Rule 23-213-1.8 - Evaluation and Re-EvaluationA. Medicaid requires a Certificate of Medical Necessity for Initial Referral/Orders completed by the prescribing provider, and it must be received by the therapist prior to performing the initial evaluation. The evaluation does not require prior authorization.B. Medicaid requires a comprehensive evaluation of the beneficiary's medical condition, disability, and level of functioning before therapy is initiated. A comprehensive evaluation must be performed to determine the need for treatment and, when treatment is indicated, to develop the treatment plan. 1. Medicaid requires the evaluation must be written and must demonstrate the beneficiary's need for skilled therapy based on functional diagnosis, prognosis, and positive prognostic indicators.2. The evaluation must form the basis for therapy treatment goals, and the therapist must have an expectation that the patient can achieve the established goals.3. Initial evaluations should, at a minimum contain, the following information:a) Beneficiary demographic information,b) Name of the prescribing provider,c) Date of the evaluation,d) Diagnosis/functional condition or limitation being treated and onset date,e) Applicable medical history including mechanism of injury, diagnostic imaging/testing, recent hospitalizations including dates, medications, comorbidities, either complicating or precautionary information,f) Prior therapy history for same diagnosis/condition and response to therapy,g) Level of function, prior and currenth) Clinical status including cognitive function, sensation/proprioception, edema, vision/hearing, posture, active and passive range of motion, strength, pain, coordination, bed mobility, balance by sitting and standing, transfer ability, ambulation on level and elevated surfaces, gait analysis, assistive/adaptive devices which are currently in use or required, activity tolerance, presence of wounds including description and incision status, assessment of the beneficiary's ability to perform activities of daily living and potential for rehabilitation, age appropriate information on all children such as chronological age/corrected age, motivation for treatment, other significant physical or mental disabilities/deficiencies that may affect therapy,i) Special/standardized tests including the name, scores/results, and dates administered,j) Social history including effects of the disability on the beneficiary and the family, architectural/safety considerations present in the living environment, identification of the primary caregiver, caregiver's ability/inability to assist with therapy,k) Discharge plan including requirements to return to home, school, and/or job,l) Impression/interpretation of findings, andm) Physical therapist's signature, including name, title, and date of service.C. Medicaid covers re-evaluations based on medical necessity. 1. Re-evaluations do not require prior authorization through the UM/QIO.2. Documentation must reflect a significant change in the beneficiary's condition or functional status. Medicaid defines significant change as a measurable and substantial increase or decrease in the beneficiary's present functional level compared to the level documented at the beginning of treatment.23 Miss. Code. R. 213-1.8
42 C.F.R. § 410.60; Miss. Code Ann. §§ 43-13-117, 43-13-121.