Home Health Agency Regulations and Requirements Attachment #1

Transcription

1 Home Health Agency Regulations and Requirements Attachment #1 Regulations/ UMCM Contract Regulation and/or Rules 28 TAC (a) Each EOC providing basic health care services shall provide the following basic health care services when they are provided by network physicians or providers, or by non-network physicians and providers as set forth in (10) or (15) of this title. Outpatient rehabilitation therapies including physical therapy, speech therapy and occupational therapy 28 TAC (1)(F) Outpatient Therapies 28 TAC (1)(G) Home health Care Home Health services, as prescribed or directed by the responsible physician or other authority designated by the HMO UMCM B-1 Section 8, Home health services: The HMO must have a contract(s) with a home health Provider so that all Members Provider Network living within the HMO s Service Area will have access to at least one such Provider for home health Covered Services. (These services are provided as part of the Acute Care Covered Services, not the Community Long-term Care Services.) UMCM B-2 STAR Covered Services 1.15 Services included under the HMO capitation payment Ambulance services Audiology services, including hearing aids, for adults (audiology services and hearing aids for children are a non-capitated service) Effective until the later of September 1, 2010 or upon final approval of the Medicaid State Plan and the 1915(b) STAR waiver, Behavioral Health Services, including: Inpatient and outpatient mental health services for Children (under age 21) Outpatient chemical dependency services for children (under age 21) Detoxification services Psychiatry services Counseling services for adults (21 years of age and over) Effective beginning the later of September 1, 2010 or upon final approval of the Medicaid State Plan and the 1915(b) STAR waiver, Behavioral Health Services, including: Inpatient and outpatient mental health services for Adults and Children Psychiatry services Counseling services for adults (21 years of age and over) Assessment via Provider or self-referral Detoxification services

2 Substance use disorder treatment in residential (including room and board) and non-residential settings Medication assisted therapy Birthing services provided by a certified nurse midwife in a birthing center Chiropractic services Dialysis Durable medical equipment and supplies Emergency Services Family planning services Home health care services Hospital services, including inpatient and outpatient Laboratory Medical checkups and Comprehensive Care Program (CCP) Services for children (under age 21) through the Texas Health Steps Program Oral evaluation and fluoride varnish in the Medical Home in conjunction with Texas Health Steps medical checkup for children 6 months through 35 months of age. Podiatry Prenatal care Primary care services Preventive services including an annual adult well check for patients 21 years of age and over Radiology, imaging, and X-rays Specialty physician services Therapies physical, occupational and speech Transplantation of organs and tissues Vision (Includes optometry and glasses. Contact lenses are only covered if they are medically necessary for vision correction, which can not be accomplished by glasses.) UMCM B-2 CHIP Covered Services 1.15 Services include, but are not limited to, the following services provided in a hospital clinic or emergency room, a clinic or health center, hospital-based emergency department or an ambulatory health care setting: X-ray, imaging, and radiological tests (technical component) Laboratory and pathology services (technical component) Machine diagnostic tests

3 Ambulatory surgical facility services Drugs, medications and biologicals Casts, splints, dressings Preventive health services Physical, occupational and speech therapy Renal dialysis Respiratory services Radiation and chemotherapy Blood or blood products that are not provided free-of-charge to the patient and the administration of these products Outpatient services associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero). Outpatient services associated with miscarriage or nonviable pregnancy include, but are not limited to: dilation and curettage (D&C) procedures; appropriate provider-administered medications; ultrasounds, and histological examination of tissue samples. Facility and related medical services, such as anesthesia, associated with dental care, when provided in a licensed ambulatory surgical facility. Surgical implants Other artificial aids including surgical implants Outpatient services provided at an outpatient hospital and ambulatory health care center for a mastectomy and breast reconstruction as clinically appropriate, include: all stages of reconstruction on the affected breast; surgery and reconstruction on the other breast to produce symmetrical appearance; and treatment of physical complications from the mastectomy and treatment of lymphedemas. UMCM B-2 CHIP Covered Services 1.15 Services that are provided in the home and community, including, but not limited to: Home infusion Respiratory therapy Visits for private duty nursing (R.N., L.V.N.) Skilled nursing visits as defined for home health purposes (may include R.N. or L.V.N.). Home health aide when included as part of a plan of care during a period that skilled visits have been

4 approved. Speech, physical and occupational therapies. Services are not intended to replace the CHILD'S caretaker or to provide relief for the caretaker Skilled nursing visits are provided on intermittent level and not intended to provide 24-hour skilled nursing services Services are not intended to replace 24-hour inpatient or skilled nursing facility services 2009 Texas Medicaid Provider Procedures Manual 24.4 Home Health Benefits. Texas Medicaid (Title XIX) Home Health Services Benefits Home health services include SN, HHA, PT and OT services, DME, and expendable medical supplies that are provided to eligible Medicaid clients at their place of residence. Note: THSteps-eligible clients who qualify for medically necessary services beyond the limits of this Home Health Services benefit may receive those services through THSteps-CCP. Refer to: Texas Health Steps (THSteps) on page 43-1 for more information on clients birth through 20 years of age. An SN and/or HHA visit may be provided up to a maximum of 2.5 hours per visit. A combined total of three SN and/or HHA visits may be reimbursed per day. When services are provided to more than one client in the same setting, only the units directly provided to each client at distinct, separate time periods will be reimbursed. Provider documentation must support the services were delivered at distinct, separate time periods. Total home health services billed for all clients cannot exceed the individual provider s total number of hours spent at the place of service (POS). As needed (PRN), one SN visit may be reimbursed every 30 days outside of the prior authorized visits when SN visits have been authorized for the particular client. For reimbursement purposes, Home Health SN and/or HHA services are always billed as POS 2 (home) regardless of the setting in which the services are actually provided. SN and/or HHA services provided in the day care or school setting will not be reimbursed unless delivered before or after school hours. All unique procedure codes must be billed according to the description of the procedure code. The quantity billed must be identified and each procedure code must be listed as separate line items on the claim. SN, HHA, PT, and OT must be billed in 15 minute increments. Procedural modifiers are required when billing SN, HHA, PT, and OT visits. Prior authorization must be obtained for all professional services, some supplies, and most DME from TMHP within three business days of SOC. Although providers may supply some DME and medical supplies to a client without prior authorization, they must still retain a copy of the Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form that has Section B completed, signed, and dated by the client s attending physician. For reimbursement, providers should note the following: The client s attending physician must request professional and/or HHA services through a home health agency, and sign and date the POC. Claims are approved or denied according to the eligibility, prior authorization

