HCBS TBI Drug / Alchohol Therapy

Transcription

1 KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL HCBS TBI Drug / Alchohol Therapy

2 PART II TBI DRUG/ALCOHOL ABUSE THERAPY PROVIDER MANUAL Section BILLING INSTRUCTIONS Page 7000 TBI Drug/Alcohol Abuse Therapy Billing Instructions Submission of Claim TBI Drug/Alcohol Abuse Therapy Specific Billing Information BENEFITS AND LIMITATIONS 8400 Medicaid/MediKan HCFA-1500 CMS-1500 Form

3 INTRODUCTION TO THE HCBS/TBI WAIVER PROGRAM Updated 04/07 The Home and Community Based Services (HCBS) Traumatic Brain Injury (TBI) Waiver is designed to meet the needs of individuals who have sustained a traumatically acquired external nondegenerative, structural brain injury resulting in residual deficits and disability. The HCBS waivers are designed to prevent institutionalization of consumers. The variety of services listed below are designed to provide the least restrictive means for maintaining the overall physical and mental condition of those individuals with the desire to live outside of an institution. It is the consumer s choice to participate in HCBS programs. Services include: Assistive Services Personal Emergency Response Systems Personal Services Rehabilitation Therapies: Behavioral, Cognitive, Drug and Alcohol Therapy, Physical Therapy, Speech-Language Therapy, and Occupational Therapy Sleep Cycle Support Transitional Living Skills All HCBS TBI waiver services (with the exception of Adult Oral Health Services) require prior authorization through the plan of care process. Effective with dates of service on and after April 1, 2007, oral health services are available to adults ages 21 and older who are enrolled in the HCBS MR/DD, Traumatic Brain Injury (TBI), and Physically Disabled (PD) waiver programs. Refer to Exhibit D in the Dental Provider Manual for services available for HCBS MR/DD, TBI, and PD adult beneficiaries. Enrollment: HCBS TBI All HCBS TBI providers must enroll in the Kansas Medical Assistance Program and receive a provider number for HCBS TBI services. Contact EDS for enrollment. Note: EDS supplies manuals for each HCBS TBI program in which the provider is enrolled. HIPAA Compliance As a participant in the Kansas Medical Assistance Program, providers are required to comply with compliance reviews and complaint investigations conducted by the Secretary of the Department of Health and Human Services as part of the Health Insurance Portability and Accountability Act (HIPAA) in accordance with section 45 of the code of regulations parts 160 and 164. Providers are required to furnish the Department of Health and Human Services all information required by the Department during its review and investigation. The provider is required to provide the same forms of access to records to the Medicaid Fraud and Abuse Division of the Kansas Attorney General's Office upon request from such office as required by K.S.A and amendments thereto. A provider who receives such a request for access to or inspection of documents and records must promptly and reasonably comply with access to the records and facility at reasonable times and places. A provider must not obstruct any audit, review or investigation, including the relevant questioning of employees of the provider. The provider shall not charge a fee for retrieving and copying documents and records related to compliance reviews and complaint investigations.

4 7000. TBI DRUG/ALCOHOL ABUSE THERAPY BILLING INSTRUCTIONS Introduction to the HCFA-1500 CMS-1500 Claim Form Updated 05/07 Providers must use the HCFA-1500 CMS-1500 claim form (unless submitting electronically) when requesting payment for medical services provided under the Kansas Medical Assistance Program (KMAP). An example of the HCFA-1500 CMS-1500 claim form is shown at the end of this manual. The Kansas MMIS will be using electronic imaging and optical character recognition (OCR) equipment. Therefore, information will not be recognized if not submitted in the correct fields as instructed. EDS does not furnish the HCFA-1500 CMS-1500 claim form to providers. Refer to Section 1100 of the General Introduction Provider Manual. Complete, line by line instructions for completion of the HCFA 1500 CMS-1500 are available in the General Billing Provider Manual., pages 5-14 through SUBMISSION OF CLAIM: Send completed first page of each claim and any necessary attachments to: Kansas Medical Assistance Program Office of the Fiscal Agent P.O. Box 3571 Topeka, Kansas BILLING INSTRUCTIONS 7-1

