Page 58

State of Maryland Medical Assistance Manual Revised April 2014

Client Name_____________________________________ Part C – MR/MI Please Complete the Following on All Individuals:

Review Item Answer Y N 1. Is there a diagnosis or presenting evidence of mental retardation/related condition, or has the client received MR services within the past two years?

2. Is there any presenting evidence of mental illness? Please note: Dementia/Alzheimer’s is not considered a mental illness

a. If yes, check all that apply.

Schizophrenia Personality disorder Somatoform disorder Panic or sever anxiety disorder Mood disorder Paranoia Other psychotic or mental disorder leading to chronic disability 3. Has the client received inpatient services for mental illness within the past two years

4. Is the client on any medication for the treatment of a major mental illness or psychiatric diagnosis? If yes, is the mental illness or psychiatric diagnosis controlled with medication?

5. Is the client a danger to self or others?

Part D – Diagnoses Primary diagnosis related to the need for requested level of care ICD Code Description

Descriptions Part E – Skilled Services: Requires a physician’s order; requires the skills of technical or professional personnel such as a registered nurse, licensed practical nurse, respiratory therapist, physical therapist, and/or occupational therapist. The service must be inherently complex such that it can be safely and effectively performed only by, or under the supervision of, professional or technical personnel. Items listed under Rehabilitation and Extensive Services may overlap.

Table I. Extensive Services (serious/unstable medical condition and need for service) Review Item (Please indicate the number of days per week each service is required) # of days services is required/wk. (0-7) 1. Tracheotomy Care: (Please indicate the number of day per week each service is required.)

2. Suctioning: Not including routine oral-pharyngeal suctioning, at least once a day

3. IV therapy: Peripheral or central (not including self administration)

4. IM/SC Injections: At least once a day (not including self-administration)

5. Pressure Ulcer Care: Stage 3 or 4 and one or more skin treatments (including pressure-relieving bed, nutrition or hydration intervention, application of dressing and/or medications)

6. Wound Care: Surgical wounds or open lesions with one or more skin treatments per day (e.g., application of a dressing and/or medications daily)

7. Tube Feedings: 51% or more of total calories or 500cc or more per day fluid intake via tube

8. Ventilator Care: Individual would be a ventilator all or part of the day.

9. Complex respiratory services: Excluding aerosol therapy, spirometry, postural drainage or routine continuous 02 usage

10. Parenteral Feeding or TPN: Necessary for providing main source of nutrition

11. Catheter Care: Not routine foley

12. Ostomy Care: New

13. Monitor Machine: For example, apnea or bradycardia

14. Formal Teaching/Training Program: Teach client or caregiver how to manage the treatment regime or perform self care or treatment skills for recently diagnosed conditions (must be ordered by a physician)

DHMH Form 3871B Rev 10/11 (2 of 4)