5 2009 Texas Medicaid Provider Procedures Manual 24.4 Home Health Benefits. status, and medical appropriateness. Claims must represent a numerical quantity of 1 month for supplies according to the billing requirements. Nursing, HHA, PT, and OT services must be provided through a Medicaid-enrolled home health agency. These services must be billed using the home health agency s provider identifier. File these services on a UB-04 CMS-1450 claim form. PT and/or OT are always billed as POS 2 and may be prior authorized to be provided in the following locations: home of the client, home of the caregiver/guardian, client s day care facility, or the client s school. Services provided to a client on school premises are only permitted when delivered before or after school hours. The only THSteps-CCP therapy that can be delivered in the client s school during regular school hours are those delivered by school districts as School Health and Related Services (SHARS) in POS 9. DME/supplies must be provided by either a Medicaid enrolled home health agency s Medicaid/DME supply provider or an independently-enrolled Medicaid/DME supply provider. Both must enroll and bill using the provider identifier enrolled as a DME supplier. File these services on a CMS-1500 claim form. Note: Medical social services and speech-language pathology services are available to clients 20 years of age or younger and are not a benefit of Home Health Services. These services may be considered a benefit for clients who qualify for THSteps-CCP. Texas Medicaid does not reimburse separately for associated DME charges, including but not limited to, battery disposal fees or state taxes. Reimbursement for any associated charges is included in the reimbursement for a specific piece of equipment. Refer to: Reimbursement Methodology on page 2-2 for more information about reimbursement Home Health Skilled Nursing (SN) Services Home health SN services are a benefit of the Home Health Services when a client requires nursing, PT, or OT, services for an acute condition or an acute exacerbation of a chronic condition that can be met on an intermittent or part-time basis and typically has an end-point. SN visits may be provided on consecutive days. SN visits are intended to provide SN care to promote independence and support the client living at home. Home Health Services must be provided by a licensed and certified home health agency enrolled in Texas Medicaid. Note: Nursing visits for the primary purpose of assessing a client s care needs to develop a POC are considered administrative and not billable. These visit costs are reflected on the cost report. An acute condition is considered a condition or exacer-bation that is anticipated to improve and reach resolution within 60 days. An intermittent basis is considered an SN visit provided for less than eight hours per visit and less frequently than daily. Intermittent visits may be delivered in interval visits up to 2.5 hours per visit, not to exceed a combined total of three visits per day. A part-time basis is considered an SN visit provided less than eight hours per day for any number of days per week. Part-time visits may be continuous up to 7.5 hours per day (not to exceed a combined total of three 2.5 hour visits). SN visits are considered medically necessary for

6 clients who require the following: Skillful observations and judgment to improve health status, skilled assessment, or skilled treatments/procedures Individualized, intermittent, acute skilled care Skilled interventions to improve health status, and if skilled intervention is delayed, it is expected to result in the deterioration of a chronic condition or one of the following: Loss of function Imminent risk to health status due to medical fragility, or risk of death When documentation does not support medical necessity for home health SN visits, providers may be directed to possible alternative services based on the client s age and needs SN Visits All SN services must be prior authorized. SN visits (procedure code G0154) are limited to SN proce-dures performed by an RN or licensed vocational nurse (LVN) licensed to perform these services under the Texas Nursing Practice Act and include direct SN care, and parent or guardian, caregiver training, and education as well as SN observation, assessment, and evaluation by an RN, provided a physician specifically requests that a nurse visit the client for this purpose, and the physician s order reflects the medical necessity for the visit. For all clients, SN visits may be provided in the following locations: Home of the client, parent, guardian, or caregiver Foster homes Independent living arrangements SN Care SN care consists of those services that must, under state law, be performed by an RN or LVN, and meet the criteria for SN services specified in the Title 42 Code of Federal Regulations (CFR) , , and In determining whether a service requires the skill of a licensed nurse, consideration must be given to the inherent complexity of the service, the condition of the client, and the accepted standards of medical and nursing practice. The fact that the SN service can be, or is, taught to the client or to the client s family or friends does not negate the skilled aspect of the service when the service is performed by a nurse. If the service could be performed by the average nonmedical person, the absence of a competent person to perform it does not cause it to be an SN service. If the nature of a service is such that it can safely and effectively be performed by the average nonmedical person without direct supervision of a licensed nurse, the service cannot be regarded as an SN service. Some services are classified as SN services on the basis of complexity alone (e.g., intravenous and intramuscular injections or insertion of catheters), and if reasonable and necessary to the treatment of the client s illness or injury, would be covered on that basis. However, in some cases, the client s condition may cause a service that would ordinarily be considered unskilled to be considered an SN service. This would occur when the client s condition is such that the service can be safely and effectively provided only by a nurse. A service which, by its nature, requires the skills of a nurse to be provided safely and effectively continues to be a skilled service even if it is taught to the client, the client s family, or other caregivers. Where the client needs the SN care and there is no one trained, able and willing to provide it, the services of a nurse would be reasonable and necessary to