5 7010. TBI DRUG/ALCOHOL ABUSE THERAPY SPECIFIC BILLING INFORMATION Updated 05/07 Enter procedure code T1012 (TBI Drug/Alcohol Abuse Therapy) in field 24D of the HCFA-1500 CMS-1500 claim form. One unit = 15 minutes Client Obligation: If a case manager has assigned client obligation to a particular provider and informed that provider that they are to collect this portion of the cost of service from the client, the provider will not reduce the billed amount on the claim by the client obligation because the liability will automatically be deducted as claims are processed. Overlapping Dates of Service: The dates of service on the claim must match the dates approved on the plan of care and cannot overlap Example: An electronic Plan of Care has two detail lines items: the first line ends on the 15th of the month and the second line begins on the 16th with and increase of units. A claim with a line item for services dated 8th thru 16th, will deny because it conflicts with the dates that have been approved on the electronic Plan of Care. At this time the claims system is not able to read two different lines on the Plan of Care for one line on a claim. For the first detail line item listed above (up to the 15th of the month), any service dates that fall between the 1st and the 15th of that month, will be accepted by the system and not deny because of a conflict in the dates of service. Services for multiple months should be separated out and each month submitted on a separate claim. Same Day Service: For certain situations, HCBS services approved on a plan of care and provided the same time a consumer is hospitalized or in a nursing facility may be allowed. Situations are limited to:. HCBS services provided the date of admission, if provided prior to consumer being admitted. HCBS services provided the date of discharge, if provided following the consumer s discharge. Targeted Case Management. Medical Alert services BILLING INSTRUCTIONS 7-2

6 8400. Updated 9/04 MEDICAID BENEFITS AND LIMITATIONS Home and community based waiver services for persons with a traumatically acquired brain injury (HCBS/TBI) are designed to prevent individuals from entering or remaining in a head injury rehabilitation facility (HIRF). Limitations: HCBS/TBI services are available to individuals who are Medicaid-eligible and meet the criteria for institutionalization in a HIRF. The eligible individual must meet the following qualifications: Be a Kansas resident upon receiving services, and for the duration of services. Have been diagnosed with external, traumatically acquired non-degenerative, structural brain injury resulting in residual deficits and disability. Trauma is defined as a physical injury caused by external force or violence. All beneficiaries will be diagnosed as having closed brain injury. Examples of situations where the brain injury may have occurred include: a. Blow to the head b. Motor vehicular accident c. Fall to the ground d. Physical abuse e. Coup/Contre-Coup injuries An individual must be at least 16 years of age but less than 65 years of age to receive HCBS/TBI waiver services. However, if a person is receiving waiver services at age 65 and is still showing progress in their rehabilitation, special consideration may be given by the TBI Program Manager for them to remain on the waiver past the age of 65 until a time when they no longer significantly benefit from transitional living skills and rehabilitation therapies. If the consumer will be age 16 by the time services are due to begin, the assessment may be completed prior to age 16. If a consumer is 64 years of age at the time of the assessment, they must begin services before the age of 65 to be eligible. Requires and can benefit from training in transitional living skills, Requires restorative/rehabilitation, treatment, or care, Requires restorative/rehabilitation, social activity, and dietary services which are restorative and rehabilitative, May require supervision for safety. Rehabilitation services under the Kansas State Plan for Medicaid funding are not covered after the sixth month following the date of the first treatment following a physical debilitation resulting from acute physical trauma. Since many consumers with brain injury continue to require these services well beyond the seventh month post injury and these therapies will be necessary to maintain skills that were learned, they are included in the waiver. BENEFITS & LIMITATIONS 8-1

