Introduction

Answer:

Welcome to the School-Based Medicaid webpage. We acknowledge that School-Based Medicaid services and billing can be complicated and confusing to understand and implement.  The purpose of this webpage is to provide information, resources, clarification, and training to better help you serve your students with disabilities and support your staff.  This webpage has seven sections:

Introduction – This first section provides a brief overview and describes the organization of this webpage, including contact information.

What’s New – This section includes new information as it becomes available. Check this section frequently to learn about any exciting news or upcoming events.  Information in this section will move into other relevant sections as it ages.

Clarification Form – Use this form to ask questions, seek clarification, or share thoughts and suggestions regarding School-Based Medicaid and/or associated IDAPA rules. Specific details regarding how to use the Clarification Form are described in that section.

Clarifications – Here is where you can learn from each other’s questions. This section contains responses to the questions and issues submitted on Clarification Forms. Clarifications appear in alphabetical order by topic. Consider browsing the Clarifications section before submitting your own Clarification Form because one of your peers may have already asked your question. However, do not hesitate to submit your own Clarification Form if you cannot find an answer to your question or issue in this section.

Trainings – This section includes recordings from webinars, web-based training modules, and associated handouts. As new webinars happen their recordings will be added to this section.

Resource Links – This section includes links to School-Based Medicaid resources.

Resources - This is where you will find the most up-to-date sample documents within the 2017 Idaho Medicaid Guidance Handbook for Educators. Simply use the search bar to find a specific document, search by category, or scroll through the list.

The Department of Health and Welfare, Division of Medicaid, and the State Department of Education come together quarterly in the School-Based Medicaid Advisory Committee. These meetings are necessary to facilitate better communication between school districts (School-Based Medicaid providers), Medicaid policy makers, and the office Medicaid Integrity. This committee meets to address changes in School-Based Medicaid IDAPA rules, discuss audit findings and ways to make practice corrections, and provide clarification to districts on School-Based Medicaid policies and procedures. Quarterly meeting agendas, meeting minutes, and other supporting documents are located in the Documents section of this webpage.

You may address any questions or concerns related to School-Based Medicaid to Angie Williams. We look forward to working with you.

Angie Williams
Alternative Care Coordinator, School Based Services
Bureau of Developmental Disability Services
Idaho Division of Medicaid
208-287-1169
Angie.Williams@dhw.idaho.gov

 


What's New

REVISION TO FBA YEARLY REQUIREMENT CLARIFICATION – The clarification entitled FBA Yearly Requirement in the Assessment and Evaluation and CBRS sections has been revised. Please review it carefully for guidance on this issue. (posted 9-26-2017)

30-Day Retroactive Billing Temporary Rule In Effect August 1, 2017 – A new temporary rule for retroactively billing Medicaid reimbursable services went into effect on August 1, 2017. This temporary rule addresses the issue of schools not being able to receive Medicaid reimbursement for Medicaid services provided between the time the need was identified by the school and the time a recommendation or referral could be obtained from a physician or practitioner of the healing arts.  Amendments to the Medicaid School-Based rules identified in IDAPA 16.03.09 Sections 850-859 allow schools to bill for services identified as needed retroactively, up to 30 days, once a recommendation or referral for a Medicaid reimbursable service delivered in a school setting is received. (posted 9-26-2017)

EXCITING BACK TO SCHOOL READING - 2017 Medicaid Guidance Handbook for Educators (posted August 2017)

HOT OFF THE PRESS - 2017 Desk Review Self-Assessment Tool (posted August 2017)

NEW AND IMPROVED - Medicaid Clarification Form REV (posted August 2017)


Clarification Form

Answer:

Use this form to ask questions, seek clarification, or share thoughts and suggestions regarding School-Based Medicaid implementation and/or associated IDAPA rules. Follow the steps below to submit and get a response to your Clarification Form.
1. Download the form.
2. Open the form using Adobe PDF Reader.
3. Complete all fields comprehensively and to the best of your ability.
4. Please “Save As” with your district number and date in the file name. For example: D91 Aug 14 Medicaid Clarification Form.
5. Save the document for your future reference.
6. Send as an e-mail attachment to Angie.Williams@dhw.idaho.gov
7. A written response will be returned to you using your form. You may need to click the View Response at the bottom of page one for the response to be visible.
8. The response to your question/issue/suggestion will be posted to the What’s New section for one month, then added alphabetically to the list of responses under the Clarifications section.
9. If additional action is required, the School-Based Medicaid Advisory Committee will provide additional guidance.

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Clarifications

Assessment and Evaluation

Answer: DHW will accept any version of a Department Approved assessment.

IDAPA 16.03.09.851.05: Parental Consent. Providers must obtain a one-time parental consent to access public benefits or insurance from a parent or legal guardian for school-based Medicaid reimbursement.

IDAPA 16.03.09.854.07: Parental Notification. School districts and charter schools must document that parents were notified of the health-related services and equipment for which they will bill Medicaid. Notification must comply with the requirements in Subsection 854.08 of this rule.
08. Requirements for Cooperation with and Notification of Parents and Agencies. Each school district or charter school billing for Medicaid services must act in cooperation with students’ parent or guardian, and with community and state agencies and professionals who provide like Medicaid services to the student.
a. Notification of Parents. For all students who are receiving Medicaid reimbursed services, school districts and charter schools must document that parents are notified of the Medicaid services and equipment for which they will bill Medicaid. Notification must describe the service(s), service provider(s), and state the type, location, frequency, and duration of the service(s). The school district must document that they provided the student’s parent or guardian with a current copy of the child’s plan and any pertinent addenda; and
b. Primary Care Physician (PCP). School districts and charter schools must request the name of the student’s primary care physician and request a written consent to release and obtain information between the PCP and the school from the parent or guardian.
c. Other Community and State Agencies. Upon receiving a request for a copy of the evaluations or the current plan, the school district or charter school must furnish the requesting agency or professional with a copy of the plan or appropriate evaluation after obtaining consent for release of information from the student's parent or guardian.
You may not seek reimbursement prior to the date the parents/guardians sign the one-time consent form.

The 30-day Retroactive Billing Temporary Rule applies to the physician's signature only.

Answer: DHW will accept any version of a Department Approved assessment.

Currently we are working to add a statement to this fact on the www.sbs.dhw.idaho.gov website. In the Idaho Medicaid Guidance Document posted on the Idaho Training Clearinghouse topic site School-Based Medicaid on page 71 there is a document that helps clarify the scoring of varies assessments.

Answer:16.03.09.853.3.a
a. Behavioral Intervention. Behavioral Intervention is used to promote the student’s ability to
participate in educational services, as defined in Section 850 of these rules, through a consistent, assertive, and
continuous intervention process to address behavior goals identified on the IEP. It includes the development of
replacement behaviors by conducting a functional behavior assessment and behavior implementation plan with the purpose of preventing or treating behavioral conditions for students who exhibit maladaptive behaviors. Services include individual or group behavioral interventions.

16.03.09.854.02
02. Evaluations and Assessments. Evaluations and assessments must support services billed to
Medicaid, and must accurately reflect the student’s current status. Evaluations and assessments must be completed at
least every (3) years.

Medicaid does not require annual completion of an FBA or BIP, but does require 3 year reevaluation. This aligns with IDEA and our obligation to conduct reevaluations every 3 years. IDEA does not require behavioral assessments, however, if there is an IEP goal addressing a student's behavior, this would need to be reviewed annually and updated when necessary.

Answer: CBRS does not have a yearly requirement for a FBA, Behavioral Intervention for students who qualify under the Developmental Disabilities rules has this requirement.

16.03.09.853.03.a
a. Behavioral Intervention. Behavioral Intervention is used to promote the student’s ability to participate in educational services, as defined in Section 850 of these rules, through a consistent, assertive, and continuous intervention process to address behavior goals identified on the IEP. It includes the development of replacement behaviors by conducting a functional behavior assessment and behavior implementation plan with the purpose of preventing or treating behavioral conditions for students who exhibit maladaptive behaviors. Services include individual or group behavioral interventions.