7 the treatment of the illness or injury. SN services must be reasonable and necessary to the diagnosis and treatment of the client s illness or injury within the context of the client s unique medical condition. To be considered reasonable and necessary for the diagnosis or treatment of the client s illness or injury, the services must be consistent with the nature and severity of the illness or injury, the client s particular medical needs, and within accepted standards of medical and nursing practice. A client s overall medical condition is a valid factor in deciding whether skilled services are needed. A client s diagnosis should never be the sole factor in deciding whether the service the client needs is either skilled or not skilled. The determination of whether the services are reasonable and necessary should be made in consideration of the physician s determination that the services ordered are reasonable and necessary. The services must, therefore, be viewed from the perspective of the condition of the client when the services were ordered, and what was, at that time, reasonably expected to be appropriate treatment for the illness or injury throughout the certifi-cation period. SN care must be provided on a parttime or intermittent basis. Professional Nursing Professional nursing provided by an RN, as defined in the Texas Nurse Practice Act, means the performance of an act that requires substantial specialized judgment and skill, the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of professional nursing. The term does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures. Professional nursing involves: The observation, assessment, intervention, evaluation, rehabilitation, care and counsel, or health teachings of a person who is ill, injured, infirm, or experiencing a change in normal health processes. The maintenance of health or prevention of illness. The administration of a medication or treatment as ordered by a physician, podiatrist, or dentist. The supervision of delegated nursing tasks or teaching of nursing. The administration, supervision, and evaluation of nursing practices, policies, and procedures. The performance of an act delegated by a physician. Development of the nursing care plan. Professional nursing also involves assisting in the evalu-ation of an individual s response to a nursing intervention and the identification of an individual s needs and engaging in other acts that require education and training, as prescribed by board rules and policies, commensurate with the nurse s experience, continuing education, and demonstrated competency. Vocational Nursing Vocational nursing, as defined in the Texas Nurse Practice Act, means a directed scope of nursing practice, including the performance of an act that requires specialized judgment and skill, the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of vocational nursing. The term does not include acts of medical diagnosis or the prescription of therapeutic or corrective

8 2009 Texas Medicaid Provider Procedures Manual 24.4 Home Health Benefits. measures. Vocational nursing involves: Collecting data and performing focused nursing assess-ments of the health status of an individual. Participating in the planning of the nursing care needs of an individual. Participating in the development and modification of the nursing care plan. Participating in health teaching and counseling to promote, attain, and maintain the optimum health level of an individual. Vocational nursing also involves assisting in the evaluation of an individual s response to a nursing intervention and the identification of an individual s needs and engaging in other acts that require education and training, as prescribed by board rules and policies, commensurate with the nurse s experience, continuing education, and demonstrated competency Home Health Aide (HHA) Services HHA visits (procedure code G0156) are a benefit of Home Health Services when a client requires nursing, PT, or OT services for an acute condition or an acute exacerbation of a chronic condition that can be met on an intermittent or part-time basis. HHA visits are intended to provide personal care services under the supervision of an RN, PT, or OT employed by the home health agency to promote independence and support the client living at home. An acute condition is considered a condition or exacerbation that is anticipated to improve and reach resolution within 60 days. An intermittent basis is considered an SN visit provided for less than eight hours per visit and less frequently than daily. Intermittent visits may be delivered in interval visits up to 2.5 hours per visit, not to exceed a combined total of three visits per day. A part-time basis is considered an SN visit provided less than eight hours per day for any number of days per week. Part-time visits may be continuous up to 7.5 hours per day (not to exceed a combined total of three 2.5 hour visits). HHA visits are considered medically necessary for clients who require general supervision of nursing care provided by an HHA over whom the RN, PT, or OT is administratively or professionally responsible in addition to the following: Skillful observations and judgment to improve health status, skilled assessment, or skilled treatments or procedures Individualized, intermittent, acute skilled care Skilled interventions to improve health status, and if skilled intervention is delayed, it is expected to result in the deterioration of a chronic condition or one of the following: Loss of function Imminent risk to health status due to medical fragility, or risk of death When documentation does not support medical necessity for HHA visits, providers may be directed to possible alter-native services based on the client s age and needs HHA Visits HHA visits are intended to provide hands-on personal care, performance of simple procedures as an extension of therapy or nursing services, assistance in ambulation or exercises, and assistance in administering medications that are ordinarily selfadministered. Any HHA services offered by a home health agency must be provided by a qualified HHA under the supervision of a qualified licensed individual (RN, PT, OT) employed by the home health agency. For all clients, HHA visits may be provided in the following locations: Home of the client, parent,

9 2009 Texas Medicaid Provider Procedures Manual 24.4 Home Health Benefits. guardian, or caregiver Foster homes Independent living arrangements The duties of an HHA during a visit include, but are not limited to, the following: Ambulation Assistance with medication that is ordinarily self-administered Assisting with nutrition and fluid intake Completing appropriate documentation Exercise Household services essential to the client s health care at home Obtaining and recording the client s vital signs (temper-ature, pulse, respirations, and blood pressure) Observation, reporting and documentation of the client s status, and the care or service furnished Personal care (hygiene and grooming), including, but not limited to, the following: Sponge, tub or shower bath Shampoo, sink, tub or bed bath Nail and skin care Oral hygiene Positioning Range of motion Reporting changes in the client s condition and needs Safe transfer Toileting and elimination care Supervision of HHA Supervision, as defined by the Texas Nurse Practice Act, is the process of directing, guiding, and influencing the outcome of an individual s performance of an activity. An RN or therapist (PT/OT) must provide the HHA written instructions for all the tasks delegated to the HHA. A therapist may prepare the written instructions if the client is receiving only HHA visits, which do not include delegated SN tasks, in addition to the therapy services. The requirements for HHA supervision are as follows: When only HHA visits are provided, an RN must make a supervisory visit to the client s residence at least once every 60 days. The supervisory visit must occur when the HHA is providing care to the client. When SN, PT, and/or OT visits are provided in addition to a HHA visit, an RN must make a supervisory visit to the client s residence at least every two weeks. The supervisory visit must occur when the HHA is providing care to the client. When only PT and/or OT visits are provided in addition to HHA visits, the appropriate therapist may make the supervisory visit in place of an RN. The supervisory visit must occur when the HHA is providing care to the client. Documentation of HHA supervision must be maintained in the client s medical record Home Health SN and HHA Services Provider Responsibilities Providers must be a licensed home health agency enrolled in Texas Medicaid and must comply with all applicable federal, state, and local laws and regulations and Texas Medicaid policies and procedures. All providers must maintain written policies and procedures for obtaining consent for medical treatment for clients in the absence of the primary caregiver that meet the standards of the Texas Family Code, Chapter 32, and obtaining physician signatures for all telephone orders within 14 calendar days of receipt of the order. Providers must only accept clients on the basis of a reasonable expectation that the client s needs can be adequately met in the POS. The essential elements of safe and effective home health SN and/or HHA services include a trained parent, guardian, or caregiver, a primary physician, competent providers, and an environment that supports the client s health and safety needs. The place of service must be

