Local Health Jurisdictions - Coding Scenarios Medicaid Administrative Match. 1 Direct Medical Care (Providing care, treatment and counseling services)

Transcription

1 Local Health Jurisdictions - Coding Scenarios Medicaid Administrative Match Code 1 Direct Medical Care (Providing care, treatment and counseling services) 2 Non-Medicaid Other Program Scenario Activity: A nurse makes a Maternity Support Services (MSS) home visit to a postpartum mother and her infant. Takes infant s height/weight, assists mother with a dental referral, and does charting after the visit. Explanation: MSS is a direct service covered by Medicaid. Charting for a patient care visit is also part of direct patient care. Random moments that occur during this time should all be reported as Code 1. Activity: A social worker prepares to teach a parenting class. Explanation: Preparing for and teaching parenting classes (and other education classes on healthy lifestyles or general health maintenance, such as CPR or weight reduction) should be reported to Code 2. Parenting education is not a Medicaid-covered service. Activity: A public health nurse is charting her activity related to a contact investigation for TB. Explanation: Public health activities, such as communicable disease investigations and other non-medical or non- Medicaid-related direct services, should be reported Code 2, as well as any related charting or paperwork. 25 General Administration Activity: A nurse submits her monthly summary for her time card. Explanation: related to payroll are general administrative in nature and are reported as Code 25. reported as Code 25, generally, are not client-focused and not related to a specific program. 26 Paid Time Off Activity: An outreach worker takes a vacation day. Explanation: Paid leave time should be reported as Code Unpaid Time; Time Not Scheduled to Work Outreach and Eligibility 3a Non-Medicaid Outreach 3b Medicaid Outreach for Adults Activity: A nurse is scheduled to work Monday-Friday from 8 am to 5 pm. She attends a community meeting about prenatal health disparities one evening, and comes in at 10 am the next morning. The payroll record captures the time spent at the community meeting, but will show that she was not working and not paid Friday morning from 8 to 10 am. Explanation: A random moment that occurs on the morning when the nurse is not working (and not paid) is reported as Code 27. Activity: A public health employee gives a client a list of food banks in his neighborhood. Activity: An outreach worker provides an adult with information about the Basic Health program. Explanation: Informing individuals about social services or other non-medicaid programs and services and how to access them is reported to Code 3a. Activity: A public health nurse is reviewing a flyer for a Medicaid outreach campaign to inform women about the availability of Medicaid-covered breast and cervical health screens. Explanation: Providing information about Medicaid and Medicaid-covered services to adults is reported to Code 3b. Page 1

2 3c Medical Assistance Outreach for Children Under 19 5a Facilitating Application for Non-Medicaid Programs 5b Facilitating Medicaid Applications for Adults 5c Facilitating Medical Assistance Applications for Children Under 19 Referral, Coordination & Monitoring (Linkage) 8a Non-SPMP Referral, Coordination & Monitoring of Non-Medicaid Services 8b Non-SPMP Referral, Coordination & Monitoring of Medicaid Services for Adults 8c Non-SPMP Referral, Coordination & Monitoring of Medical Assistance Services for Children Under 19 Activity: A nurse gives information about applying for Medicaid to an unemployed family whose children are uninsured. Activity: An office assistant gives caller information on the availability of dental care that will be covered by her child s medical coupon. Explanation: Providing information about medical assistance and its benefits to children under 19 is reported to Code 3c. Activity: A clerk in a public health office gives information by phone about eligibility requirements for WIC. Explanation: Explaining eligibility rules and the eligibility process for non-medicaid programs, such as WIC, TANF, SSI, etc., as well as assisting with applications for these programs is reported to Code 5a. Activity: A nurse assists a woman to complete an application for Alien Emergency Medical for her own mother, who just had emergency surgery. Activity: An office assistant assists a woman to complete an application for Take Charge (her agency is not a Take Charge provider). Explanation: Explaining eligibility rules and the eligibility process for Medicaid for adults is Code 5b. Activity: A social worker assists a parent to complete an Apple Health for Kids application for her children and assists in assembling the documentation required for the application. Explanation: A random moment that occurs while assisting someone to complete an application for medical assistance benefits is reported to Code 5c. Explaining eligibility rules and the eligibility process for Apple Health for Kids is also Code 5c. Activity: A home visiting nurse refers a client to Section 8 housing. Explanation: Time spent making a referral to housing or any service that is not covered by Medicaid is reported to Code 8a. Activity: A public health nurse refers a client to a Medical Center Hepatitis Clinic for follow up with his Hepatitis C diagnosis. Activity: A few days later she checks back with the client to make sure he was able to keep the appointment, and to assist with arrangements for recommended medical care. Explanation: The time the nurse spends making a referral to a service covered by Medicaid is reported to Code 8b. The time spent following up on the referral is also Code 8b. Activity: A public health nurse refers a child to his primary care provider because mother described symptoms that suggest mumps. Activity: A few days later she checks back with the mother to make sure she got the child to the doctor, and to see if any assistance is needed with medical follow up. Page 2