Regarding the date question, you will NOT need to complete a new FBA within 365 days from the date of the completion of the previous assessment, rather we recommend they are REVIEWED ANNUALLY to accurately reflect the student's current status.

Answer: The school has no obligation to provide this IQ test. Often school district, if they have the assessment, provide this service to the family, but it is not an obligation. The parent will need to go to a community based psychologist to acquire the appropriate IQ test. Please suggest to the family to contact the Medicaid contracted assessor, Liberty or case manager.

Answer: The activity of compiling various pieces of information gathered from various sources into a Medicaid/Social History is billable to Medicaid if completed by a qualified person outlined in this rule. If a questionnaire is part of the information gathered, it is a billable activity to summarize in the report.

Answer: Activities conducted through evaluation and assessment following the IDAPA rule cited below, are billable activities. The questionnaire, interpretation, and child observation are all assessment activities.

Utilizing the AOTA guidelines that were posted on the ITC under FAQs this will help you OT determine what level of complexity the questionnaire would fall under.

Please let us know if you have additional questions.

2. Evaluation And Diagnostic Services. Evaluations to determine eligibility or the need for health-related
services may be reimbursed even if the student is not found eligible for health-related services. Evaluations
completed for educational services only cannot be billed. Evaluations completed must: (3-30-07)
a. Be recommended or referred by a physician or other practitioner of the healing arts. A school
district or charter school may not seek reimbursement for services provided prior to receiving a signed and dated
recommendation or referral; (7-1-13)
b. Be conducted by qualified professionals for the respective discipline as defined in Section 855 of
these rules; (3-20-14)
c. Be directed toward a diagnosis; (7-1-16)
d. Include recommended interventions to address each need; and (7-1-16)
e. Include name, title, and signature of the person conducting the evaluation. (7-1-16)

Answer: Per the MedicAide newsletter in January 2017 describes "High, Medium, and Low Complexity that directs you to the new fee schedule. The new fee schedule then defines the time, complexity, and rate for each evaluation level. However, it does not outline the different components for each level. The new codes are related to how much time is needed to complete the OT/PT evaluations, in addition to how the performance deficits are identified and counted.

CMS for 2017 has changed the related service provider codes for OT and PT. OT and PT codes differ in their reimbursement methodology. The traditional evaluation code has be broken into 3 new complexity codes, which are all reimbursed at the same rate. In addition a new re-evaluation code has been added. The re-evaluation code is reimbursed at a different rate than the initial evaluation.

CMS has identified 2017 as a data collection year to determine if in subsequent years the 3 new evaluation codes might result in a tiered level of reimbursement rate. CMS is requesting that service provides (OT and PT) be critical in choosing the most accurate code for the level evaluation complexity.

CMS is allowing 2017 to be a training year for practitioners on the use of the new coding system. Medical reviewers will not be able to penalize providers regarding the Medical Necessity for the new medical evaluation requirements for the billing year of 2017.

Both the OT and PT national associations have developed guidance for their respective members. Please refer to those association documents.

Additional assessment requirements related to the new complexity codes can be found at the two following links:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9782.pdf

https://www.webpt.com/blog/post/farewell-97001-how-to-use-the-new-pt-and-ot-evaluation-codes

This document: AOTA Evaluation-Codes-Overview-2016 is another resource that may provide guidance.

Answer: The assessment codes, as outlined in the CPT manual - psychological evaluations 96101, allows school personnel to complete reports when school is not in sessions. The report would reflect the activities involving the student that would occur Monday-Friday or during school, but report writing can be done at other times..

Answer:A 3-year evaluation can be billed as a psychological evaluation as long as the following rule is followed without new testings, unless required in another section of these rules. See 16.03.09.852.01.a where CBRS requires annual assessment. Other services might also require specific annual testing.

02. Evaluation And Diagnostic Services. Evaluations to determine eligibility or the need for
health- related services may be reimbursed even if the student is not found eligible for
health-related services. Evaluations completed for educational services only cannot be billed.
Evaluations completed must: (3-30-07)

a. Be recommended or referred by a physician or other practitioner of the healing arts. A school
district or charter school may not seek reimbursement for services provided prior to receiving a
signed and dated recommendation or referral; (7-1-13)
b. Be conducted by qualified professionals for the respective discipline as defined in Section 855 of
c. Be directed toward a diagnosis; (7-1-16)
d. Include recommended interventions to address each need; and (7-1-16)
e. Include name, title, and signature of the person conducting the evaluation. (7-1-16)

Answer: The MedicAide Newsletter June 2011(click link to be redirected).

This newsletter provides specific guidance related to this issue, page 8. This addresses specifically same service same day.

"Several CPT and HCPCS codes used for evaluations, therapy modalities and procedures specify that one unit equals 15 minutes. Providers may bill a single 15-minute unit for treatment that is greater than or equal to eight minutes. Two units should be billed when the interaction with the participant is greater than or equal to 23 minutes but is less than 38 minutes. This pattern remains the same when calculating the time spent providing the service."

Your question was related to the same service within the same week or month, so if the sessions are 25 minutes on different days the school would bill 2 units for the 25 minutes. The IEP can say 120 minutes per month for any related service.

This information was verified by the Medicaid Integrity Unit.

Answer:If I understand your question correctly, you are wanting to know if you could bill at a professional level if a 3 C'd, licensed, ASHA certified SLP was supervising the entire grad student's therapy session. Per the rule below the SLP would be providing supervision to a para you would be billing the para rate while the para is providing the therapy. If the licensed SLP was providing the therapy and the para was observing the therapy then you would be billing at the professional rate. You bill based on who is providing the therapy or service, not who is in the room.

16.03.09.855.14.c
14. Therapy Paraprofessionals. The schools may use paraprofessionals to provide occupational
therapy, physical therapy, and speech therapy if they are under the supervision of the appropriate
professional. The services provided by paraprofessionals must be delegated and supervised by a
professional therapist as defined by the appropriate licensure and certification rules. The
portions of the treatment plan that can be delegated to the paraprofessional must be identified in
the IEP or transitional IFSP. (7-1-16)

c. Speech-Language Pathology (SLP). Refer to IDAPA 24.23.01, “Rule of the Speech and Hearing
Services Licensure Board,” and the American Speech-Language-Hearing Association (ASHA) guidelines
for qualifications, supervision and service requirements for speech-language pathology. The
guidelines have been incorporated by reference in Section 004 of these rules. (7-1-16)

i. Supervision must be provided by an SLP professional as defined in Section 734 of this
chapter of rules. (7-1-16)

ii. The professional must observe and review the direct services performed by the
paraprofessional on a monthly basis, or more often as necessary, to ensure the paraprofessional
demonstrates the necessary skills to correctly provide the SLP service. (7-1-16)

16.03.09.734.3

03. Speech-Language Pathologist, Licensed. A person licensed by the Speech and Hearing Services
Licensure Board to conduct speech-language assessments and therapy in accordance with the Speech and Hearing Services Practice Act, Title 54, Chapter 29, Idaho Code, and IDAPA 24.23.01, “Rules of the Speech and Hearing Services Licensure Board,” who possesses a certificate of clinical competence in speech-language pathology from the American Speech, Language, and Hearing Association (ASHA) or who will be eligible for certification within one (1) year of employment.

Behavioral Intervention/Behavioral Consultation

Answer: Can we bill BI Professional rate for provider who is with a 1.5 SD student (who of course meets all the eligibility requirements)? When I started I was told by my predecessor that we could not bill Pro with a 1.5 SD student. But I do not see where that is the case per the code.