10 2009 Texas Medicaid Provider Procedures Manual 24.4 Home Health Benefits. able to support the health and safety needs of the client and must be adequate to accommodate the use, maintenance, and cleaning of all medical devices, equipment, and supplies required by the client. Necessary primary and back-up utility, communi-cation, and fire safety systems must be available. Note: A parent or guardian, primary caregiver, or alternate caregiver may not provide SN and/or HHA services even if he or she is an enrolled provider or employed by an enrolled provider Home Health SN and HHA Services Prior Authorization Requirements SN and HHA services require prior authorization. Requests must be submitted by fax or in writing by mail. Providers must obtain prior authorization within three business days of the SOC date for an initial prior authorization. For extension of the prior authorization providers must obtain prior authorization within seven business days of the new SOC date. During the prior authorization process, providers are required to deliver the requested services from the SOC date, which is the date agreed to by the physician, the RN, the home health agency, and the client, parent, guardian, or caregiver. The SOC date must be documented on the POC. A provider requesting prior authorization for SN and/or HHA services must submit the following documentation: A completed client assessment A completed Texas Medicaid Home Health Services POC that must: Be signed and dated by the assessing RN Signed and dated by the physician or submitted with the signed and dated physician s orders Prior authorization of SN or HHA visits requires that a client s primary care physician complete the following steps: Provide specific, written, dated orders for SN or home health agency visits or recertification that identifies that the prescribed visits are medically necessary as defined in Section , Home Health Skilled Nursing (SN) Services and Section , Home Health Aide (HHA) Services. Maintain documentation in the client s medical record that supports the medical necessity of the prescribed visits. Maintain documentation in the client s medical record that demonstrates that the client s medical condition is sufficiently stable to permit safe delivery of the prescribed visits as described in the client s Home Health Services POC. Establish a medical plan of care that is maintained in the client s medical record. Provide continuing care and medical supervision. Review and approve the client s Home Health Services POC once every 60 days or more frequently as the physician determines necessary, including but not limited to a change in the client s condition. All signatures and dates must be current, unaltered, original, and handwritten; computerized or stamped signatures/dates will not be accepted. All documentation, including all written and verbal orders, and all physician-signed POCs, must be maintained by the ordering physician. The home health agency must keep the original, signed copy of the POC in the client s medical record. Requests must be based on the medical needs of the client. Documentation must support the quantity and frequency of intermittent or part-time SN and/or HHA visits that will safely meet the client s needs. The amount and duration of SN and/or HHA visits requested will be evaluated by the claims administrator. The home health agency must ensure the

11 requested services are supported by the client assessment, POC, and the physician s orders. The length of the prior authorization is determined on an individual basis and is based on the goals and timelines identified by the physician, home health agency, RN, and client, parent, guardian, or caregiver. SN and HHA visits will be prior authorized for no more than 60 days at a time. As a client s problems are resolved and goals are met, a client s condition is expected to become more stable, and the client s needs for SN and HHA services may decrease. SN visits to obtain routine laboratory specimens may be considered when the only alternative to obtain the specimen is to transport the client by ambulance. SN visits to address hyperbilirubinemia will not be considered for prior authorization if the client has an open prior authorization for home phototherapy. Home phototherapy is reimbursed as a daily global fee and includes coverage of SN visits for parent or caregiver teaching, client monitoring, and obtaining customary and routine laboratory specimens. SN visits to address total parenteral nutrition (TPN) will not be considered for prior authorization if the client has an open prior authorization for TPN. TPN is reimbursed as a daily global fee and includes coverage of SN visits for client, parent or caregiver teaching and monitoring, obtaining customary and routine laboratory specimens, and enteral supplies and equipment. Up to a maximum combined total of three SN and HHA visits may be prior authorized per day. One visit may last up to a maximum of 2.5 hours. SN and/or HHA visits may be provided on consecutive days. When documentation does not support medical necessity for home health SN and/or HHA visits, providers may be directed to possible alternative services based on the client s age and needs. A prior authorization for SN and/or HHA visits is no longer valid when: The client is no longer eligible for Medicaid. The client no longer meets the medical necessity criteria for SN and/or HHA services. The place of service cannot provide for the health and safety of the client. The client, parent, guardian, or caregiver refuses to comply with the attending physician s plan of treatment and compliance is necessary to ensure the health and safety of the client. The client changes providers and the change of notifi-cation is submitted to the claims administrator in writing with a prior authorization request from the new provider. A nurse/hha may be prior authorized to provide services to more than one client over the span of the day as long as each client s care is based on an individualized POC and each client s needs and POC do not overlap with another client s needs and POC. Settings in which a nurse/hha provider may provide services in a provider-client ratio greater than 1:1 include, but are not limited to, homes with more than one client receiving home health services, foster homes, and independent living arrangements Canceling a Prior Authorization The client has the right to choose their home health agency provider and to change providers. If the client changes providers, TMHP must receive a change of provider letter with a new POC or Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form. The client must sign and date the letter, which must include the name of the previous provider, the current provider, and the effective date for the change. The client is responsible for notifying the original