3 Explanation: The time the nurse spends making a referral to a service covered by medical assistance is reported to Code 8c. The time spent following up on the referral is also Code 8c. 9a SPMP Care Management for Non-Medicaid Services 9b SPMP Medical Care Management Transportation 12a Arranging Transportation for Non-Medicaid Covered Services 12b Arranging Transportation for Medicaid-Covered Services Activity: A registered dietician is talking with a parent about the need for iron supplements for her son - how not providing them may affect the child s development. Explanation: Professional dietician training and education in the consequences of diet deficiencies required to determine need for or adequacy of child s nutritional care. Code 9a includes determining the need for or adequacy of non-medicaid services. Activity: A public health nurse calls a medical provider to respond to a request for additional medical information on the need for Synagis for a premature infant with significant pulmonary compromise. Explanation: Professional nursing training and education in the medical complications of premature birth required to determine need for or adequacy of medical care and services. Code 9b includes determining the need for or adequacy of Medicaid-covered services when not an integral part of Direct Medical Care. Activity: A case aide arranges transportation for a mother and her infant to get to a WIC appointment. Explanation: Arranging, scheduling or providing transportation so that an individual can access WIC or other services not covered by Medicaid is reported to Code 12a. Activity: A case aide helps an individual arrange transportation through the DSHS Medicaid transportation brokerage system so that she can get her children to their well-child exams. Activity: A social worker arranges for a young mom with premature twins to obtain transportation to their pediatrician s appointment. Explanation: Time spent educating clients on the Medicaid transportation brokerage system, and assisting individuals to arrange transportation to Medicaid services, are reported to Code 12b. Interpretation Codes 14, 15, and 16 may only be used by individuals certified by DSHS or qualified by the LHJ to furnish interpreter services. 14a Interpretation for Non- Activity: A certified or qualified interpreter provides interpreter services for a public health nurse who is talking Medicaid Services to a parent about nutrition issues for her child. Explanation: Interpreter services furnished for a non-medicaid service such as WIC are reported to Code 14a. 14b Interpretation for Medicaid-Covered Medical Services for Adults 14c Interpretation for Medical Assistance Services for Children Under 19 Activity: A certified or qualified interpreter interprets for a nurse vaccinating an elderly client. Explanation: Code 14b is limited to interpretation services that are integral to the delivery of Medicaidcovered services furnished to adults. Activity: A certified or qualified interpreter provides interpreter services for a public health nurse during a billable MSS visit. Explanation: Code 14c is limited to interpretation services that are integral to the delivery of a medical Page 3