Yes. A BI professional and/or a BI paraprofessional can provide services to any child who meets the eligibility requirements for behavioral intervention (16.03.09.855.a, 16.03.09.855.b). This means that a child scoring 1.5 SD below the mean can receive services from the BI professional and/or BI paraprofessional (16.03.09.852.2.b,). This also means that you can bill and be reimbursed for BI services provided by a BI professional working with a student scoring 1.5 SD below the mean.

Answer: The candidate would need to meet the following qualification to provide the service. Because the candidate does not meet the certification requirements, unless the candidate met the criteria for and held a Habilitative Intervention certification. The candidate would meet the qualification of a paraprofessional.

855.SCHOOL-BASED SERVICE: PROVIDER QUALIFICATIONS AND DUTIES.
Medicaid will only reimburse for services provided by qualified staff. The following are the minimum qualifications for providers of covered services: (7-1-13)

01. Behavioral Intervention. Behavioral intervention must be provided by or under the supervision of
a professional. (7-1-13)

a. A behavioral intervention professional must meet the following: (7-1-13)

i. An individual with an Exceptional Child Certificate who meets the qualifications defined under
IDAPA 08.02.02, “Rules Governing Uniformity,” Section 028; or (7-1-13)

ii. An individual with an Early Childhood/Early Childhood Special Education Blended Certificate
who meets the qualifications defined under IDAPA 08.02.02, “Rules Governing Uniformity,” Section 019; or
(7-1-13)

iii. A Special Education Consulting Teacher who meets the qualifications defined under IDAPA
08.02.02, “Rules Governing Uniformity,” Section 029; or (7-1-13)

iv. Habilitative intervention professional who meets the requirements defined in IDAPA 16.03.10
“Medicaid Enhanced Plan Benefits,” Section 685; or (7-1-13)

v. Individuals employed by a school as certified Intensive Behavioral Intervention (IBI) professionals prior to July 1, 2013, are qualified to provide behavioral intervention; and (7-1-13)

vi. Must be able to provide documentation of one (1) year’s supervised experience working with
children with developmental disabilities. This can be achieved by previous work experience gained through paid
employment, university practicum experience, or internship. It can also be achieved by increased on-the-job
supervision experience gained during employment at a school district or charter school. (7-1-13)

b. A paraprofessional under the direction of a qualified behavioral intervention professional, must
meet the following: (7-1-13)

i. Must be at least eighteen (18) years of age; (7-1-13)
ii. Demonstrate the knowledge, have the skills needed to support the program to which they are
assigned; and (7-1-16)

iii. Must meet the paraprofessional requirements under the Elementary and Secondary Education Act
of 1965, as amended, Title 1, Part A, Section 1119. (7-1-13)
c. A paraprofessional delivering behavioral intervention services must be under the supervision of a
behavioral intervention professional or behavioral consultation provider.

Answer: DHW will accept any version of a Department Approved assessment.

Currently we are working to add a statement to this fact on the www.sbs.dhw.idaho.gov website. In the Idaho Medicaid Guidance Document posted on the Idaho Training Clearinghouse topic site School-Based Medicaid on page 71 there is a document that helps clarify the scoring of varies assessments.

Answer: It will be the responsibility of the school psychologist to interpret the testing results and justify whether they can be considered as a substantial limitation. So with the example above if the student is 6 years 4 months of age and functioning at a 1 year 1 month of age, this can be considered a substantial limitation. The responsibility goes back to the justification from the school psychologist.

Answer: Here is the hyperlink to the paraprofessional requirements set out by the Idaho State Department of Education. The certification that the individual provided does not meet the Title 1 Paraprofessional requirements.
https://www.sde.idaho.gov/federal-programs/basic/files/professional/Title-I-A-Paraprofessional-Requirements.pdf
Title I Paraprofessional Requirements
All instructional paraprofessionals and working in a program supported by title I funds must have the following qualifications:
High school diploma (or GED) AND
1) Two years of college (32 credit hours) OR
2) Associate’s degree OR
3) Rigorous standard of quality on formal state or local assessment* In Idaho, the “rigorous formal state assessment” is the ParaPro Assessment offered by the Education Testing Service (ETS). For more information, go to www.ets.org . Click on ‘Tests’ link and then the ParaPro Assessment link. Information about the test and how and when to register to take the test is available at this website. All paraprofessional who provide instructional services and who work in a program supported with Title I funds must meet these qualifications. This means that in a schoolwide program, the Title I requirements apply to all instructional paraprofessionals, for the same reasons that all teachers in a schoolwide program are considered Title I-paid teachers. However, in a targeted assistance program, the paraprofessional qualification requirements apply to instructional paraprofessionals who are paid with Title I, Part A funds. It does not apply to paraprofessionals who are paid from other federal funds such as Title I-C, 21st Century Schools, of IDEA or from non-federal funds, even if those individuals are working with Title I students. For more information, contact Kathy Gauby at kgauby@sde.idaho.gov .

Answer:16.03.09.853.3.a
a. Behavioral Intervention. Behavioral Intervention is used to promote the student’s ability to
participate in educational services, as defined in Section 850 of these rules, through a consistent, assertive, and
continuous intervention process to address behavior goals identified on the IEP. It includes the development of
replacement behaviors by conducting a functional behavior assessment and behavior implementation plan with the purpose of preventing or treating behavioral conditions for students who exhibit maladaptive behaviors. Services include individual or group behavioral interventions.

16.03.09.854.02
02. Evaluations and Assessments. Evaluations and assessments must support services billed to
Medicaid, and must accurately reflect the student’s current status. Evaluations and assessments must be completed at
least every (3) years.

Medicaid does not require annual completion of an FBA or BIP, but does require 3 year reevaluation. This aligns with IDEA and our obligation to conduct reevaluations every 3 years. IDEA does not require behavioral assessments, however, if there is an IEP goal addressing a student's behavior, this would need to be reviewed annually and updated when necessary.

Answer: CBRS does not have a yearly requirement for a FBA, Behavioral Intervention for students who qualify under the Developmental Disabilities rules has this requirement.

16.03.09.853.03.a
a. Behavioral Intervention. Behavioral Intervention is used to promote the student’s ability to participate in educational services, as defined in Section 850 of these rules, through a consistent, assertive, and continuous intervention process to address behavior goals identified on the IEP. It includes the development of replacement behaviors by conducting a functional behavior assessment and behavior implementation plan with the purpose of preventing or treating behavioral conditions for students who exhibit maladaptive behaviors. Services include individual or group behavioral interventions.

Regarding the date question, you will need to complete a new FBA within 365 days from the date of the completion of the previous assessment.


Answer:1) We put Special Ed Teacher in Grid then our optional statement will state "...services provided by a BI Professional...and/or will be provided by a BI Paraprofessional ...under the direction of a BI Professional." As Special Ed Teacher is the provider/supervisor and para is under their supervision. Is this in compliance OR must we add Paraprofessional to the Grid above also?

This issue was a result of school district using M-Codes on the IEP services grids. If the district does not use the M-Code there is not conflict.

2) Do the minutes in Grid need to match the Optional Statement of Services? We only have conflict for BI services.
As these are provided throughout the school day, if we put all the BI minutes also in the GRID we appear to be providing services over the school day total. Confusing for parents. Our optional statement of services is the accurate minutes provided for BI services. Are we in compliance?

No. The number of BI minutes do not need to be in the grid, Medicaid requires that all of the components are there. This can be in the "optional section".

Billing/CPT Codes/Fee Schedule

Answer: DHW will accept any version of a Department Approved assessment.

IDAPA 16.03.09.851.05: Parental Consent. Providers must obtain a one-time parental consent to access public benefits or insurance from a parent or legal guardian for school-based Medicaid reimbursement.