7 8400. Updated 9/04 There is a limitation of 3744 units (one unit = 15 minutes) per consumer, per calendar year for any combination of the following HCBS/TBI therapies: behavioral, cognitive, drug/alcohol, occupational, physical, and speech/language. Recordkeeping: Recordkeeping responsibilities rest primarily with the provider. Each visit must be documented by date and be goal directed to meet the objectives of being restorative and rehabilitative. Documentation: Documentation is the responsibility of the provider of the service. Documentation should be clear, concise and factual. Consumers' files should include a report of the facts, summary of an activity, a chronological history, and any observations that have been made. Documentation should be legible, accurate and timely. Consumers' files may be used for supervisory reviews, HSST, Quality Assurance Review and issues related to client obligations. Each visit must be documented. Documentation must include: Identify service being provided Consumer s first & last name Date of Service (MM/DD/YY) Start time for each visit; include AM/PM or utilize 2400 clock hours Stop time for each visit; include AM/PM or utilize 2400 clock hours Identified goals & objectives with target dates and ongoing evaluation of effectiveness of therapy Narrative log that is goal directed to meet the objectives of being restorative and rehabilitative Service provider s name & signature with credentials Time should be totaled by actual minutes/hours worked. Billing staff may round the total to the quarter hour at the end of the billing cycle. Providers are responsible to insure the service was provided prior to submitting claims. Documentation must be completed at the time of the visit. Generating documentation after-thefact is not acceptable. Documentation must be clearly written and self-explanatory, or reimbursement may be subject to recoupment. Signature Limitations In all situations the expectation is that the consumer provides oversight and accountability for people providing services for them. Signature options are provided in recognition that a consumer's limitations make it necessary that they be assisted in carrying out this function. A designated signatory may be anyone who is aware services were provided. The individual providing the services cannot sign the timesheet on behalf of the consumer. BENEFITS & LIMITATIONS 8-2

8 8400 Updated 9/04 Each time sheet must contain the signature of the consumer or designated signatory verifying that the consumer received the services and that the time recorded on the timesheet is accurate. The approved signing options include: 1. Consumer's signature, 2. Consumer making a distinct mark representing their signature, 3. Consumer using their signature stamp or, 4. Designated signatory. In situations where there is no one to serve as designated signatory the billing provider establishes, documents and monitors a plan based on the first three concepts above. Consumers that refused to sign accurate time sheets when there is no legitimate reason, should be advised that the attendants time may not be paid or money may be taken back. Time sheets that do not reflect time and services accurately should not be signed. Unsigned timesheets are a matter for the billing provider to address. Provider Requirements: Assessment, coordinated program planning and direct services on an intensive, regular and continuing basis must be provided by a licensed professional with training, experience, and expertise in brain injury rehabilitation. Definitions: Alcohol and drug abuse therapy must be provided by Community Mental Health Centers, or individuals licensed by the Behavior Sciences Regulatory Board, or individuals who have a Masters degree in a behavioral science field,( e.g., psychologists, social workers, counselors, etc.) with eight hours of training or one year of experience working with individuals with brain injuries. An individual working under the supervision of an enrolled, licensed/educated provider meeting the above qualifications may also provide these services. Drug and alcohol abuse therapy - A procedure used by clinical social workers and other professionals in guiding individuals by giving advice, delineating alternatives, and providing needed information in order to alter drug and/or alcohol abuse and addiction. Plan of Care - a document completed following the determination of traumatic brain injury eligibility, after the individual elects home and community based services (HCBS/TBI) instead of head injury rehabilitation facilities (HIRF). This document, subject to the approval of the TBI Program Manager or other designated SRS staff, must include:. The service to be provided,. The frequency of each service,. Who will provide the service, and. The cost of the service. BENEFITS & LIMITATIONS 8-3

9 Updated 9/04 Expected Service Outcomes For Individuals or Agencies Providing HCBS/TBI Services 1. Services are provided according to the plan of care and in a quality manner and as authorized on the notice of action. 2. Coordinate provision of services in a cost-effective and quality manner. 3. Maintain consumers' independence and health where possible, and in a safe and dignified manner. 4. Communicate consumer concerns/needs, changes in health status, etc., to the Case Manager or Independent Living Counselor within 48 hours including any ongoing reporting as required by the Medicaid program. 5. Any failure or inability to provide services as scheduled in accordance with the plan of care must be reported immediately, but not to exceed 48 hours, to the Case Manager or the Independent Living Counselor. BENEFITS & LIMITATIONS 8-4

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