12 2009 Texas Medicaid Provider Procedures Manual 24.4 Home Health Benefits. provider of the change and the effective date. Prior authorization for the new provider can only be issued up to three business days before the date TMHP receives the change of provider letter and the new Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form Home Health SN Services and HHA Services That Will Not Be Prior Authorized SN visits requested primarily to provide the following will not be prior authorized: Respite care Child care Activities of daily living for the client Housekeeping services Routine post-operative disease, treatment, or medication teaching after a physician visit Routine disease, treatment, or medication teaching after a physician visit Individualized, comprehensive case management beyond the service coordination required by the Texas Nurse Practice Act HHA visits requested primarily to provide the following will not be prior authorized: Housekeeping services Services provided to a client residing in a hospital, SN facility, or intermediate care facility Certain facilities are required by licensure to meet all the medical needs of the client. SN and/or HHA visits will not be prior authorized for clients receiving care in any of the following facilities: Hospitals SN facilities Intermediate care facilities for the mentally retarded (ICF-MR) Special care facilities, including but not limited to, sub-acute units and facilities for the treatment of acquired immunodeficiency syndrome (AIDS) Home Health SN and HHA Services Assessments and Reassessments When a provider has received a referral and has physician orders for SN and/or HHA services, the provider must have an RN perform an initial client assessment in the client s home. A client can be referred to a home health agency for SN and/or HHA services by the client, the client s physician, or the client s family. The client assessment or reassessment should include, but is not limited to, the following: Whether the setting can support the health and safety needs of the client and is adequate to accommodate the use, maintenance, and cleaning of all medical devices, equipment, and supplies required by the client Comprehension level of client, parent, guardian, or caregiver Receptivity to training and ability level of the client, parent, guardian, or caregiver A nursing assessment of medical necessity for the requested visits which includes: Complexity and intensity of the client s care Stability and predictability of the client s condition Frequency of the client s need for SN care Identified medical needs and goals Description of wounds, if present Cardiac status The initial assessment and any reassessments performed by an RN are required when changes in the client s condition occur during the course of the prior authorization period. If there is no change in the client s condition, the reassessment must document medical necessity to support continued and ongoing SN and/or HHA visits beyond the initial 60-day prior authorization period.

13 2009 Texas Medicaid Provider Procedures Manual 24.4 Home Health Benefits Texas Medicaid Provider Procedures Manual 24.4 Home Health Benefits Texas Medicaid Provider Procedures Manual 24.4 Home Health Benefits Physical Therapy (PT) Services As stated in the TAC, in order to be payable as a Home Health Services benefit, PT services must be: Requested for a payable ICD-9-CM diagnosis code. Provided by a physical therapist or physical therapist assistant. A physical therapist assistant must be supervised by a licensed physical therapist who is currently licensed by the Executive Council of Physical Therapy and Occupational Therapy Examiners. For the treatment of an acute musculoskeletal or neuro-muscular condition or an acute exacerbation of a chronic musculoskeletal or neuromuscular condition. Expected to improve the client s condition in a reasonable and generally predictable period of time, based on the physician s assessment of the client s restorative potential after any needed consultation with the therapist. The evaluation and function-oriented treatment of individuals whose ability to function in life roles is impaired by recent or current physical illness, injury, or condition. Specific goal-directed activities to achieve a functional level of mobility and communication and prevent further dysfunction within a reasonable length of time based on the therapist s evaluation and physician s assessment and POC. PT POC should encourage the client and other caregivers to learn self-therapy skills to the greatest extent possible while still providing all medically necessary services. Provided only until the client has reached the maximum level of improvement. Repetitive services designed to maintain function when the maximum level of improvement has been reached are not a benefit. Services related to activities for the general good and welfare of clients, such as general exercises to promote overall fitness and flexibility, and activities to provide diversion or general motivation are not reimbursed. Billed by the home health agency and reimbursed to the home health agency. Independently-enrolled therapists are not reimbursed under Home Health Services. PT prior authorization must be requested by the home health agency s RN and initiated after the RN home assessment. Requests are not accepted, nor prior autho-rization granted, directly to the physical therapist or assistant physical therapist. Note: THSteps-eligible clients who qualify for medically necessary services beyond the limits of this Home Health Services benefit may receive those services through THSteps-CCP. Refer to: Eligibility on page PT Prior Authorization Procedures To obtain prior authorization for initial and an extension of prior authorization of PT services provided through a home health agency, providers should contact the TMHP Home Health Services Prior Authorization Department at or fax the request to Home health agencies must provide an initial or subsequent POC to include PT goals, accurate diagnostic information (including ICD-9-CM diagnosis codes), PT procedure codes, and PT evaluation or re-evaluation results at the time a request is made using the POC PT/OT Procedure Codes The procedure codes listed above for PT and OT are only payable to