IDAPA 16.03.09.854.07: Parental Notification. School districts and charter schools must document that parents were notified of the health-related services and equipment for which they will bill Medicaid. Notification must comply with the requirements in Subsection 854.08 of this rule.
08. Requirements for Cooperation with and Notification of Parents and Agencies. Each school district or charter school billing for Medicaid services must act in cooperation with students’ parent or guardian, and with community and state agencies and professionals who provide like Medicaid services to the student.
a. Notification of Parents. For all students who are receiving Medicaid reimbursed services, school districts and charter schools must document that parents are notified of the Medicaid services and equipment for which they will bill Medicaid. Notification must describe the service(s), service provider(s), and state the type, location, frequency, and duration of the service(s). The school district must document that they provided the student’s parent or guardian with a current copy of the child’s plan and any pertinent addenda; and
b. Primary Care Physician (PCP). School districts and charter schools must request the name of the student’s primary care physician and request a written consent to release and obtain information between the PCP and the school from the parent or guardian.
c. Other Community and State Agencies. Upon receiving a request for a copy of the evaluations or the current plan, the school district or charter school must furnish the requesting agency or professional with a copy of the plan or appropriate evaluation after obtaining consent for release of information from the student's parent or guardian.
You may not seek reimbursement prior to the date the parents/guardians sign the one-time consent form.

The 30-day Retroactive Billing Temporary Rule applies to the physician's signature only.

Answer: No. Federal regulations and IDAPA rule address one-time parental consent. This means that the district only has to obtain parental consent one time, regardless of whether or not the student is continuously enrolled. However, it is incumbent the district to provide annual written notification to the parents regarding their one-time parental consent. Quotations from CFR and IDAPA are below: IDAPA 16.03.09.851.05 Parental Consent. Providers must obtain a one-time parental consent to access public benefits or insurance from a parent or legal guardian for school-based Medicaid reimbursement.

34 CFR 300.154(d)(2)(iv) Prior to accessing a child's or parent's public benefits or insurance for the first time, and after providing notification to the child's parents consistent with paragraph (d)(2)(v) of this section, must obtain written, parental consent…

34 CFR 300.154(d)(2)(v): Prior to accessing a child's or parent's public benefits or insurance for the first time, and annually thereafter, must provide written notification, consistent with § 300.503(c), to the child's parents…

Answer: The MedicAide Newsletter June 2011(click link to be redirected).

This newsletter provides specific guidance related to this issue, page 8. This addresses specifically same service same day.

"Several CPT and HCPCS codes used for evaluations, therapy modalities and procedures specify that one unit equals 15 minutes. Providers may bill a single 15-minute unit for treatment that is greater than or equal to eight minutes. Two units should be billed when the interaction with the participant is greater than or equal to 23 minutes but is less than 38 minutes. This pattern remains the same when calculating the time spent providing the service."

Your question was related to the same service within the same week or month, so if the sessions are 25 minutes on different days the school would bill 2 units for the 25 minutes. The IEP can say 120 minutes per month for any related service.

This information was verified by the Medicaid Integrity Unit.

Answer: The school district must follow the definition of SED as outlined in Idaho Code. The student must have a DSM-V diagnosis that meets the criteria that is outlined in that section of Code from a qualified mental health provider.

(13) "Serious emotional disturbance" means an emotional or behavioral disorder, or a neuropsychiatric condition which results in a serious disability, and which requires sustained treatment interventions, and causes the child's functioning to be impaired in thought, perception, affect or behavior. A disorder shall be considered to "result in a serious disability" if it causes substantial impairment of functioning in family, school or community. A substance abuse disorder does not, by itself, constitute a serious emotional disturbance, although it may coexist with serious emotional disturbance.

IDAPA 16.03.09.852.01

01. Community Based Rehabilitation Services (CBRS). To be eligible for CBRS, the student
participant must meet one (1) of the following: (7-1-16)

a. A student who is a child under eighteen (18) years of age must meet the Serious Emotional
Disturbance (SED) eligibility criteria for children in accordance with the Children’s Mental Health Services Act,
Section 16-2403, Idaho Code. A child who meets the criteria for SED must experience a substantial impairment in
functioning. The child’s level and type of functional impairment must be documented in the school record. A
Department-approved assessment must be used to obtain the child’s initial functional impairment score. Subsequent scores must be obtained at least annually in order to determine the child’s change in functioning that occurs as a result of mental health treatment. (7-1-16)

Answer: Answers from School-Based Fee Schedule revised 08/08/17:

#1 The rates set on July 1, 2017 are rates calculated by Idaho based on guidance from the Centers for Medicare and Medicaid Services (CMS). The H2017 rate did not increase and will remain at $11.35 per unit.

#2 The 96153 code without the modifier "HM" has been corrected to reflect "Professional" and just updated on the 08/08/17 revision of the School-Based Fee Schedule. The 96153 code with the modifier "HM" remains correct to reflect "Paraprofessional."

#3: Yes, the rate for 96153 decreased from $4.56 to $3.98.

Answer: A) If an FBA and/or BIP are completed during the psychological evaluation they can be included in the units billed under 96101 [School Based Fee Schedule: Psychological Testing for Diagnosis/Evaluation by School District – Psychologist/Physician (1 unit = 1 hour)].

B) If the FBA and/or BIP are completed separately from the psychological evaluation, they should be included in the units billed under 96150 [School Based Fee Schedule: Behavioral Assessment (1 unit = 15 minutes)].

Answer: T1002 CPT code is only billed when providing RN oversight of an LPN.
T1002 TD CPT code is the RN actually performing the nursing services.

To clarify the T1002 codes are only allowable when service is delivered by an RN.

T1003 CPT code is billed when LPN is providing the nursing service.

Clarification you will receive RN rates for RN service delivery. LPN will NOT receive RN reimbursement rates. Nurses will be reimbursed by on their license. If there is a nursing shortage of LPNs a RN can provide the service and be reimbursed as an RN. The LPN would never be reimbursed at the RN rate, because they do not meet the qualification to deliver that level of service.

Answer: Per the MedicAide newsletter in January 2017 describes "High, Medium, and Low Complexity that directs you to the new fee schedule. The new fee schedule then defines the time, complexity, and rate for each evaluation level. The new codes are related to how much time is needed to complete the OT/PT evaluations. Student that require 20 minutes to complete the PT evaluation would be considered a "Low Complexity", students requiring 30 minutes would be "Medium Complexity", and 45 minutes a "High Complexity". Evaluations taking longer than 45 minutes cap at the "High Complexity" rate. The rates and times of OT are spelled out in the same way. Please refer to the School-Based Medicaid fee schedule.

Answer: Activities conducted through evaluation and assessment following the IDAPA rule cited below, are billable activities. The questionnaire, interpretation, and child observation are all assessment activities.

Utilizing the AOTA guidelines that were posted on the ITC under FAQs this will help you OT determine what level of complexity the questionnaire would fall under.

Please let us know if you have additional questions.

2. Evaluation And Diagnostic Services. Evaluations to determine eligibility or the need for health-related
services may be reimbursed even if the student is not found eligible for health-related services. Evaluations
completed for educational services only cannot be billed. Evaluations completed must: (3-30-07)
a. Be recommended or referred by a physician or other practitioner of the healing arts. A school
district or charter school may not seek reimbursement for services provided prior to receiving a signed and dated
recommendation or referral; (7-1-13)
b. Be conducted by qualified professionals for the respective discipline as defined in Section 855 of
these rules; (3-20-14)
c. Be directed toward a diagnosis; (7-1-16)
d. Include recommended interventions to address each need; and (7-1-16)
e. Include name, title, and signature of the person conducting the evaluation. (7-1-16)

Answer: Per the MedicAide newsletter in January 2017 describes "High, Medium, and Low Complexity that directs you to the new fee schedule. The new fee schedule then defines the time, complexity, and rate for each evaluation level. However, it does not outline the different components for each level. The new codes are related to how much time is needed to complete the OT/PT evaluations, in addition to how the performance deficits are identified and counted.

CMS for 2017 has changed the related service provider codes for OT and PT. OT and PT codes differ in their reimbursement methodology. The traditional evaluation code has be broken into 3 new complexity codes, which are all reimbursed at the same rate. In addition a new re-evaluation code has been added. The re-evaluation code is reimbursed at a different rate than the initial evaluation.