4 assistance service furnished to a child under a Interpretation for Non- Medicaid Related Outreach 15b Interpretation for Medicaid Outreach for Adults 15c Interpretation for Medical Assistance Outreach for Children Under 19 16a Interpretation for Non- Medicaid Related Linkage 16b Interpretation for Medicaid-Related Linkage for Adults 16c Interpretation for Medical Assistance-Related Linkage for Children Under 19 Activity: A certified or qualified interpreter is translating information for an outreach worker to use in a HIV prevention campaign. Explanation: Interpreter services furnished for non-medicaid outreach, such as HIV prevention, are reported to Code 15a. Activity: A certified or qualified interpreter is interpreting for a public health nurse assisting a woman to apply for the Take Charge program. The LHJ is not a Take Charge provider. Explanation: Code 15b may be used when interpreting information about the Medicaid program or Medicaid services to adults. It also includes assisting with applications and written translation of Medicaid outreach material. Activity: A certified or qualified interpreter is translating a brochure on immunizations to be used in an outreach campaign focused on families of children aged 0-5 in specific zip codes of the county. Explanation: Code 15c may be used when interpreting information about the medical assistance program and its services to children under 19. It also includes assistance with the application and written translation of medical assistance outreach material. Activity: A certified or qualified interpreter interprets for a public health nurse who is gathering information from a non-english speaking client in order to refer her to a domestic violence shelter. Explanation: Interpretation services that assist an individual to access non-medicaid services, such as domestic violence services, are reported to Code 16a. Activity: At the request of the public health nurse, who is not bilingual, a certified or qualified interpreter helps a woman schedule a mammogram. Explanation: Code16b may be used for interpreting that assists adults to access Medicaid-covered services. Activity: A certified or qualified interpreter helps a Spanish-speaking mother schedule an evaluation for her hearing-impaired child with an audiologist. Explanation: Code 16c maybe used for interpreting that assists children under 19 to access medical assistance services. Child Profile and Immunization Program 18a Non-Medicaid Activity: A nurse consults with a local provider about vaccines needed to be given to a child about to travel Immunization Program with her parents to Africa. Explanation: Immunization program activities not related to Medicaid-covered immunization services are reported to Code 18a. 18b Child Profile and Activity: An office assistant retrieves a child s immunization history from Child Profile for a parent who called in Page 4

5 Pediatric Immunization Program Systems Level 19a Non-SPMP Program Planning, Policy Development, and/or Interagency Coordination Related to Non- Medicaid Services 19b Non-SPMP Program Planning, Policy Development, and/or Interagency Coordination Related to Medicaid Services 9c SPMP Program Planning, Policy Development, and/or Interagency Coordination Related to Non-Medicaid Services 9d SPMP Program Planning, Policy Development, and/or Interagency Coordination Related to Medicaid Services to request the information. Explanation: The Medicaid State Plan requires that children eligible for vaccines under the Pediatric Immunization Program are provided medically appropriate vaccines according the schedule developed by the Advisory Committee on Immunization Practices, so time spent on this activity is reported to Code 18b. Activity: A nurse arranges for some of the LHJ s pediatric vaccines to be transferred to a rural pediatric provider, whose vaccines were compromised during a lengthy power outage. There is no stock on hand and the next shipment is not expected to arrive for two weeks. Explanation: The Medicaid State Plan language for the Pediatric Immunization Program requires that eligible children be provided with medically appropriate vaccines and that the availability of the vaccines is ensured, so this activity is reported to Code 18b. Activity: A social worker participates in a planning meeting to develop an after-school program for middle school youth. There are several community agencies involved. Explanation: As no specific Medicaid services are being planned, this interagency planning/community resource development activity is reported to Code 19a. Activity: An oral health coordinator is attending a State Oral Health Coalition meeting where the discussion focuses on a report describing the reasons dentists are reluctant to treat Medicaid patients. Report was commissioned as the first step in a regional planning effort to improve access to oral health care for Medicaid and uninsured children. Activity: A public health nurse manager is attending a regional meeting on children with special health care needs where the discussion is on barriers being experienced by parents when attempting to obtain medical services for their children, and strategizing about how best to address these concerns. Explanation: When activity at the time of the random moment is related to developing or planning services, programs and resources that relate to Medicaid covered services, as well as interagency activities to improve the availability, quality and cost-effectiveness of the Medicaid health care delivery system, it is reported to Code 19b. Collecting and analyzing Medicaid data to identify needs or improve service coordination and delivery is also reported to this code. Activity: A public health nurse is attending a meeting with staff from a local hospital discussing infection control protocols for patients with resistant staph wound infections. Explanation: Professional medical training and education is needed to establish protocols for this interagency activity, but infection control is not a Medicaid covered service. Activity: A public health nurse attends a meeting at office of community medical provider to discuss most current clinical practices for assessing and treating the increased occurrence of methicillin resistant staph infections in their patients. Explanation: Professional nursing training and education in assessment, transmission, and treatment of MRSA needed to consult with medical provider on most clinically effective methods of Medicaid-covered care for Page 5