14 home health agencies. Independently enrolled occupational and physical therapists are not paid under home health services. All PT and OT procedure codes are billed in 15 minute increments. Only one visit per day per discipline is allowed. The procedure codes are paid at the Statewide visit rate available on the TMHP website at Therapy services that can be designated either as PT or OT must be requested and billed with the correct procedural modifier Occupational Therapy (OT) Services As stated in the TAC, to be payable as a Home Health Services benefit, OT services must be: Requested for a payable ICD-9-CM diagnosis code Provided by an occupational therapist or an occupa-tional therapy assistant who is currently registered and licensed by the Executive Council of Physical Therapy and Occupational Therapy Examiners. An occupational therapy assistant must be supervised by a licensed occupational therapist. For the treatment of an acute musculoskeletal or neuro-muscular condition or an acute exacerbation of a chronic musculoskeletal or neuromuscular condition OT prior authorization must be requested by the home health agency s RN and recommended to be done after the RN assessment. Requests are not accepted, nor prior authorization granted, directly to the occupational therapist or the occupational therapy assistant. For the evaluation and function-oriented treatment of individuals whose ability to function in life roles is impaired by recent or current physical illness, injury, or condition For specific goal-directed activities to achieve a functional level of mobility and communication and prevent further dysfunction within a reasonable length of time based on the therapist s evaluation, physician s assessment, and POC Procedure Codes Procedure Codes Modifier Visit Service Category GP PT GO OT Provided only until the client has reached the maximum level of improvement. Repetitive services designed to maintain function when the maximum level of improvement has been reached are not reimbursed. Services related to activities for the general good and welfare of clients, such as general exercises to promote overall fitness and flexibility, and activities to provide diversion or general motivation are not reimbursed. Refer to: Occupational Therapists (CCP) on page Note: THSteps-eligible clients who qualify for medically necessary services beyond the limits of this Home Health Services benefit will receive those services through THSteps-CCP. Refer to: Eligibility on page OT Prior Authorization Procedures To obtain prior authorization for the initial and recertification of OT services provided through a home health agency, providers should contact the

15 TMHP Home Health Services Prior Authorization Department at Home health agencies must provide accurate diagnostic information (including ICD-9-CM diagnosis codes), OT procedure codes, and an initial or subsequent plan of care to include OT goals. Providers must use the codes listed under PT/OT Procedure Codes to submit claims for OT services that are provided through a home health agency. Bill OT services on a UB-04 CMS-1450 claim form. Providers must use procedure code when requesting prior authorization and billing for wheelchair evaluations Texas Medicaid Provider Procedures Physical Therapists/Independent Practitioners 35.1 Enrollment To enroll in Texas Medicaid, licensed physical therapists must be enrolled in Medicare. The Medicare enrollment requirement is waived for therapists that only provide services to Texas Health Steps (THSteps)-eligible clients who are 20 years of age or younger and who do not receive Medicare benefits. These therapists must enroll as individuals. If providers are currently enrolled with Texas Medicaid or plan to provide regular acute care services to clients with Medicaid coverage, enrollment in the THSteps-Comprehensive Care Program (CCP) is not necessary. All non-ccp physical therapy (PT) services must be billed with the current provider identifier. Providers cannot be enrolled if their license is due to expire within 30 days of application. A current license must be submitted. Important: All providers are required to read and comply with Section 1, Provider Enrollment and Responsibilities. In addition to required compliance with all requirements specific to Texas Medicaid, it is a violation of Texas Medicaid Program rules when a provider fails to provide health-care services or items to Medicaid clients in accor-dance with accepted medical community standards and standards that govern occupations, as explained in Title 1 Texas Administrative Code (TAC) (a)(6)(A). Accordingly, in addition to being subject to sanctions for failure to comply with the requirements that are specific to Texas Medicaid, providers can also be subject to Texas Medicaid Program sanctions for failure, at all times, to deliver health-care items and services to Medicaid clients in full accordance with all applicable licensure and certifi-cation requirements including, without limitation, those related to documentation and record maintenance. Refer to: Provider Enrollment on page 1-3 for more information about enrollment procedures. THSteps-CCP Overview on page for more information about providing services to Medicaid/THSteps clients. Texas Medicaid (Title XIX) Home Health Services on page 24-1 for more information about providing services to clients in the home setting. Managed Care on page Reimbursement The Medicaid rates for physical therapists and independent practitioners are calculated in accordance with 1 TAC and The applicable Medicaid rates are listed in the current physician fee schedule, which is available on the TMHP website at Refer to: Reimbursement Methodology on page 2-2 for more information Benefits and Limitations Payments for PT are limited to acute disorders of the musculoskeletal system or exacerbations of chronic disorders

16 necessitating PT to restore function. Claims must include the AT modifier to represent treatment provided for an acute condition or an exacer-bation of a chronic condition that persists less than 180 days from the start date of therapy. If the condition persists for more than 180 days from the start of therapy, the condition is considered chronic, and treatment is no longer considered acute. Providers may file an appeal for claims denied as being beyond the 180 days of therapy with supporting documentation that the client s condition has not become chronic and the client has not reached the point of plateauing. Plateauing is defined as the point that maximum improvement has been documented and more improvement ceases. Examples of what may be considered acute are as follows: A new injury Therapy before or after surgery Acute exacerbations of conditions such as rheumatoid arthritis Interventions such as a newly implanted intrathecal pump to decrease spasticity or Botulinum Toxin Type A injections PT, including functional evaluations, must be provided according to the current written orders of a physician (within 60 days) and based on medical necessity. It may be performed by auxiliary personnel under the direct supervision of the physician or the independently practicing physical therapist. Payment cannot be made to a provider or an indepen-dently practicing physical therapist who provides physical medicine to a resident of a nursing facility. Such services must be made available on an as-needed basis and must be provided directly by the staff of the facility or furnished by the facility through arrangements with outside qualified resources. Nursing facilities must refrain from admitting clients who need goal-directed therapy if the facility is unable to provide these services. The following procedure codes are limited to once per day: The following procedure codes may be paid in multiple 15-minute quantities: Procedure Codes Procedure Codes Procedure codes 97535, 97537, 97542, 97760, and are only payable for clients 20 years of age or younger. Procedure codes 97010, 97265, 97545, 97546, 97770, 97780, and are not benefits. Procedure codes and are comprehensive codes and include an office visit. If an office visit is billed for the same day by the same provider, the office visit will be denied as part of another procedure billed for the same day. Procedure code is payable once per 6 months, any provider. Procedure code 97002, is payable once per month, any provider. Procedure codes and are not payable on the same day as the following procedure codes: Procedure codes that may be billed in multiple quantities (i.e., 15 minutes each) are limited to a total of 2 hours per day of individual, group, or a combination of individual and group therapy. PT services that are not benefits of the regular Texas Medicaid Program may be benefits under THSteps-CCP when they are provided to clients who have chronic muscu-loskeletal or neuromusculoskeletal conditions, or other chronic conditions that require medically necessary physical therapy. CCP is for Medicaid THSteps-eligible clients who are 20 years of age or younger. CCP eligibility

