook (MMY) is the standard reference to determine reliability/validity. Refer to “Accepted Tests” sections for a list of standardized tests accepted by Arkansas Medicaid for retrospective reviews.

7. Range of Motion: A limitation of greater than ten (10) degrees or documentation of how a deficit limits function.

8. Muscle Tone: Modified Ashworth Scale.

9. Manual Muscle Test: A deficit is a muscle strength grade of fair (3/5) or below that impedes functional skills. With increased muscle tone, as in cerebral palsy, testing is unreliable.

10. Transfer Skills: Documented as the amount of assistance required to perform transfer, i.e., maximum, moderate, or minimal assistance. A deficit is defined as the inability to perform a transfer safely and independently.

11. Children (birth to age twenty-one (21)) receiving services outside of the public schools must be evaluated annually.

12. Children (birth to age two (2)) in the Early Intervention Day Treatment (EIDT) program must be evaluated every six (6) months.

13. Children (age three (3) to twenty-one (21)) receiving services within public schools, as a part of an Individual Program Plan (IPP) or an Individual Education Plan (IEP), must have a full evaluation every three (3) years; however, an annual update of progress is required.

1. Monitoring: May be used to ensure that the child is maintaining a desired skill level or to assess the effectiveness and fit of equipment such as orthotics and other durable medical equipment. Monitoring frequency should be based on a time interval that is reasonable for the complexity of the problem being addressed.

2. Maintenance Therapy: Services that are performed primarily to maintain range of motion or to provide positioning services for the patient do not qualify for physical or occupational therapy services. These services can be provided to the child as part of a home program implemented by the child's caregivers and do not necessarily require the skilled services of a physical or occupational therapist to be performed safely and effectively.

3. Duration of Services: Therapy services should be provided if reasonable progress is made toward established goals. If reasonable functional progress cannot be expected with continued therapy, then services should be discontinued and monitoring, or establishment of a home program, should be implemented.

1. Child's name;

2. Date of service;

3. Time in and time out of each therapy session;

4. Objectives addressed (should coincide with the plan of care);

5. A description of specific therapy services provided daily, and the activities rendered during each therapy session, along with a form measurement;

6. Progress notes must be legible;

7. Therapists must sign each date of entry with a full signature and credentials; and

8. Graduate students must have the supervising physical therapist or occupational therapist co-sign progress notes.