CMS has identified 2017 as a data collection year to determine if in subsequent years the 3 new evaluation codes might result in a tiered level of reimbursement rate. CMS is requesting that service provides (OT and PT) be critical in choosing the most accurate code for the level evaluation complexity.

CMS is allowing 2017 to be a training year for practitioners on the use of the new coding system. Medical reviewers will not be able to penalize providers regarding the Medical Necessity for the new medical evaluation requirements for the billing year of 2017.

Both the OT and PT national associations have developed guidance for their respective members. Please refer to those association documents.

Additional assessment requirements related to the new complexity codes can be found at the two following links:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9782.pdf

https://www.webpt.com/blog/post/farewell-97001-how-to-use-the-new-pt-and-ot-evaluation-codes

This document: AOTA Evaluation-Codes-Overview-2016 is another resource that may provide guidance.

 

Answer: Low, medium or high (97161-97163 and 97165-97167) codes are for initial evaluation and on-going therapy service delivery. You will use the following codes for OT/PT re-evaluations (97164 and 97168).

Answer: 16.03.09.855.01.b.iii states that the paraprofessional must meet the requirements under the Elementary and Secondary Education Act of 1965, as amended, Title 1, Part A, Section 1119. Page 160 of the Idaho Special Education Manual provides clarification:
1. All Title I paraprofessionals must have a secondary school diploma or its recognized equivalent.
2. Additionally, except as noted below, paraprofessionals hired after January 8, 2002, and working in a program supported with Title I, Part A funds must have:
a. Completed two years of study at an institution of higher education (In Idaho, this is thirty-two (32) credits from an accredited university or college); or
b. Obtained an associate’s (or higher) degree; or
c. Met a rigorous standard of quality and be able to demonstrate, through a formal State or local academic assessment, knowledge of and the ability to assist in instructing, reading, writing, and mathematics (or, as appropriate, reading readiness, writing readiness, and mathematics readiness) (in Idaho this is the ETS Parapro Praxis with a minimum score of 460).

The paraprofessional must meet the above requirements before the district can file for Medicaid reimbursement.

Answer: The rule below does not specify a need to identify the evaluation complexity code. The therapy professional will complete their evaluation assuring the following rule is in compliance and bill according to the activities completed. 01. Physician Orders. (4-2-08) a. All therapy must be ordered by a physician, nurse practitioner, or physician assistant. Such orders must include at a minimum, the service to be provided, the frequency, and, where applicable, the expected duration of time for which the therapy will be needed. If the initial order is to evaluate and treat, but does not specify at least the type of service ordered and the frequency, then: (7-1-16) i. The therapist may perform a therapy evaluation based on the initial physician order for the evaluation; and (7-1-16) ii. The therapist must then develop a therapy plan of care based on that evaluation and send the plan to the ordering physician, nurse practitioner, or physician assistant and begin care; and (7-1-16) iii. The physician, nurse practitioner, or physician assistant must either sign an order specifying the service to be provided, the frequency and the duration, or they must sign the therapy plan of care that includes that information within thirty (30) days for therapy to continue. No claims may be billed until the complete order or the plan of care is signed by the physician, nurse practitioner, or physician assistant. (7-1-16)

Answer: Yes.

The school psychologist will be completing a psychological evaluation that takes in multiple sources of information to determine the need for services in a school environment. You would use a psychological evaluation code 96101.

Answer: 24.13.01.10 Definitions

03. Physical Therapist. An individual who meets all the requirements of Title 54, Chapter 22, Idaho
Code, holds an active license and who engages in the practice of physical therapy. (3-19-07)

04. Physical Therapist Assistant. An individual who meets the requirements of Title 54, Chapter 22,
Idaho Code, holds an active license, and who performs physical therapy procedures and related tasks that have been selected and delegated only by a supervising physical therapist.

16.03.09.734.02
The following provider is qualified to provide therapy services as Medicaid provider.

Physical Therapist, Licensed. A person licensed by the Physical Therapy Licensure Board to
conduct physical therapy assessments and therapy in accordance with the Physical Therapy Practice Act, Title 54,
Chapter 22, Idaho Code, and IDAPA 24.13.01, “Rules Governing the Physical Therapy Licensure Board.” (4-2-08)

Since both individuals must be licensed in the State of Idaho to provide the service, both would bill at the professional rate.

Answer: No. According to IDAPA 16.03.09.853.03: Reimbursable Services. School districts and charter schools can bill for the following health-related services provided to eligible students when the services are provided under the recommendation of a physician or other practitioner of the healing arts for the Medicaid services for which the school district or charter school is seeking reimbursement. A school district or charter school may not seek reimbursement for services provided more than thirty (30) days prior to the signed and dated recommendation or referral. The recommendations or referrals are valid up to three hundred sixty-five (365) days.
a. Behavioral Intervention
b. Behavioral Consultation
c. Medical Equipment and Supplies
d. Nursing Services
e. Occupational Therapy and Evaluation
f. Personal Care Services
g. Physical Therapy and Evaluation
h. Psychological Evaluation
i. Psychotherapy
j. Community Based Rehabilitation Services (CBRS)
k. Speech/Audiological Therapy and Evaluation
l. Social History and Evaluation
m. Transportation Services
n. Interpretive Services

Families can seek financial help to pay for daily nutrition through the Idaho Food Stamps Program at http://healthandwelfare.idaho.gov/Default.aspx?TabId=90.

Answer: Residential treatment facilities are not a Medicaid Provide in the State of Idaho and would be considered the student's home. The school district could provide homebound School-Based Medicaid services as long as the services are identified on the student's IEP.

Answer:1) We put Special Ed Teacher in Grid then our optional statement will state "...services provided by a BI Professional...and/or will be provided by a BI Paraprofessional ...under the direction of a BI Professional." As Special Ed Teacher is the provider/supervisor and para is under their supervision. Is this in compliance OR must we add Paraprofessional to the Grid above also?

This issue was a result of school district using M-Codes on the IEP services grids. If the district does not use the M-Code there is not conflict.

2) Do the minutes in Grid need to match the Optional Statement of Services? We only have conflict for BI services.
As these are provided throughout the school day, if we put all the BI minutes also in the GRID we appear to be providing services over the school day total. Confusing for parents. Our optional statement of services is the accurate minutes provided for BI services. Are we in compliance?

No. The number of BI minutes do not need to be in the grid, Medicaid requires that all of the components are there. This can be in the "optional section".

Answer: A school can bill 96102 for the technician to conduct the Psychological Testing for Diagnosis/Evaluation. The technician must have the experience and training and be qualified to conduct the evaluation. The mental health professional (school psychologist) must interpret the results from the Psychological Testing for Diagnosis Evaluation. To demonstrate compliance, the school would have the evaluation and the results in addition to a service detail report from the technician and the professional. They can perform the assessment but the school psych must interpret the assessment and bill for that interpretation under 96101.

Answer: The description for CPT code 96125, found on the Idaho School-Based Medicaid Fee Schedule, reads: "Standardized cognitive performance testing per hour both face to face administering tests to the patient and time interpreting the test results and preparing the report. (This a Speech and Language test)." Note the reference in parentheses...This is a Speech and Language assessment.

The 2017 Medicare Fee Schedule for Speech-Language Pathologist, published by the American Speech-Language-Hearing Association (http://www.asha.org/uploadedFiles/2017-Medicare-Physician-Fee-Schedule-SLP.pdf) reads: "Standardized cognitive performance testing (e.g., Ross Information Processing Assessment) per hour of a qualified health care professional's time, both face to face administering tests to the patient and time interpreting the test results and preparing the report."

CPT code 96125 is not a code for other assessments, such as the WISC-4 given by a school psychologist.

Answer: Per Idaho Special Education Manual Glossary:
Homebound student. A student whose IEP team determines the child’s home is the least restrictive environment. So if a student is homebound they are receiving all of their instructional time in that environment.