17 2009 Texas Medicaid Provider Procedures 43.4 THSteps Medicaid Children s Services (Comprehensive Care Program [CCP]) ends on the day of the client s 21st birthday. Clients 21 years of age or older receive PT through Texas Medicaid (Title XIX) Home Health Services. Refer to: Home Health Services on page 24-6 for information about PT services provided in the home setting. THSteps Medicaid Children s Services (Comprehensive Care Program [CCP]) on page for information about PT, occupa-tional therapy (OT), and speech language- pathology (SLP) services Rehabilitative Services Rehabilitative Services is a program administered by TMHP to nursing facility clients who need rehabilitation. These services must be prior authorized through TMHP before the therapy is provided and paid by TMHP. Covered services include OT, PT, and SLP to clients who are eligible for Medicaid, with an acute onset of an illness orinjury, with the expectation that function will be improved measurably. For all rehabilitative services inquiries, call Rehabilitative Services at Claims Information Submit services provided by an independently practicing physical therapist to TMHP in an approved electronic format or on a CMS-1500 paper claim form. Providers may purchase CMS-1500 claim forms from the vendor of their choice. TMHP does not supply the forms. Claims may be filed electronically in a CMS-1500 format as long as the nine-digit prior authorization number is reflected in the equivalent electronic field. Refer to: TMHP Electronic Data Interchange (EDI) on page 3-1 for information on electronic claims submissions. Claims Filing on page 5-1 for general infor-mation about claims filing. CMS-1500 Claim Filing Instructions on page Blocks that are not referenced are not required for processing by TMHP and may be left blank Claim Filing Resources Refer to the following sections and/or forms when filing claims: Procedure Codes Resource Page Number Automated Inquiry System (AIS) xiii TMHP Electronic Data Interchange (EDI) 3-1 CMS-1500 Claim Filing Instructions 5-26 TMHP Electronic Claims Submission 5-15 Communication Guide A-1 Physical Therapist D-26 Physical Therapists (THSteps-CCP Only) D-26 Acronym Dictionary F THSteps Medicaid Children s Services (Comprehensive Care Program [CCP]) THSteps-CCP Overview THSteps-CCP is an expansion of the EPSDT service as mandated by the OBRA of 1989, which requires all states to provide all medically necessary treatment for correction of physical or mental problems to THSteps-eligible clients when FFP is available, even if the services are not covered under the state s Medicaid plan. This expansion of services is provided only for those clients who are birth through 20 years of age who are eligible to receive THSteps services. If the client's Medicaid identification (Form H3087) states Emergency Care, PE, or QMB, the client is not eligible for THSteps-CCP benefits. The following THSteps-CCP provider sections describe the specific requirements of each area of responsibility: Comprehensive Outpatient Rehabilitation Facilities (CORFs)/Outpatient Rehabilitation

18 Facilities (ORFs) on page Durable Medical Equipment Supplier (CCP) on page Early Childhood Intervention (ECI) (CCP) on page Licensed Dietitians (CCP) on page Occupational Therapists (CCP) on page Orthotic and Prosthetic Suppliers (CCP) on page Personal Care Services (PCS) (CCP) on page Pharmacies (CCP) on page Private Duty Nursing (CCP) on page Psychiatric Hospital/Facility (Freestanding) (CCP) on page Speech-Language Pathologists (CCP) on page Refer to: THSteps Medical and Dental Administrative Information on page 43-5 for more information Enrollment THSteps-CCP providers must meet Medicaid/HHSC participation standards to enroll in the program. All THSteps- CCP providers must be enrolled in Texas Medicaid to be reimbursed for services. Provider enrollment inquiries and application requests must be sent to the TMHP Provider Enrollment department at: Provider Enrollment Texas Medicaid & Healthcare Partnership PO Box Austin, TX Home and community support services agencies (HCSSAs) that want to provide THSteps-CCP private-duty nursing (PDN), physical therapy (PT), speech therapy (ST), or occupational therapy (OT) services under the licensed-only home health (LHH) category must first enroll with TMHP. To enroll with TMHP in the LHH category, an HCSSA must: Complete a provider enrollment form, which can be found on the TMHP website at provide its license information, and check the Only CCP services box on the form. Obtain a Texas Provider Identifier (TPI) for CCP services. Provide THSteps-CCP PDN, PT, OT, or ST services only to THSteps-eligible CCP clients and use the TPI number assigned for CCP services. Texas Medicaid fee-for-service services must be delivered under the licensed and certified home health (LCHH) category. Refer to: Managed Care on page Communication with THSteps-CCP Providers can use the TMHP website and the following telephone and fax numbers for prior authorization or information on THSteps-CCP services: Note: Prior authorization is a condition for reimbursement, not a guarantee of payment. Providers can submit the following prior authorization requests on the TMHP website: CCIP: Psychiatric Inpatient Initial Admission Request Form Psychiatric Inpatient Extended Stay Request Form CCP: THSteps-CCP ECI Request for Initial/Renewal Outpa-tient Therapy Request for Initial Outpatient Therapy (Form TP-1) Request for Extension of Outpatient Therapy (Form TP-2) Donor Human Milk Request Form Pulse Oximeter Form Wheelchair/Scooter/Stroller Seating Assessment Form (THSteps-CCP/Home Health Services) Texas Medicaid Palivizumab (Synagis) Prior Authori-zation Request Form THSteps-CCP Prior Authorization Request Form Apnea Monitor Bed/Crib Formula Total Parenteral Nutrition (TPN) PDN Miscellaneous Refer to: Prior Authorization Requests Through the TMHP Website on page 5-5 for additional information including mandatory documentation requirements and retention. Send requests for prior authorization and appeals of prior authorization requests to the following address: Texas