6 these patients. Time spent working with other medical providers to improve the delivery of Medicaid services to persons at risk of poor health outcome should be reported to Code 9d when SPMP education and training is required, and the individual s job description requires an SPMP. Activity: A public health nurse analyzes a community medical provider s history of vaccine usage to assess whether children are receiving medically appropriate vaccines. Explanation: Professional nursing training and education in viability of vaccines in out of range situations is needed to recommend improvements in clinical effectiveness of immunization services. Providing medical expertise around clinical standards of care in Medicaid-covered services is reported to Code 9d when SPMP education and training is required, and the individual s job description requires an SPMP. 21a Outreach to Non- Medicaid Providers to Accept Underserved Clients 21b -- Outreach to Medicaid Providers to Accept Medicaid Patients Coordination, Claims Administration & Oversight and Time Survey Training 23a Coordination, Claims Administration, and Oversight of Non-Medicaid and Other Grant Programs 23b Coordination, Claims Administration, and Oversight of the LHJ Medicaid Administrative Match Program 24a Time Survey and Activity Code Training for Other Non- Medicaid Administrative Match Activity: A social worker is speaking to the director of a housing program that has recently stopped serving pregnant clients to try and get her client accepted. Explanation: The social worker is aware that the housing program has accepted pregnant clients in the past, and its county contract has not changed since that time. Working to get the program to accept this underserved group would meet the definition of this code. Activity: An oral health coordinator is on the phone with a dentist who is an enrolled Medicaid provider, asking him to accept a 7-year old on Medicaid into his care. Explanation: Working to get Medicaid providers, such as a dentist, to accept Medicaid clients into their care would be reported to Code 21b. Activity: An LHJ coordinator completes a program report for a grant from a private foundation. Explanation: Only individuals designated by the LHJ to manage or coordinate components of the AdMatch program (such as overall program administration, administration of the RMTS, or preparing the MAM invoice and A19-1A) may use Code 23. If one of these individuals was coordinating, overseeing or administering a non-medicaid or other grant program, then Code 23a would be used. Activity: A fiscal coordinator prepares the local health jurisdiction s MAM invoice. Activity: A RMTS coordinator reviews quarterly time survey reports in order to plan time survey training for claiming unit staff. Explanation: Only individuals designated by the LHJ to manage or coordinate components of the AdMatch program (such as overall program administration, administration of the RMTS, or preparing the MAM invoice and A19-1A) report their activity as Code 23b. Activity: An office assistant attends training for the WIC time survey. Explanation: Staff participation in training for any time survey but the one used for Medicaid Administrative Match is reported to Code 24a. Page 6

7 Programs 24b Time Survey and Activity Code Training for the LHJ Medicaid Administrative Match Program Activity: A nurse attends a training session on the MAM random moment time survey. Explanation: Staff participation in MAM training is reported as Code 24b. Page 7