| Program Name: | BadgerCare Plus and Medicaid | Handbook Area: | Therapies: Physical, Occupational, and Speech and Language Pathology | | 05/21/2024 | Provider Enrollment and Ongoing Responsibilities : DocumentationTopic #2778 Evaluations
PT, OT, and SLP providers are required to include a written report of the member's evaluation in the member's medical record. The evaluation report must be signed and dated and include the following:
- Assessment of the member's condition and recommendations for therapy intervention
- Baseline measurements that establish a performance or ability level using units of objective measurement that can be consistently applied when reporting subsequent status of the member's progress
- Chronological history of treatment provided for the diagnosis
- Diagnosis(es) with date(s) of onset, current medical status, and functional status of the member
- List of other PT, OT, and SLP service providers who are currently treating the member to the extent known by the evaluating PT, OT, or SLP provider
- Procedures to be used in treatment. Providers may identify procedures with the applicable CPT code(s)
- Goals of treatment
- Previous level of function and change in medical status since previous PA requests if performing a re-evaluation
- Reason for the referral
- Recommended frequency and duration of treatment
- Test charts or forms used in the evaluation, if applicable
- Underlying conditions or impairments to be treated
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