1 - who determines when the student is at school or at home? If the IEP team has determined that the LRE for education is in the student's home then the IEP service would be considered "homebound services." The school would then send in the BI staff and educational staff, since they are not the same person, to provide "homebound" educational services.

2 - If the student is home due to modified school schedule then the activities at home would not be school related. The services provided at home would be community based services, not provided by the school and not a school-based, educational service.

Answer: IDAPA 16.03.09.856.02 Third Party. For requirements regarding third party billing, see Section 215 of these rules. IDAPA 16.03.09.215.05: Billing Third Parties First. Medicaid providers must bill all other sources of direct third party payment...

Medicaid is the payer of last result. Therefore, the district should seek reimbursement from the student's primary insurance FIRST. Keep all documentation associated with billing the primary insurance.

Answer: Question 1: IDAPA 16.03.09.853. SCHOOL-BASED SERVICE: COVERAGE AND LIMITATIONS.
03. Reimbursable Services.
m. Transportation Services. School districts and charter schools can receive reimbursement for mileage for transporting a student to and from home and school when:
i. The student requires special transportation assistance, a wheelchair lift, an attendant, or both, when medically necessary for the health and safety of the student;
ii. The transportation occurs in a vehicle specifically adapted to meet the needs of a student with a disability;
iii. The student requires and receives another Medicaid reimbursable service billed by the school-based services provider, other than transportation, on the day that transportation is being provided;
iv. Both the Medicaid-covered service and the need for the special transportation are included on the student's plan; and
v. The mileage, as well as the services performed by the attendant, are documented.

The requirement is that transportation is documented on the student's plan (IEP).

Questions 2: No; Letter m. Transportation Services. School districts and charter schools can receive reimbursement for mileage for transporting a student to and from home and school ...

CBRS

Answer: The school district must follow the definition of SED as outlined in Idaho Code. The student must have a DSM-V diagnosis that meets the criteria that is outlined in that section of Code from a qualified mental health provider.

(13) "Serious emotional disturbance" means an emotional or behavioral disorder, or a neuropsychiatric condition which results in a serious disability, and which requires sustained treatment interventions, and causes the child's functioning to be impaired in thought, perception, affect or behavior. A disorder shall be considered to "result in a serious disability" if it causes substantial impairment of functioning in family, school or community. A substance abuse disorder does not, by itself, constitute a serious emotional disturbance, although it may coexist with serious emotional disturbance.

IDAPA 16.03.09.852.01

01. Community Based Rehabilitation Services (CBRS). To be eligible for CBRS, the student
participant must meet one (1) of the following: (7-1-16)

a. A student who is a child under eighteen (18) years of age must meet the Serious Emotional
Disturbance (SED) eligibility criteria for children in accordance with the Children’s Mental Health Services Act,
Section 16-2403, Idaho Code. A child who meets the criteria for SED must experience a substantial impairment in
functioning. The child’s level and type of functional impairment must be documented in the school record. A
Department-approved assessment must be used to obtain the child’s initial functional impairment score. Subsequent scores must be obtained at least annually in order to determine the child’s change in functioning that occurs as a result of mental health treatment. (7-1-16)

Answer: Individuals that were hired prior to November 1, 2010 would have already received their PRA certification. The rules prior to this date are found in archived IDAPA rules. I have copied and provided you the section of rule.

See 16.03.10.131

131. PSYCHOSOCIAL REHABILITATIVE SERVICES (PSR) - AGENCY STAFF QUALIFICATIONS. All agency staff delivering direct services must have at least one (1) of the following credentials: (5-8-09)

01. Any of the Professions Listed Under IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Subsection 715.01. (5-8-09)

02. Clinician. A clinician must hold a master's degree, be employed by a state agency and meet the minimum standards established by the Idaho Division of Human Resources and the Idaho Department of Health and Welfare Division of Human Resources. (5-8-09)

03. Psychosocial Rehabilitation (PSR) Specialist. (5-8-09)

a. As of June 30, 2009, persons who are working as PSR Specialists delivering Medicaid- reimbursable mental health services may continue to do so until January 1, 2012, at which time they must be certified as PSR Specialists in accordance with USPRA requirements. (5-8-09)

b. As of July 1, 2009, applicants to become PSR Specialists delivering Medicaid-reimbursable mental health services must have a bachelor’s degree from a nationally-accredited university in Primary Education, Special Education, Adult Education, Counseling, Human Services, Early Childhood Development, Family Science, Psychology, or Applied Behavioral Analysis. Applicants who have a major in one (1) of these identified subject areas, but have a bachelor’s degree in another field, also meet this requirement. (5-8-09)

c. An applicant who meets the educational requirements under Subsection 131.03.b. of this rule may work as a PSR Specialist for a period not to exceed eighteen (18) months while under the supervision of a staff member with a Master's degree or higher credential or a certified PSR Specialist. In order to continue as a PSR Specialist beyond a total period of eighteen (18) months, the worker must obtain the USPRA certification. (5-8-09)

d. An individual who has been denied licensure or who is qualified to apply for licensure to the Idaho Bureau of Occupational Licenses, in the professions identified under Subsections 131.01 through 131.03 of this rule, designation of PSR Specialist with the exception of those individuals who SPRA PSR Specialist certification. (5-8-09)

Answer:Per IDAPA 16.03.09.855.10.k

k. Community Based Rehabilitation Services specialist. A CBRS specialist is:
(7-1-16)
i. An individual who has a Bachelor’s degree and holds a current PRA credential; or
(3-20-14)

ii. An individual who has a Bachelor’s degree or higher and was hired on or after November
1, 2010, to work as a CBRS specialist to deliver Medicaid-reimbursable mental health services. This
individual may continue to do so for a period not to exceed thirty (30) months from the initial
date of hire. The individual must show documentation that they are working towards this
certification. In order to continue as a CBRS specialist beyond a total period of thirty (30)
months from the date of hire, the worker must have completed a certificate program or
rehabilitation based upon the primary population with whom he works in e requirements set by
the PRA. (7-1-16)

iii. Credential required for CBRS specialists.

The following link with take you to the PRA recertification site: http://psychrehabassociation.org/cfrp-recertification

In 2016 the Psychiatric Rehabilitation Association transitioned from a certificate to certification. Individuals wanting to obtain PRA credentialing after May 1, 2016 will be required to meet specific educational requirements, passing a test, and be re-certified every three years. Current holders of a PRA certificate (not certification) do not have a recertification requirement and continue to meet the current IDAPA rule qualification.

Answer: 42 CFR 483.102 - Applicability and definitions

IDAPA 16.03.09.852.1.b refers you to 42 CFR 483.102(b)(1) which is summarized below. PLEASE pull up the full citation and read for clarification.

(b) Definitions.

(1) An individual is considered to have a serious mental illness (MI) if the individual meets the following requirements on diagnosis, level of impairment and duration of illness:

(i) Diagnosis.
(A) A schizophrenic, mood, paranoid, panic or other severe anxiety disorder; somatoform disorder; personality disorder; other psychotic disorder; or another mental disorder that may lead to a chronic disability; but

(ii) Level of impairment. The disorder results in functional limitations in major life activities within the past 3 to 6 months that would be appropriate for the individual's developmental stage. An individual typically has at least one of the following characteristics on a continuing or intermittent basis:

(A) Interpersonal functioning.

(B) Concentration, persistence, and pace.

(C) Adaptation to change. T

(iii) Recent treatment. The treatment history indicates that the individual has experienced at least one of the following:

(A) Psychiatric treatment more intensive than outpatient care more than once in the past 2 years (e.g., partial hospitalization or inpatient hospitalization); or

(B) Within the last 2 years, due to the mental disorder, experienced an episode of significant disruption to the normal living situation, for which supportive services were required to maintain functioning at home, or in a residential treatment environment, or which resulted in intervention by housing or law enforcement officials.