19 Medicaid & Healthcare Partnership Comprehensive Care Program PO Box Austin, TX Address first-time claims and appeals of incomplete claims for THSteps-CCP only to the following address: Texas Medicaid & Healthcare Partnership PO Box Austin, TX Direct all other correspondence to a specific department (e.g., Provider Enrollment). Send all other claims, appeals, and resubmissions to the following address: Texas Medicaid & Healthcare Partnership PO Box Austin, TX Clients should direct written communication to HHSC at the following address: HHSC Customer Service 1100 West 49th Street Austin, TX Medicaid clients and families may contact HHSC toll-free at Documentation requirements for specific services and supplies are found in the provider-specific sections of this manual Client Eligibility The client must be from birth through 20 years of age and eligible for THSteps at the time of the service request and service delivery. If the client s Medicaid Identification (Form H3087) states Emergency Care, PE, or QMB, the client is not eligible for THSteps-CCP benefits. Clients are ineligible for THSteps-CCP services beginning the day of their 21st birthday Benefits Payment is considered for any health-care service that is medically necessary and for which FFP is available. THSteps-CCP benefits are allowable services not currently covered under Texas Medicaid (e.g., speech-language pathology [SLP] services for nonacute conditions, PDN, prosthetics, orthotics, apnea monitors and some durable medical equipment [DME], some specific medical nutritional products, medical nutrition services, inpatient rehabilitation, travel strollers, and special needs car seats). THSteps-CCP benefits also include expanded coverage of current Texas Medicaid services where services are subject to limitations (e.g., diagnosis restrictions for TPN or diagnosis restrictions for attendant care services). Requests for services that require a prior authorization must be submitted to TMHP. Prior authorization is a condition for reimbursement, not a guarantee of payment. For information about dental, TPN, respiratorytherapy, personal care services (PCS), and vision care benefits, providers can refer to provider-specific sections of this manual. Medicaid Benefits for Children The following are Medicaid benefits for clients living with a family (including foster care): Medical services (physician, hospital, hearing services, and eyeglasses) THSteps medical checkups (including immunizations) and dental exams and services Medications through the Texas Medicaid Vendor Drug Program (VDP) (unlimited prescriptions and some over-the-counter with prescription) THSteps-CCP (prosthetics, orthotics, PCS, and SLP services for nonacute conditions) Texas Medicaid (Title XIX) Home Health Services that may be considered medically necessary (e.g., nursing visits, supplies, DME, and PT and OT for acute condi-tions provided in the home) Medicaid benefits for clients living in residential treatment centers include the following: Medical services

20 1 TAC Home Health Services Benefits and Limitations (physician, hospital, hearing services, and eyeglasses) THSteps medical checkups (including immunizations) and dental exams and services Medications through VDP (unlimited prescriptions, some over-the-counter with prescription) THSteps-CCP, excluding outpatient mental health services Medicaid benefits for clients living in nursing facilities include the following: Medical services (physician, hospital, hearing services, and eyeglasses) THSteps medical checkups (including immunizations) and dental exams and services Medications through VDP (unlimited prescriptions) Medicaid benefits for clients in intermediate care facilities for the mentally retarded (ICF-MR) facilities (not state schools) include the following: Medical services (physician, hospital, hearing services, and eyeglasses) THSteps medical checkups (including immunizations) and dental exams and services Medications through VDP (unlimited prescriptions) THSteps-CCP DME (covered in the daily rate) Medicaid Procedure Codes The following table identifies THSteps-CCP-related Medicaid procedure codes. This list is not all-inclusive but represents the most commonly billed THSteps-CCP procedures that are not listed in specific sections. These codes are not payable for all provider types. Other codes are listed in specific THSteps-CCP sections of this manual, and additional codes can be found in Texas Medicaid (Title XIX) Home Health Services on page Prices are subject to change. Limitations Payment cannot be made for any service, supply, or equipment for which FFP is not available. The following are some examples: Vehicle modification, mechanical, and/or structural (such as wheelchair lifts) Structural changes to homes, domiciles, or other living arrangements Environmental equipment, supplies, or services, such as room dehumidifiers, air conditioners, filters, space heaters, fans, water purification systems, vacuum cleaners, and treatments for dust mites, rodents, and insects Ancillary power sources and other types of standby equipment (except for technology-dependent clients such as those who are ventilator-dependent for more than 6 hours per day) Educational programs, supplies, or equipment (such as a personal computer or software) Equine or hippotherapy Exercise equipment, home spas or gyms, toys, therapeutic balls, or tricycles Tennis shoes Respite care (relief to caregivers) Aids for daily living (toothbrushes, spoons, and foot stools) Takehome drugs from hospitals (Eligible hospitals may enroll in and bill VDP. Pharmacies that want to enroll should call ) Therapy involving any breed of animal (a) The State determines authorization requirements and limitations for covered home health service benefits. The home health agency is responsible for obtaining prior authorization where specified for the healthcare service, supply, equipment, or appliance. Home health service benefits include the following: (1) Skilled nursing. Nursing services provided by a registered nurse (RN) who is currently licensed by the Board of Nurse Examiners for the State of Texas and/or a licensed vocational nurse (LVN) licensed by the Texas Board of Vocational Nurse Examiners provided on a part-time or intermittent basis and furnished through an enrolled home health agency are covered benefits. Billable nursing visits may also include: