20 CAR Part 603 — Adult Developmental Day Treatment Provider Manual

Chapter XV

Subchapter B

20 CAR pt. 603 Adult Developmental Day Treatment Provider Manual {#sec-20-car-pt.-603 omnilex-key=us-ar-regs-official--title-20-part-603--20 CAR pt. 603}

Adult Developmental Day Treatment Section II Section II-1

SECTION II – ADULT DEVELOPMENTAL DAY TREATMENT CONTENTS

200.000 ADULT DEVELOPMENTAL DAY TREATMENT (ADDT) GENERAL INFORMATION 201.000 Arkansas Medicaid Participation Requirements for Adult Developmental Day Treatment (ADDT) Providers 201.100 ADDT Providers in Arkansas and Bordering States 202.000 Documentation Requirements 202.100 Documentation Requirements for All Medicaid Providers 202.200 ADDT Documentation Requirements 202.300 Electronic Signatures 210.000 PROGRAM COVERAGE 211.000 Introduction 212.000 Establishing Eligibility 212.100 Age Requirement 212.200 Prescription 212.300 Qualifying Diagnosis 213.000 Non-Covered Services 214.000 Covered ADDT Services 214.100 ADDT Core Services 214.110 ADDT Evaluation and Treatment Planning Services 214.120 Day Habilitative Services 214.200 ADDT Optional Services 214.210 Occupational Therapy, Physical Therapy, and Speech-Language Pathology Services 214.220 Nursing Services 214.230 ADDT Transportation Services 215.000 Individual Treatment Plan (ITP) 220.000 PRIOR AUTHORIZATION 230.000 REIMBURSEMENT AND RECOUPMENT 231.000 Method of Reimbursement 231.100 Fee Schedules

200.000 ADULT DEVELOPMENTAL DAY TREATMENT (ADDT) GENERAL INFORMATION

201.000 Arkansas Medicaid Participation Requirements for Adult Developmental Day Treatment (ADDT) Providers 8-1 -22 A provider must meet the following participation requirements to qualify as an Adult Developmental Day Treatment (ADDT) provider under Arkansas Medicaid: A. Obtain an Adult Developmental Day Treatment license issued by the Arkansas Department of Human Services, Division of Provider Services and Quality Assurance, and B. Complete the provider participation and enrollment requirements contained within Section 140.000 of this manual ADDT providers may furnish and claim reimbursement for covered ADDT services subject to all requirements and restrictions set forth and referenced in this manual. 201.100 ADDT Providers in Arkansas and Bordering States 8-1 -22

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ADDT providers in Arkansas and within fifty (50) miles of the state line in the six (6) bordering states (Louisiana, Mississippi, Missouri, Oklahoma, Tennessee and Texas) may be enrolled as ADDT providers if they meet all Arkansas Medicaid participation requirements. 202.000 Documentation Requirements

202.100 Documentation Requirements for All Medicaid Providers 8-1 -22 See Section 140.000 of this manual for the documentation that is required for all Arkansas Medicaid providers. 202.200 ADDT Documentation Requirements 8-1 -22 A. ADDT providers must maintain in each client’s service record sufficient, contemporaneous written documentation demonstrating the medical necessity of all covered ADDT services included on a client’s individual treatment plan (ITP). B. ADDT providers must maintain in each client’s service record the following documentation for all day habilitative and nursing services performed pursuant to Sections 214.120 and 214.220 of this manual:

1. The specific services furnished each day;
2. The date and beginning and ending time for each of the services performed each day;
3. Name(s) and credential(s) of the person(s) providing each service each day;
4. Which client ITP goal(s) and objective(s) the day’s services are intended to address; and
5. Weekly or more frequent progress notes signed or initialed by the person(s) providing the service(s) describing the client’s status with respect to ITP goals and objectives for that service. C. ADDT providers must maintain in the client’s service record the documentation specified in Section 204.200 of Section II of the Occupational Therapy, Physical Therapy, and Speech- Language Therapy Pathology Services Medicaid manual for all occupational therapy, physical therapy, and speech-language pathology services performed pursuant to Section 214.210 of this manual. D. ADDT providers must maintain the following documentation related to ADDT transportation services performed pursuant to Section 214.230 of this manual:
6. A separate transportation log must be maintained for each trip that a vehicle is used by an ADDT to transport clients that lists:
   1. Each transported client’s:
   2. Name;
   ii. Age; iii. Date of birth; iv. Medicaid ID number; v. Exact address of pick up and drop off; and vi. Exact time of pick up and drop off. b. The driver of the vehicle; c. Each attendant or any other persons transported; and d. Odometer reading for vehicle at a trip’s: i. Initial pick up; and

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ii. Final drop off.

2. The driver of each vehicle must sign and date each transportation log verifying that

each client that received transportation services from the ADDT was safely

transported to and from:

1. The client’s home (or other scheduled pick-up or drop-off location); or
2. The ADDT facility; or
3. Other appropriate location.

3. An ADDT must maintain all transportation logs for five (5) years from the date of

transportation.

202.300 Electronic Signatures

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Arkansas Medicaid will accept electronic signatures in compliance with Arkansas Code § 25-31-

103 et seq.

210.000 PROGRAM COVERAGE

211.000 Introduction 8-1 -22 Arkansas Medicaid will reimburse licensed and enrolled ADDT providers for medically necessary covered ADDT services provided to an eligible client pursuant to an individual treatment plan in compliance with this manual. 212.000 Establishing Eligibility 1-1 -21

212.100 Age Requirement

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A client must meet one of the following age criteria to be enrolled in an ADDT program and

receive covered ADDT services through the Arkansas Medicaid Program:

1. The client is at least twenty-one (21) years of age; or
2. The client is between eighteen (18) and twenty-one (21) years of age and has a high

school diploma or a certificate of completion.

212.200 Prescription

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A. All covered ADDT services other than ADDT Transportation services under Section

214.230 require a written prescription signed and dated by the client’s primary care

provider (PCP) or attending licensed physician.

B. A prescription for covered ADDT services is valid for one (1) year, unless a shorter period

is specified. The prescription must be renewed at least once a year for covered ADDT

services to continue.

D. When prescribing ADDT services, the client’s PCP or attending licensed physician shall

not make any self-referrals in violation of state or federal law.

212.300 Qualifying Diagnosis

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A. A client must have a documented qualifying intellectual or developmental disability

diagnosis that originated before the age of twenty-two (22) and is expected to continue

indefinitely to receive covered ADDT services.

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B. A qualifying intellectual or developmental disability diagnosis is any one of the following:

1. A diagnosis of Cerebral Palsy established by the results of a medical examination performed by the client’s primary care provider (PCP) or attending licensed physician;
2. A diagnosis of Spina Bifida established by the results of a medical examination performed by the client’s PCP or attending licensed physician;
3. A diagnosis of Down Syndrome established by the results of a medical examination performed by the client’s PCP or attending licensed physician;
4. A diagnosis of Epilepsy established by the results of a medical examination performed by the client’s primary care provider (PCP) or attending licensed physician;
5. A diagnosis of Autism Spectrum Disorder established by the results of evaluations performed by at least two (2) of the following three (3) licensed professionals either individually or as a team: physician, psychologist, and speech pathologist; or
6. A diagnosis of intellectual and developmental disability or other similar condition found to be closely related to intellectual or developmental disability because it results in an impairment of general intellectual functioning or adaptive behavior similar to that of a person with an intellectual or developmental disability or requires treatment and services similar to that required for a person with an intellectual or developmental disability, based on the results of a team evaluation performed by the client’s PCP or attending licensed physician and a licensed psychologist. C. The qualifying diagnosis must constitute a substantial handicap to the client’s ability to function without appropriate support services in areas such as daily living and social activities, medical services, physical therapy, speech-language pathology, occupational therapy, job training, and employment services. 213.000 Non-Covered Services 8-1 -22 Arkansas Medicaid will only reimburse for those covered ADDT services listed in Sections 214.000. Additionally, Arkansas Medicaid will only reimburse for ADDT services when such services are provided to a client meeting the eligibility requirements in Section 212.000 by an ADDT meeting the requirements of this manual. 214.000 Covered ADDT Services 8-1 -22 Covered ADDT services are either core services or optional services. A. All covered ADDT services must be provided at the ADDT facility, or, in the case of ADDT transportation services, only involve the transportation of clients to or from the ADDT facility. B. All covered ADDT services must be provided by individuals employed or contracted with the ADDT provider. 214.100 ADDT Core Services 8-1 -22 ADDT core services are those covered ADDT services that a provider must offer to its enrolled clients to be licensed as an ADDT provider. 214.110 ADDT Evaluation and Treatment Planning Services 8-1 -22 A. An ADDT provider may be reimbursed for medically necessary ADDT evaluation and treatment planning services. ADDT evaluation and treatment planning services are a

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component of the process of determining a client’s eligibility for ADDT services and developing the client’s individualized treatment plan (ITP). B. Medical necessity for ADDT evaluation and treatment planning services is established by a qualifying diagnosis pursuant to Section 212.300. C. ADDT evaluation and treatment planning services are covered once per calendar year and reimbursed on a per unit basis. The billable unit includes time spent administering an evaluation, scoring an evaluation, writing an evaluation report, and developing the ITP. 214.120 Day Habilitative Services 8-1 -22 A. An ADDT provider may be reimbursed for medically necessary day habilitative services. B. Medical necessity for day habilitative services is established by a qualifying diagnosis under Section 212.300. C. ADDT day habilitative services include the following:

1. Instruction in areas of cognition, communication, social and emotional, motor or adaptive (including self-care) skills;
2. Instruction to reinforce skills learned and practiced as part of occupational therapy, physical therapy, or speech-language pathology services; or
3. Prevocational services that prepare a client for employment. a. Prevocational services may not be used to provide job specific skill and task instruction, or address explicit employment objectives, but may: i. Include habilitative goals such as compliance, attending, task completion, problem solving, and safety; and ii. Be provided only to clients who are not expected to be able to join the general work force or to participate in a transitional sheltered workshop within one (1) year (excluding supported employment programs). b. A client’s compensation for prevocational services must be less than fifty percent (50%) of the minimum wage for the training to qualify as prevocational services. c. A client receiving prevocational services must have documentation in his or her file demonstrating such services are not available under a program funded under Section 110 of the Rehabilitation Act of 1973, as amended, or the Individuals with Disabilities Education Act (IDEA) of 1997. D. ADDT day habilitative services are reimbursed on a per unit basis. No more than five (5) hours of ADDT day habilitative services may be billed per day without an extension of benefits. The unit of service calculation does not include time spent in transit to and from the ADDT facility. View or print the billable ADDT day habilitative services procedure codes and descriptions. 214.200 ADDT Optional Services 8-1 -22 ADDT optional services are those covered ADDT services that a licensed ADDT provider may, but is not required to, offer to its clients. 214.210 Occupational Therapy, Physical Therapy, and Speech-Language Pathology Services 8-1 -22 A. An ADDT provider may be reimbursed for medically necessary occupational therapy, physical therapy, and speech-language pathology evaluation and treatment planning services.

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1. A qualifying diagnosis pursuant to Section 212.300 of this manual alone does not establish the medical necessity of occupational therapy, physical therapy, or speech- language pathology evaluation and treatment planning services.
2. The medical necessity for occupational therapy, physical therapy, and speech- language pathology evaluation and treatment planning services is demonstrated by a written referral to evaluate that is signed by the client’s primary care provider (PCP) or attending physician.
3. All of occupational therapy, physical therapy, or speech-language evaluation and treatment planning services must be performed by an enrolled Arkansas Medicaid provider that is licensed in the applicable service discipline.
4. An individual treatment plan that includes occupational therapy, physical therapy, or speech-language pathology services must be signed by one of the following: a. The licensed practitioner that conducted the evaluation and treatment planning for the service discipline; or b. The prescribing PCP or licensed attending physician.
5. Occupational therapy, physical therapy, and speech-language pathology evaluation and treatment planning services are reimbursed on a per unit basis. a. The billable unit includes time spent for clinical observation, administering and scoring a standardized evaluation, administering supplemental tests and tools, writing an evaluation report and comprehensive assessment, and developing the individual treatment plan. b. View or print the billable Occupational Therapy, Physical Therapy, and Speech-language Pathology evaluation and treatment planning services procedure codes and descriptions. B. An ADDT provider may be reimbursed for medically necessary occupational therapy, physical therapy, and speech-language pathology treatment services.
6. Occupational therapy, physical therapy, and speech-language pathology treatment services require a written prescription meeting the requirements of Section 212.300 of the Occupational Therapy, Physical Therapy, and Speech-Language Pathology Services Medicaid manual.
7. A prescription for occupational therapy, physical therapy, or speech-language pathology services is valid for the shorter of the length of time specified on the prescription or one (1) year.
8. Occupational therapy, physical therapy, and speech-language pathology treatment services must be medically necessary as demonstrated by the results of a comprehensive assessment. a. The comprehensive assessment must meet the requirements of Sections 212.400, 212.410, and 212.420 of Section II of the Occupational Therapy, Physical Therapy, and Speech-Language Pathology Services Medicaid manual. b. A comprehensive assessment used to establish a client’s eligibility for occupational therapy, physical therapy, and speech-language pathology treatment services must include the administration of a standardized evaluation meeting the requirements of Sections 212.500, 212.510, and 212.520 of Section II of the Occupational Therapy, Physical Therapy, and Speech-Language Pathology Services Medicaid manual.
9. Occupational therapy, physical therapy, and speech-language pathology treatment services are reimbursed on a per unit basis and each discipline is covered up to six (6) units per week without authorization. a. See Section 216.000 of Section II of the Occupational Therapy, Physical Therapy, and Speech-Language Pathology Services Medicaid manual

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regarding requests for an extension of benefits to be reimbursed for more than six (6) units of services in a single discipline per week. b. View or print the billable occupational therapy, physical therapy, and speech-language pathology treatment procedure codes and descriptions. C. An ADDT provider must contract with or employ its qualified occupational therapy, physical therapy, and speech-language pathology practitioners.

1. The ADDT provider must identify the licensed practitioner as the performing provider on the claim when billing for the service.
2. The licensed practitioner must be an enrolled Arkansas Medicaid provider and the group provider requirements of Section 201.200 of Section II of the Occupational Therapy, Physical Therapy, and Speech-Language Pathology Services Medicaid manual must be met. 214.220 Nursing Services 8-1 -22 A. An ADDT provider may be reimbursed for medically necessary nursing services.
3. Medical necessity for nursing services is established by a medical diagnosis and a comprehensive nursing evaluation approved by the client’s primary care provider (PCP) or attending licensed physician who prescribed the ADDT services.
4. The nursing evaluation must specify the required nursing services.
5. The client’s PCP or attending licensed physician must prescribe the specific number of medically necessary nursing service units per day. B. ADDT nursing services must be:
6. Performed by a licensed registered nurse or licensed practical nurse; and
7. Within the performing nurse’s scope of practice as set forth by the Arkansas State Board of Nursing. C. For the purposes of this manual, ADDT nursing services are defined as the following, or similar, activities:
8. Assisting ventilator dependent clients;
9. Tracheostomy suctioning and care;
10. Feeding tube administration, care, and maintenance;
11. Catheterizations;
12. Breathing treatments;
13. Monitoring of vital statistics, including diabetes sugar checks, insulin, blood draws, and pulse ox;
14. Cecostomy tube administration, care, and maintenance;
15. Ileostomy tube administration, care, and maintenance; and
16. Administration of medication when the administration of medication is not the client’s only medically necessary nursing service. D. ADDT nursing services must be prior authorized and are reimbursed on a per unit basis. Time spent taking a client’s temperature and performing other acts of standard first aid is not included in the units of an ADDT nursing service calculation. View or print the billable ADDT nursing services procedure codes and descriptions. 214.230 ADDT Transportation Services 8-1 -22

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A. An ADDT provider may be reimbursed for providing its clients with transportation services to and from its ADDT facility. B. ADDT transportation services are reimbursable if each of the following is met:

1. The transportation is provided by a licensed ADDT provider;
2. The client transported is receiving ADDT services from the ADDT that is providing the ADDT transportation service; and
3. The transportation is provided only to or from the ADDT provider’s facility. C. ADDT transportation services are reimbursed on a per person, per mile basis. When transporting more than one client, an ADDT must make all reasonable efforts to minimize the total number of miles for each client each trip. For example, when transporting multiple clients to an ADDT facility the client with a pick-up location farthest away from the ADDT facility should be picked up first, and the client with the pick-up location closest to the ADDT facility should be picked up last. View or print the billable ADDT transportation services procedure codes and description. 215.000 Individual Treatment Plan (ITP) 8-1 -22 A. Each client receiving covered ADDT services must have an individual treatment plan (ITP).
4. An ITP is a written, individualized plan to improve or maintain the client’s condition based upon evaluation of the client.
5. An ITP must be reevaluated and updated at least annually. B. Each ITP must at a minimum contain:
6. A written description of the goals and objectives for each covered EIDT service. Each client goal and objective must be: a. Written in the form of a regular function, task, or activity the client is working toward successfully performing; b. Measurable; and c. Specific to each individual client.
7. The specific medical and remedial services, therapies, and activities that will be provided and how those services, therapies, and activities are designed to achieve the client’s goals and objectives;
8. Any evaluations or other documentation that supports the medical necessity of the covered ADDT services specified in the ITP;
9. A schedule of service delivery that includes the frequency and duration of each type of covered ADDT service;
10. The job title(s) or credential(s) of the personnel that will furnish each covered ADDT service;
11. The schedule for completing re-evaluations of the client’s condition and updating the ITP.

220.000 PRIOR AUTHORIZATION 8-1-22 Prior authorization is required for an ADDT provider to be reimbursed for: A. Over five (5) hours of day habilitative services in a single day; B: Over ninety (90) minutes per week of any of the following services:

1. Occupational therapy;

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2. Physical therapy; or
3. Speech-language pathology;
   3. All ADDT nursing services; and
   4. Over eight (8) total combined hours of the following services in a single day:
4. Day habilitative;
5. Occupational therapy;
6. Physical therapy;
7. Speech-language pathology; and
8. Nursing.

230.000 REIMBURSEMENT AND RECOUPMENT

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231.000 Method of Reimbursement

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Except as otherwise provided in this manual, covered ADDT services use fee schedule

reimbursement methodology. Under fee schedule methodology, reimbursement is made at the

lower of the billed charge for the service or the maximum allowable reimbursement for the

service under Arkansas Medicaid. The maximum allowable reimbursement for a service is the

same for all ADDT providers.

1. A full unit of service must be rendered to bill a unit of service.
2. Partial units of service may not be rounded up and are not reimbursable.
3. Non-consecutive periods of service delivery over the course of a single day may be

aggregated when computing a unit of service.

231.100 Fee Schedules

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A. Arkansas Medicaid provides fee schedules on the DMS website. View or print the ADDT

fee schedule.

B. Fee schedules do not address coverage limitations or special instructions applied by

Arkansas Medicaid before final payment is determined.

C. Fee schedules and procedure codes do not guarantee payment, coverage, or the

reimbursement amount. Fee schedule and procedure code information may be changed

or updated at any time.