Answer: CBRS does not have a yearly requirement for a FBA, Behavioral Intervention for students who qualify under the Developmental Disabilities rules has this requirement.

16.03.09.853.03.a
a. Behavioral Intervention. Behavioral Intervention is used to promote the student’s ability to participate in educational services, as defined in Section 850 of these rules, through a consistent, assertive, and continuous intervention process to address behavior goals identified on the IEP. It includes the development of replacement behaviors by conducting a functional behavior assessment and behavior implementation plan with the purpose of preventing or treating behavioral conditions for students who exhibit maladaptive behaviors. Services include individual or group behavioral interventions.

Regarding the date question, you will need to complete a new FBA within 365 days from the date of the completion of the previous assessment.

Answer: The eligible student must be diagnosed by a licensed professional that can give a DSM-V Diagnosis.

Answer: Residential treatment facilities are not a Medicaid Provide in the State of Idaho and would be considered the student's home. The school district could provide homebound School-Based Medicaid services as long as the services are identified on the student's IEP.

PCS/Nursing

Answer: T1002 CPT code is only billed when providing RN oversight of an LPN.
T1002 TD CPT code is the RN actually performing the nursing services.

To clarify the T1002 codes are only allowable when service is delivered by an RN.

T1003 CPT code is billed when LPN is providing the nursing service.

Clarification you will receive RN rates for RN service delivery. LPN will NOT receive RN reimbursement rates. Nurses will be reimbursed by on their license. If there is a nursing shortage of LPNs a RN can provide the service and be reimbursed as an RN. The LPN would never be reimbursed at the RN rate, because they do not meet the qualification to deliver that level of service.

Answer: 16.03.09.855.01.b.iii states that the paraprofessional must meet the requirements under the Elementary and Secondary Education Act of 1965, as amended, Title 1, Part A, Section 1119. Page 160 of the Idaho Special Education Manual provides clarification:
1. All Title I paraprofessionals must have a secondary school diploma or its recognized equivalent.
2. Additionally, except as noted below, paraprofessionals hired after January 8, 2002, and working in a program supported with Title I, Part A funds must have:
a. Completed two years of study at an institution of higher education (In Idaho, this is thirty-two (32) credits from an accredited university or college); or
b. Obtained an associate’s (or higher) degree; or
c. Met a rigorous standard of quality and be able to demonstrate, through a formal State or local academic assessment, knowledge of and the ability to assist in instructing, reading, writing, and mathematics (or, as appropriate, reading readiness, writing readiness, and mathematics readiness) (in Idaho this is the ETS Parapro Praxis with a minimum score of 460).

The paraprofessional must meet the above requirements before the district can file for Medicaid reimbursement.

Answer: Thank you for bringing our attention to these discrepancies. The draft version of the Personal Care Services (PCS) Nursing Assessment Tool posted on the Idaho Training Clearinghouse is being removed. The other two forms are correct and have a revised date of 06/2017.

Answer: The rule below does not specify a need to identify the evaluation complexity code. The therapy professional will complete their evaluation assuring the following rule is in compliance and bill according to the activities completed. 01. Physician Orders. (4-2-08) a. All therapy must be ordered by a physician, nurse practitioner, or physician assistant. Such orders must include at a minimum, the service to be provided, the frequency, and, where applicable, the expected duration of time for which the therapy will be needed. If the initial order is to evaluate and treat, but does not specify at least the type of service ordered and the frequency, then: (7-1-16) i. The therapist may perform a therapy evaluation based on the initial physician order for the evaluation; and (7-1-16) ii. The therapist must then develop a therapy plan of care based on that evaluation and send the plan to the ordering physician, nurse practitioner, or physician assistant and begin care; and (7-1-16) iii. The physician, nurse practitioner, or physician assistant must either sign an order specifying the service to be provided, the frequency and the duration, or they must sign the therapy plan of care that includes that information within thirty (30) days for therapy to continue. No claims may be billed until the complete order or the plan of care is signed by the physician, nurse practitioner, or physician assistant. (7-1-16)

Answer: No. According to IDAPA 16.03.09.853.03: Reimbursable Services. School districts and charter schools can bill for the following health-related services provided to eligible students when the services are provided under the recommendation of a physician or other practitioner of the healing arts for the Medicaid services for which the school district or charter school is seeking reimbursement. A school district or charter school may not seek reimbursement for services provided more than thirty (30) days prior to the signed and dated recommendation or referral. The recommendations or referrals are valid up to three hundred sixty-five (365) days.
a. Behavioral Intervention
b. Behavioral Consultation
c. Medical Equipment and Supplies
d. Nursing Services
e. Occupational Therapy and Evaluation
f. Personal Care Services
g. Physical Therapy and Evaluation
h. Psychological Evaluation
i. Psychotherapy
j. Community Based Rehabilitation Services (CBRS)
k. Speech/Audiological Therapy and Evaluation
l. Social History and Evaluation
m. Transportation Services
n. Interpretive Services

Families can seek financial help to pay for daily nutrition through the Idaho Food Stamps Program at http://healthandwelfare.idaho.gov/Default.aspx?TabId=90.

Answer: The School-Based services are Personal Care Services (PCS) and nursing services. As long as the plan of care identified the need for nursing services and the IEP identifies who is providing the service, the the school can bill nursing services. School-Based rules do not delineate between an LPN and RN. If the service can be delineated to a non-profession then the service is considered PCS services not nursing.

IDAPA 16.03.09.853.03.d

d. Nursing Services. Skilled nursing services must be provided by a licensed nurse, within the scope
of his or her practice. Emergency, first aid, or non-routine medications not identified on the plan as a health-related service are not reimbursed.

Answer:16.03.09.853.3.d

d. Nursing Services. Skilled nursing services must be provided by a licensed nurse, within the scope
of his or her practice. Emergency, first aid, or non-routine medications not identified on the plan as a health-related service are not reimbursed.

What is the LPN doing while monitoring the student? What activities is the LPN doing when working directly with the student? Medicaid does not reimburse of monitoring activities only for the actual nursing service.

If the student's medical condition is severe enough to require constant supervision for health and safety issues and the current level of support is beyond what Medicaid is currently providing reimbursement, the district can always submit an EPSDT request. You can find this form at the following link under Forms on the far right column at the bottom of the page. Be sure to provide all of the necessary paperwork and utilize the student's primary care physician, when making an EPSDT request.

http://healthandwelfare.idaho.gov/Medical/Medicaid/SchoolBasedServices/tabid/1587/Default.aspx

The RN can bill for PCS oversight and supervision. Are the activities conducted by the RN related to the student's health care plan or PCS services.

16.03.09.855.6.c.

c. The RN must conduct supervisory visits on a quarterly basis, or more frequently as determined by
the IEP team and defined as part of the PCS plan of care.

Therapies – OT, PT, SLP

Answer: Yes, a therapist can provide services to a homebound student any day of the week as long as it is documented on the IEP that homebound services do not follow a traditional school day and identifies that student's school day. The therapist documentation would then reflect the service.

Answer: T1002 CPT code is only billed when providing RN oversight of an LPN.
T1002 TD CPT code is the RN actually performing the nursing services.

To clarify the T1002 codes are only allowable when service is delivered by an RN.

T1003 CPT code is billed when LPN is providing the nursing service.

Clarification you will receive RN rates for RN service delivery. LPN will NOT receive RN reimbursement rates. Nurses will be reimbursed by on their license. If there is a nursing shortage of LPNs a RN can provide the service and be reimbursed as an RN. The LPN would never be reimbursed at the RN rate, because they do not meet the qualification to deliver that level of service.

Answer: Activities conducted through evaluation and assessment following the IDAPA rule cited below, are billable activities. The questionnaire, interpretation, and child observation are all assessment activities.

Utilizing the AOTA guidelines that were posted on the ITC under FAQs this will help you OT determine what level of complexity the questionnaire would fall under.

Please let us know if you have additional questions.

2. Evaluation And Diagnostic Services. Evaluations to determine eligibility or the need for health-related
services may be reimbursed even if the student is not found eligible for health-related services. Evaluations
completed for educational services only cannot be billed. Evaluations completed must: (3-30-07)
a. Be recommended or referred by a physician or other practitioner of the healing arts. A school
district or charter school may not seek reimbursement for services provided prior to receiving a signed and dated
recommendation or referral; (7-1-13)
b. Be conducted by qualified professionals for the respective discipline as defined in Section 855 of
these rules; (3-20-14)
c. Be directed toward a diagnosis; (7-1-16)
d. Include recommended interventions to address each need; and (7-1-16)
e. Include name, title, and signature of the person conducting the evaluation. (7-1-16)

Answer: Per the MedicAide newsletter in January 2017 describes "High, Medium, and Low Complexity that directs you to the new fee schedule. The new fee schedule then defines the time, complexity, and rate for each evaluation level. However, it does not outline the different components for each level. The new codes are related to how much time is needed to complete the OT/PT evaluations, in addition to how the performance deficits are identified and counted.

CMS for 2017 has changed the related service provider codes for OT and PT. OT and PT codes differ in their reimbursement methodology. The traditional evaluation code has be broken into 3 new complexity codes, which are all reimbursed at the same rate. In addition a new re-evaluation code has been added. The re-evaluation code is reimbursed at a different rate than the initial evaluation.

CMS has identified 2017 as a data collection year to determine if in subsequent years the 3 new evaluation codes might result in a tiered level of reimbursement rate. CMS is requesting that service provides (OT and PT) be critical in choosing the most accurate code for the level evaluation complexity.

CMS is allowing 2017 to be a training year for practitioners on the use of the new coding system. Medical reviewers will not be able to penalize providers regarding the Medical Necessity for the new medical evaluation requirements for the billing year of 2017.

Both the OT and PT national associations have developed guidance for their respective members. Please refer to those association documents.

Additional assessment requirements related to the new complexity codes can be found at the two following links:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9782.pdf

https://www.webpt.com/blog/post/farewell-97001-how-to-use-the-new-pt-and-ot-evaluation-codes

This document: AOTA Evaluation-Codes-Overview-2016 is another resource that may provide guidance.

 

Answer: Low, medium or high (97161-97163 and 97165-97167) codes are for initial evaluation and on-going therapy service delivery. You will use the following codes for OT/PT re-evaluations (97164 and 97168).

Answer: The rule below does not specify a need to identify the evaluation complexity code. The therapy professional will complete their evaluation assuring the following rule is in compliance and bill according to the activities completed. 01. Physician Orders. (4-2-08) a. All therapy must be ordered by a physician, nurse practitioner, or physician assistant. Such orders must include at a minimum, the service to be provided, the frequency, and, where applicable, the expected duration of time for which the therapy will be needed. If the initial order is to evaluate and treat, but does not specify at least the type of service ordered and the frequency, then: (7-1-16) i. The therapist may perform a therapy evaluation based on the initial physician order for the evaluation; and (7-1-16) ii. The therapist must then develop a therapy plan of care based on that evaluation and send the plan to the ordering physician, nurse practitioner, or physician assistant and begin care; and (7-1-16) iii. The physician, nurse practitioner, or physician assistant must either sign an order specifying the service to be provided, the frequency and the duration, or they must sign the therapy plan of care that includes that information within thirty (30) days for therapy to continue. No claims may be billed until the complete order or the plan of care is signed by the physician, nurse practitioner, or physician assistant. (7-1-16)

Answer: 24.13.01.10 Definitions

03. Physical Therapist. An individual who meets all the requirements of Title 54, Chapter 22, Idaho
Code, holds an active license and who engages in the practice of physical therapy. (3-19-07)

04. Physical Therapist Assistant. An individual who meets the requirements of Title 54, Chapter 22,
Idaho Code, holds an active license, and who performs physical therapy procedures and related tasks that have been selected and delegated only by a supervising physical therapist.

16.03.09.734.02
The following provider is qualified to provide therapy services as Medicaid provider.

Physical Therapist, Licensed. A person licensed by the Physical Therapy Licensure Board to
conduct physical therapy assessments and therapy in accordance with the Physical Therapy Practice Act, Title 54,
Chapter 22, Idaho Code, and IDAPA 24.13.01, “Rules Governing the Physical Therapy Licensure Board.” (4-2-08)

Since both individuals must be licensed in the State of Idaho to provide the service, both would bill at the professional rate.

Answer: The MedicAide Newsletter June 2011(click link to be redirected).

This newsletter provides specific guidance related to this issue, page 8. This addresses specifically same service same day.

"Several CPT and HCPCS codes used for evaluations, therapy modalities and procedures specify that one unit equals 15 minutes. Providers may bill a single 15-minute unit for treatment that is greater than or equal to eight minutes. Two units should be billed when the interaction with the participant is greater than or equal to 23 minutes but is less than 38 minutes. This pattern remains the same when calculating the time spent providing the service."

Your question was related to the same service within the same week or month, so if the sessions are 25 minutes on different days the school would bill 2 units for the 25 minutes. The IEP can say 120 minutes per month for any related service.

This information was verified by the Medicaid Integrity Unit.

Answer:If I understand your question correctly, you are wanting to know if you could bill at a professional level if a 3 C'd, licensed, ASHA certified SLP was supervising the entire grad student's therapy session. Per the rule below the SLP would be providing supervision to a para you would be billing the para rate while the para is providing the therapy. If the licensed SLP was providing the therapy and the para was observing the therapy then you would be billing at the professional rate. You bill based on who is providing the therapy or service, not who is in the room.

16.03.09.855.14.c
14. Therapy Paraprofessionals. The schools may use paraprofessionals to provide occupational
therapy, physical therapy, and speech therapy if they are under the supervision of the appropriate
professional. The services provided by paraprofessionals must be delegated and supervised by a
professional therapist as defined by the appropriate licensure and certification rules. The
portions of the treatment plan that can be delegated to the paraprofessional must be identified in
the IEP or transitional IFSP. (7-1-16)

c. Speech-Language Pathology (SLP). Refer to IDAPA 24.23.01, “Rule of the Speech and Hearing
Services Licensure Board,” and the American Speech-Language-Hearing Association (ASHA) guidelines
for qualifications, supervision and service requirements for speech-language pathology. The
guidelines have been incorporated by reference in Section 004 of these rules. (7-1-16)

i. Supervision must be provided by an SLP professional as defined in Section 734 of this
chapter of rules. (7-1-16)

ii. The professional must observe and review the direct services performed by the
paraprofessional on a monthly basis, or more often as necessary, to ensure the paraprofessional
demonstrates the necessary skills to correctly provide the SLP service. (7-1-16)

16.03.09.734.3

03. Speech-Language Pathologist, Licensed. A person licensed by the Speech and Hearing Services
Licensure Board to conduct speech-language assessments and therapy in accordance with the Speech and Hearing Services Practice Act, Title 54, Chapter 29, Idaho Code, and IDAPA 24.23.01, “Rules of the Speech and Hearing Services Licensure Board,” who possesses a certificate of clinical competence in speech-language pathology from the American Speech, Language, and Hearing Association (ASHA) or who will be eligible for certification within one (1) year of employment.

Answer: Yes, the SLP will be completing a speech language evaluation that takes in multiple sources of information to determine the need for services in a school environment. You would use the SLP evaluation code that address the part of speech being reviewed. The SLP will need to determine if it is fluency, articulation, etc.


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karren streagle, ph.d

Early Childhood/Alternate Assessment Coordinator
Idaho State Department of Education
P.O. Box 83720 Boise, Idaho 83720
208-332-6824
kstreagle@sde.idaho.gov

sde Idaho State Department of Education
650 W. State Street
PO Box 83720
Boise, ID 83720-0027