HEALTH RELATED SERVICES MEDICAID BILLING HANDBOOK

Transcription

1 Prince George's County Public Schools HEALTH RELATED SERVICES MEDICAID BILLING HANDBOOK Prince George's County Public Schools Medicaid Billing Office School Lane, Trailer # C Upper Marlboro, MD (PH) (FAX)

2 TABLE OF CONTENTS Medicaid Program Background & Description... 1 Overview of Medicaid Billing Eligibility Requirements... 2 Overview of Health Related Medicaid Billing Requirements... 2 Billing Process and Documentation Requirements... 2 Speech and Language Services... 5 Speech and Language Sample Documentation Nursing Services Nursing Services Sample Documentation Psychological Services Psychological Services Sample Documentation Occupational & Physical Therapy Occupational & Physical Therapy Sample Documentation Audit Requirements Billing Calendar... 48

3 Please go to our website for the most current information and forms. ii

4 Medicaid Program Background & Description On July 1, 1988, President Ronald Reagan signed Public Law PL , the Medicare Catastrophic Coverage Act. This law permits local education agencies to recover costs from public health insurance for services identified in a child s Individualized Education Plan (IEP). These services include speech pathology, audiology, occupational therapy, physical therapy, nursing, social work, and psychological services for screening, evaluation and treatment services. Additionally, local education agencies are allowed to submit claims for IEP coordination services (case management) as well as specialized transportation services for Medicaid eligible special education students. The Federal Government and the United States Congress have encouraged school systems to use all available federal funding, including Medical Assistance to finance special education and health related services. As a result, in 1994, Prince George's County Public Schools system began a system wide effort to recover costs for health related services, and IEP coordination services for Medicaid eligible students. Currently, there are over 4,600 Medicaid eligible special education students in Prince George's County Public School system. These students constitute 31% of the Special Education population and 3.7% of all students attending Prince George County Public Schools. Medicaid reimbursement funds support and expand existing programs and provide funding for staff, specialized supplies and equipment that enhance the learning experience for all special education students. MBO Program Mission The mission of the Medicaid Billing Office is to recover funds for health related and IEP coordination services provided to Medicaid eligible special education students in order to expand and enhance the services offered to all PGCPS special education students. MBO Program Goals Our goal is for the Medicaid Billing Office to operate with integrity, excellence and professionalism and to provide quality service that is effective, efficient accountable to all stakeholders; To increase and maximize efforts to recover Medicaid revenue in order to enhance services provided to PGCPS Special Education Department To improve efforts in order to meet regulatory compliance in accessing Medicaid reimbursement funds; To increase children and youth s access to comprehensive health services through the PGCPS school-based Medicaid reimbursement program; To increase collaboration among schools, families, and state agencies, where each partner has a defined role and demonstrates commitment and accountability to the Special Education students of PGCPS; 1

5 To develop and implement a long-range plan for helping to ensure sustainability of a comprehensive Medicaid reimbursement program Overview of Medicaid Billing Eligibility Requirements In order for PGCPS system to receive Medicaid reimbursement, the services billed must: Be provided to a Medicaid eligible student under the age of 21 Be provided to a student with an active IEP/IFSP, Be provided by a qualified practitioner (possess proper licensure/certification) Address a student s physical, mental or emotional disability Be consistent with the intent of the IEP/IFSP identified services and planned goals Have documentation that supports that the services billed relate directly to the IEP/IFSP Parental consent for PGCPS to release information in order to bill Medicaid for health related and IEP coordination services must be obtained prior to billing. Overview of Health Related Medicaid Billing Requirements The following are health related services that PGCPS currently provides to some special education students: Speech/Language Pathology Audiology Services Nursing Services Nutrition Occupational Therapy Physical Therapy Psychological Services PGCPS health related service providers must document each contact per month as prescribed in the student s IEP. The following types of services are billable; face-to-face direct service, one-on-one direct screenings, evaluations, and treatments. Billing Process for Health Related Service Providers On a monthly basis, the Medicaid Billing Office generates color-coded, pre-printed Monthly Service Record Billing Forms. Monthly Service Record billing forms are forwarded to the Medicaid Coordinators who disseminate the forms to the assigned health-related service providers. 2

6 Health-related providers: Complete the Health Related Services Monthly Service Record billing forms on time. All forms should be forwarded to the Medicaid Billing Office by the 5 th of the following month. Health Related Service Providers should keep detailed documentation of each individual session or encounter on the Related Services Log in Maryland Online. Each note must include the goal, describe the nature or extent of services provided and include a statement about the student s progress. Ensure that your billing is consistent with the Service Description on the IEP. In order to receive reimbursement for MA billable services, (Speech, OT, PT) the IEP must contain either, a daily, weekly or monthly prescription of services. (See MSDE Technical Bulletin 21 August 2010) For Nursing Services the IEP must contain a daily prescription of services. For the exceptions to the service description of daily, weekly and monthly, the therapist must provide the reason or explanation for the use of the frequencies quarterly and yearly in order for Medicaid to be able to bill for IEP Service Coordination. For quarterly and yearly frequencies, Medicaid may not bill for the related service, but may bill for the IEP Service Coordination if the IEP has an appropriate explanation. Medicaid regulations stipulate that health-related services must contain face-toface contact with the student. Monitor the session number on the Monthly Service Record (e.g., Session 1 of 10) in order to prevent over billing for prescribed services. Copies of all supporting documentation (MD Online IEP Related Service logs, treatment flow sheets (Nursing), copies of evaluations) should be stapled to all billing forms prior to submission to the Medicaid Billing Office. When submitting billing for multiple months, supporting documentation will need to accompany each Monthly Service Record. For example, do not send one service log for 3 months of billing. Documentation Requirements Acceptable documentation describes a specific service that relates directly to the IEP. The provider must detail the intent of the encounter and a description of the specific skills being addressed. Related service logs should state the goal; describe the service rendered and the student s response to the service or treatment (progress). 3

7 Related Service log notations should include the date of service, time started and time ended, the type of service (e.g., group therapy, individual therapy, and make-up session), progress code, service location and the initials of the person providing the service. For Makeup sessions please use the MU code on the Related Services Log for the type of session and place the date of the session that was missed in the Description of Service area. DO NOT USE DITTO MARKS ON THE MEDICAID MONTHLY SERVICE RECORD. If the student did not receive service during the month, please indicate that on the form and return it to the Medicaid Billing Office by the 5 th of the following month (Sasscer Administration Building Trailer # C05-451). All health related billed services must be prescribed as a direct service on the student s IEP! 4

8 SPEECH & LANGUAGE SERVICES 5

9 Speech & Language Services The following Speech/Language services are reimbursable by Medicaid: Speech/Language Diagnostic Evaluation- This is a comprehensive evaluation, which determines the child s strengths and needs in the area of communication to ascertain any weaknesses that may impede educationally on the child. Speech/Language Therapy-Individual- Speech/Language therapy involves ongoing intervention which may consist of direct contact, or classroom services, with the child Speech/Language Therapy-Group- Speech/Language Group therapy involves ongoing intervention, which may consist of, direct contact or classroom services, in a group setting. Speech & Language Credentials Are you qualified to bill? A speech language pathologist shall possess the following: A current Maryland Department of Health and Mental Hygiene (DHMH) license; Are you qualified to bill for IEP Coordination? In order to bill for IEP Coordination services: A SLP must have a current MSDE issued teaching certificate (Conditional, Standard, Advanced professional certification) 6

10 Instructions for Completing Monthly Service Record Billing Form for Speech & Language Services Note: Demographic student information and most provider information are preprinted on the Health Related Services Monthly Service Record billing form on a monthly basis. However, if you have new students begin with step #1 of the billing instructions below. If you have received a pre-printed form, begin with step # 3 of the billing form instructions. 1. Complete the child s student number, name, date of birth, and school. Use only one form per child. Also, complete the therapy, provider and certification sections of the form. USE ONLY ONE FORM PER PROVIDER (therapist, teacher, etc.). FORMS MAY BE PHOTOCOPIED. 2. Leave the DIAGNOSIS code BLANK. 3. Write in the DATE OF SERVICE of the face-to-face encounter beginning with month, day, and year. Write in the ENCOUNTER CODE for each encounter per child. An encounter is defined as a face-to-face event relating to, or directly involving a service such as an evaluation, or treatment. For example, a speech language pathologist conducted an evaluation of a student. The procedure code for this encounter would be: 42 Speech/Language Evaluation Individual 42 Speech/Language Evaluation Individual 43 Speech/Language Therapy Individual 46 Speech/Language Therapy Group Student must be present for all Medicaid billable services. 4. Document the session number. Do not bill for more sessions than those indicated in the IEP. For example, if the IEP stipulates 6 times a month, only submit billing each month for 6 times during the month. Do not put non billable dates on the Monthly Service Record. (absentee dates, IEP meetings, indirect service dates) 5. In the COMMENTS section: Please write see attached log, one time. Attach a copy of the MD Online Service Log or a copy of the evaluation. 6. SIGN & PRINT YOUR NAME. The Health Related Services Monthly Service Record form must have an ORIGINAL SIGNATURE. Nicknames and abbreviations will not be accepted. 7. If the student did not receive service during the month, please indicate that on the form and return it to the Medicaid Billing Office (Sasscer Administration Building, Trailer C05-451). 7

11 8. SUBMIT FORMS by the 5 th of the following MONTH to: Medicaid Billing Office, Sasscer Administration Building, Trailer # C File a copy of the Monthly Service Record and the log in the student s LAF folder each month. VERY IMPORTANT POINTS TO REMEMBER Services must be delivered in accordance with the IEP/IFSP and must be related to an identified health problem. Please do not bill in excess of the service description indicated on the IEP. MSDE requires that the frequency of service on the IEP must be detailed as daily, weekly or monthly. Yearly and quarterly frequencies are no longer billable for Medicaid billing purposes. If yearly and quarterly are the best description for the frequency of the service, make sure to enter a professional explanation for the specialized frequency of service so that Medicaid can bill for IEP Service Coordination. List your current MD License. Sign at the top of the log (marked Provider Signature ) and initial each entry on the MD Online Related Services Logs. Please remember that the Medicaid Monthly Service Record form is an official document. Your signature is attesting to the accuracy of the information that is being provided. Therefore, you should carefully review the form to make sure the student was not absent on the date of service listed on the form. Submit one MD Online Service Log for each billing month. Staple MD Online Service Logs to the Health Related Services Form. Attach copies of evaluations when billing Code 42- Speech and Language Evaluation Individual. Place the dates of the assessments and testing in the beginning paragraphs of the evaluation. (example: "John was tested on 9/7/12 and 9/8/12.") PLEASE DO NOT LIST DATES THE STUDENT WAS ABSENT ON THE BILLING FORM. PLEASE DO NOT BILL FOR IEP MEETINGS ON MONTHLY SERVICE RECORD FORMS. PLEASE DO NOT BILL FOR CONSULTATIONS WITH OTHER PROVIDERS, OR OTHER MEMBERS OF THE IEP TEAM ON THE MONTHLY SERVICE RECORD FORM. PLEASE BE TIMELY WITH YOUR SUBMISSION OF FORMS. FORMS ARE DUE THE 5 th OF THE FOLLOWING MONTH. Please indicate if the session was a make-up session by denoting M/U on the service log. You must also identify the date of the missed session in the Description of Service on the Related Service log. Related service logs should state the goal; describe the service rendered and the student s response to the service or treatment (progress). If the student no longer receives Speech/Language services, please check the Service is no longer prescribed on the IEP box on the Monthly Service Record form and return it to the Medicaid Billing Office. If the student did not receive services in the billing month, please check the No billable services provided this month box and return it to the Medicaid Billing Office. 8

12 When submitting billing for multiple months, supporting documentation will need to accompany each Monthly Service Record. For example, do not send one Related Service Log for 3 months of billing. Ditto marks are not permitted on the billing form Please make sure that the Medicaid Office is aware of students who are speech only students ; their only special education service is speech. The Health Related Monthly Service Record form is located on our website at the following address: Special Notice to SLP s Maryland Senate Bill 600 require local boards of education to reimburse audiologists and speech language pathologists for their licensing fees if they (1) provide audiology and speech language services on a third-party basis in schools; and (2) are licensed by the State Board of Audiologists and Speech-Language Pathologists (We currently reimburse licensing fees for DHMH licensing only). During SY , speech language pathologists will complete licensing fee reimbursement in I-expense in Oracle. The funding strand is: FEES FINES AND LICENSES Please contact your supervisor or the Special Education Office if you have any problems filing for reimbursement. 9

13 SPEECH AND LANGUAGE SAMPLE FORM & MD ON-LINE IEP DOCUMENTATION 10

14 Speech Therapy Monthly Service Record SY SERVICE MONTH Health Related Services October 2012 STUDENT NAME STUDENT # DIAGNOSIS CODE MEDICAID # DOB SCHOOL DATE OF SERVICE ENCOUNTER CODE UNITS OFFICE USE ONLY SESSION # PROVIDER #SESSIONS LENGTH OF TIME FREQUENCY BEGIN DATE END DATE Please do NOT list dates that the student was absent Janna Doe /1/2000 Musical ES Marge Simpson 2 30 Weekly 3/8/2012 3/19/2013 COMMENTS 10/9/ /9/ Make-Up Session Remember to put the date of the missed session in the Description of Service on the Related Services log NO SERVICE? No billable service provided this month Service is no longer prescribed on the IEP Provider is not licensed Services must be provided in accordance to the IEP (Frequency of service) and must be listed on the IEP as a direct service. Please remember to attach supporting documentation. Please remember to SIGN the form. NO DITTO MARKS 42 Speech/Language Evaluation Individual 43 Speech/Language Therapy Individual 46 Speech/Language Therapy Group Marge Simpson Marge Simpson 10/30/2012 PROVIDER SIGNATURE (Required) PRINT NAME DATE 0911 Return all signed forms to: Medicaid Billing Office Sasscer Administration Building, C For Assistance, call:

15 Related Services Log Notes Marge Simpson Speech-Language Pathologist Janna Doe Provider Name: Position: Student's Name: Unique Student ID: School: Student's DOB: Musical ES 12/1/2000 FOR MA USE ONLY MA#: Date of parental consent for MA Billing: Diagnostic Code: Provider Name: Position: Certified Provisional Licensure Other Marge Simpson Provider Signature Signature REQUIRED Supervisor Signature (if service provider is not credentialed) Services (from IEP) (Service Nature, number of sessions, length of time, frequency, begin/end dates Date Length of Session Type of Session/ Absence Code Description of Service Provided and Related Goal Progress Code Service Location Initials 10/9/12 Start End 10:00 10:30 I Goal:Janna will answer detail questions. Description: Janna was able to correctly respond to 2/3/questions from "The Drinking Gourd". She is making some progress in this area. S School MS 10/9/12 Start 1 : 0 End 1 : 0 M/U Goal:Janna will answer detail questions. Description: Janna was able to correctly respond to 2/3/ questions S from"a is for Arizona".This is a m/u from 9/7/12 School MS Start End Remember to INITIAL Service Description: Provide detailed description of assessment or services/treatment (must be at least two sentences) Progress Code: (P) Progress has been made and if the current rate of progress continues the goal should be achieved by the end of the duration of the IEP; (S) Some progress has been made, but it may not be sufficient to achieve the goal by the end of the duration of the IEP; (N) Progress is not sufficient to achieve the goal by the end of the duration of the IEP Service Location: School, Home, Other (specify) Type of Session: (I) Individual, (G) Group, (Ind) Indirect, (M/U) Make-up session, (MT) Music Therapy, (AT) Art Therapy Absence Code: (A) Student absent, (B) school closed, (C) student unavailable, (D) clinician/therapist absent, (E) clinician/therapist unavailable e.g., IEP team meeting Note: Absences for codes C through E must be rescheduled MA ONLY: Initials: Service Provider and Supervison (if Service Provider is not credentialed) 12

16 Name:Janna Doe Agency: Prince George's IEP Team Meeting Date: 03/18/2012 Development) General Education Sessions: 2 (Select the length of time, in 15 minute increments, that the service is provided during each session): 0 Hr.30 Min. Weekly Teacher (O) IEP Team (O) Instructional Assistant Weekly 1 Hr. 0 Min. Speech/Language Therapy as a Related Service Outside General Education Number of Sessions: 2 Length of Time (Select the length of time, in 15 minute increments, that the service is provided during each session): 0 Hr.30 Min. Frequency: Weekly 03/19/ /19/2013 (P) Speech/Language Pathologist Total service Weekly 1 Hr. 0 Min. Discussion of service(s) delivery (for all services): Special Education - Classroom Instruction: Janna will receive 27 hours and 30 minutes of Classroom Instruction for the remainder of this school year and during the school year. Related Services - Occupational Therapy: Janna will receive 30 minutes once a week of occupational therapy services during the school year. Service will consist of pull out and inside classroom sessions. Adaptive equipment will be tried as needed. Related Services - Other Therapies (Music): Janna will receive 1 hour of Music from the general education music teacher, inside of the general education setting, beginning March 19, Related Services - Other Therapies (Motor Development): Janna will receive 1.0 hour of Motor Development for the remainder of this year and during the school year. Related Services - Speech/Language Therapy as a Related Service: Speech-language therapy services for academic year for 30 minutes 2x weekly to be provided by a Speech-Language Pathologist. Services may be provided in the classroom or on a pull-out on an as needed basis. Services may include observations, IEP meetings, parent/teacher consultation. SPECIAL EDUCATION ESY Service Nature ESY Location ESY Service Description ESY Begin Date ESY End Date ESY Provider(s): (P)=Primary, (O)=Other Summary of Service Classroom Instruction (Identifying the number of sessions for Classroom Instruction is optional) Outside General Education Number of Sessions: 4 Length of Time (Select the length of time, in 15 minute increments, that the service is provided during each session): 4 Hrs.35 Min. Frequency: Weekly 07/06/ /30/2013 (P) Special Education Classroom Teacher (O) Instructional Assistant Total service Weekly 18 Hrs. 20 Min. 07/07/

17 Documentation Examples for Speech Language Pathology Services IEP Goal: Amy will use her augmentative communication skills to respond to questions and initiate conversation. (Goal is directly from the IEP.) 4/1/05 S/L therapy to stimulate greetings using the Dynavox. Using verbal reinforcement from the clinician, Amy returned 3 greetings. She is making adequate progress. 4/8/05 Language therapy to increase verbal interaction. Using question prompts, Amy responded to 8 out of 10 questions. She is improving in this area. IEP Goal: Increase speech intelligibility (Goal is directly from the IEP.) 12/11/11 Speech/ Language Treatment. Used visual cues given by clinician, to increase correct production. Allen produced /s/, /z/ in the initial position 40% of the time. His progress is slow but consistent. 2/9/12 Speech/Language Treatment. Used oral reading to improve, self monitoring. Allen self corrected /s/, /z/ 80% of the time. He is making adequate progress. IEP Goal: Increase number of fluencies by 50% in controlled settings. (Goal is directly from the IEP.) 2/1/12 S/L Therapy. Used modeling to elicit smooth easy beginnings during oral reading. John displayed an average of 4 dysfluencies during one minute readings. John is not making progress at this time. IEP Goal: John will become a more intelligible, spontaneous communicator (Goal is directly from the IEP.) 2/1/12: Therapy. Used tape recorder to help John identify what parts of speech are disrupted. John identified 60% of disruptions. John is making adequate progress. 2/8/12: Therapy. Utilized relaxation techniques to reduce overall body tension. John identified relationship between tension and speech production. He is making some progress. 14

18 NURSING SERVICES 15

19 Nursing Services The following are services that are reimbursable by Medicaid and must be reflected in the student s IEP. Nursing Assessment Nursing Treatment Nursing Credentials Are you qualified to bill? A nurse shall be a Registered Nurse (RN) or Licensed Practical Nurse (LPN) licensed to practice the state of Maryland. Requirements for Billing Nursing Services Nursing Services must be documented as a related service in the IEP. Nursing Services must be delivered in accordance with the IEP/IFSP. Nursing Services must be related to an identified health problem. Nursing Services must be ordered by a licensed prescriber, except for a nursing assessment, which results in a change of nursing care plan. Nursing Services must be indicated in the nursing care plan which must be reviewed every 60 days or more frequently when a student s medical condition changes. Billable Nursing Services Urinary Catheterizations Gastrostomy Tube Feedings Endotracheal Suctioning/Tracheotomy Ostomy Care Wound/Decubitus Care Please Note: Medicaid does not reimburse for the following services: Peak flow monitoring, administration of medication, blood glucose monitoring, nebulizer treatments and oxygen administration. Medicaid does not reimburse for the student s self administration of any medical service. 16

20 Instructions for Completing Monthly Service Record Billing Form for Nursing Services Note: Demographic student information and most provider information are preprinted on the Health Related Services Monthly Service Record billing form on a monthly basis. However, if you have new students begin with step #1 of the billing instructions below. If you have received a pre-printed form, begin with step # 3 of the billing form instructions. 1. Complete the child s student number, name, date of birth, and school. Use only one form per child. Also, complete the therapy, provider and certification sections of the form. FORMS MAY BE PHOTOCOPIED. 2. Leave the DIAGNOSIS code BLANK. 3. Write in the DATE OF SERVICE of the face-to-face encounter beginning with month, day, and year. 4. Write in the ENCOUNTER CODE for each encounter per child. An encounter is defined as a face-to-face event relating to, or directly involving a service such as assessment, or treatment. For example, a nurse administered a gastric tube feeding to a student. The procedure code for this encounter would be: 99- Nursing Services. 99 Nursing-all services 5. In the COMMENTS section: Attach a copy of the detailed Nursing notes (i.e., Treatment Flow Sheet) including the start and end time of the billable service. 6. If the student did not receive service during the month, please indicate that on the form and return it to the Medicaid Billing Office (Sasscer Administration Building, Trailer # C05-451). 7. SIGN & PRINT YOUR NAME. The Health Related Services Monthly Service Record form must have an ORIGINAL SIGNATURE. All Nurses who have an entry on the Treatment Flow Sheet must sign the flow sheet and the Medicaid Monthly Service Record. (Billing form). Nicknames and abbreviations will not be accepted. 8. SUBMIT FORMS by the 5 th of each MONTH to: Medicaid Billing Office, Sasscer Administration Building, Trailer # C Place copies of billing forms and Treatment Flow Sheets in the student s LAF file. 17

21 VERY IMPORTANT POINTS TO REMEMBER Services must be delivered in accordance with the IEP/IFSP and must be related to an identified health problem. Please do not bill in excess of the Service Description indicated on the IEP. The current service description (IEP prescription) on the IEP is printed on the Monthly Service Record form after the demographic information on preprinted Medicaid forms. Please contact the students case manager if the service description is incorrect. List your Certification/License on the billing form. Nursing services are billed in 15 minutes increments/units. PGCPS can receive reimbursement for up 8 units (2 hours) of service per day for nursing services provided to Medicaid eligible students. Nursing services should be described as Daily in the related services section of the IEP. Physician s Orders are submitted once a year to the Medicaid billing office. Please resubmit the order to Medicaid if the order changes during the year. Health Care Nursing Plan documents should be created and sent to the Medicaid Billing Office at the beginning of the school year. Then Health Care Nursing Plans are reviewed, signed, dated and submitted to the Medicaid Billing Office every 60 days. Please remember that the Medicaid Health Related Services form is an official document. Your signature is attesting to the accuracy of the information that you are providing. Therefore, you should carefully review the form to make sure the student was not absent on the date of service listed on the form. PLEASE DO NOT LIST DATES THE STUDENT WAS ABSENT ON THE BILLING FORM. PLEASE DO NOT BILL FOR IEP MEETINGS ON A HEALTH RELATED SERVICES FORM. PLEASE DO NOT BILL FOR CONSULTATIONS WITH OTHER PROVIDERS, OR OTHER MEMBERS OF THE IEP TEAM ON THE HEALTH RELATED SERVICES FORM. PLEASE BE TIMELY WITH YOUR SUBMISSION OF FORMS. FORMS ARE DUE THE 5 th OF THE FOLLOWING MONTH. Please indicate the start and end time of every billable service. If the student no longer receives Nursing services, please check the Service is no longer prescribed on the IEP box on the health related service form and return it to the Medicaid Billing Office. If the student did not receive services in the billing month, please check the No billable service provided this month. box and return it to the Medicaid Billing Office. When submitting billing for multiple months, supporting documentation will need to accompany each Monthly Service Record. For example, do not send one Treatment Flow Sheet for 3 months of billing. Ditto marks are not permitted on the billing form or on the Treatment Flow Sheet. The Health Related Monthly Service Record form is located on our website at the following address: 18

22 NURSING SERVICES SAMPLE FORM & MD ON-LINE IEP DOCUMENTATION 19

23 Nursing M E D I C A I D B I L L I N G O F F I C E Monthly Service Record SY SERVICE MONTH Health Related Services September 2012 STUDENT NAME STUDENT # DIAGNOSIS CODE MEDICAID # DOB SCHOOL DATE OF SERVICE ENCOUNTER CODE UNITS OFFICE USE SESSION # PROVIDER #SESSIONS LENGTH OF TIME FREQUENCY BEGIN DATE END DATE Please do NOT list dates that the student was absent Hannah Montana /1/2000 Della Reese ES RN 1 30 Min Daily 2/17/2012 2/16/2013 COMMENTS 9/9/ See Nursing Notes 9/10/ See Nursing Notes NO SERVICE? No billable service provided this month Service is no longer prescribed on the IEP Provider is not licensed Services must be provided in accordance to the IEP (Frequency of service) and must be listed on the IEP as a direct service. Please remember to attach supporting documentation. Please remember to SIGN the form. NO DITTO MARKS 99 Nursing-all services (per 15 min) Signature REQUIRED INTERNAL USE ONLY DO Date HCP Date Marge Simpson Marge Simpson 9/29/2012 PROVIDER SIGNATURE (Required) PRINT NAME DATE 0712 Return all signed forms to: Medicaid Billing Office Sasscer Administration Building C For Assistance, call:

24 PRINCE GEORGE S COUNTY PUBLIC SCHOOLS OFFICE OF HEALTH SERVICES Individual Health Care Plan Student: Date of Birth: Parent/Guardian: Phone: Home Work Emergency Contact: Phone: Health Care Provider Phone Nursing Diagnosis Nursing Goals Individual Concerns Nursing Interventions Individual Care Plan Initiated by Date 21

25 Prince George s County Public Schools DEPARTMENT OF HEALTH SERVICES PHYSICIAN S ORDER FOR SPECIALIZED SCHOOL HEALTH SERVICES (Catheterization) Name of Student School Year Health Services Coordinator (Nurse) Phone Referral Physician s Name Physician s Address Phone Patient Name (Last, First, Middle Initial) Date of BIrth Race Parent Information Patient Address Sex M F Phone No. Parent or Guardian Relationship to child Phone No. School Presently Attending Phone No. Diagnosis/Pertinent History (Use back as needed) Treatment Start Date Treatment End Date Describe treatment/procedure to be administered. CLEAN INTERMITTENT CATHETERIZATION AT SCHOOL Parent/Guardian Physician s Orders Frequency: Times: Special Instructions: Equipment/supplies necessary for procedure Catheter size:, wipes, lubricant, receptacle for urine. Special equipment: Dietary Recommendations Activity Limitations Physician s Signature Date I Understand that I must supply the school with the equipment/supplies listed above. Date I hereby authorize the treatment/procedure described above to be administered by Prince George s County Public School s staff to my child as directed by my child s physician. I understand that the physician will be called if a question arises about my child s procedure. Signature of Parent/Guardian Date PGCPS RN Signature Date PS-158A PGIN (9/06) White Copy: School Canary Copy: Coordinator Pink Copy: Parent Goldenrod Copy: Physician

26 Name: Hanna Montana Agency: Prince George's IEP Team Meeting Date: 02/17/20012 General Education Sessions: 1 (Select the length of time, in 15 minute increments, that the service is provided during each session): 0 Hr.30 Min. Daily (O) Other Service Provider - School Nurse Daily 2 Hrs. 30 Min.N Nursing Services Outside General Education Number of Sessions: 51 Length of Time (Select the length of time, in 15 minute increments, that the service is provided during each session): 0 Hr.30 Min. Frequency: Daily 02/17/ /16/20113 P) Nurse Total service Weekly 2 Hrs. 30 Min. Discussion of service(s) delivery (for all services): Special Education - Classroom Instruction: After evaluation the team decided that services and supplementary aides will be provided in the classroom on a consultative basis Special Education - Physical Education: Starting on February 6th,2009 Hanna will receive Adapted Physical Education services by an Adapted Physical Education teacher over a period of 36 weeks. The service will be delivered 2 times per week for a total of 60 minutes. We will be following the Adapted Physical Education curriculum and framework through out the academic year. S. Wolff, Motor Specialist. Related Services - Physical Therapy: Hanna will receive 10, 15 minute sessions of Physical Therapy to train the staff on proper use and positioning of her assigned adapted equipment and to monitor and make adjustments to her equipment as needed. Related Services - Nursing Services ): Hanna will be g-tube fed daily in the nurses office. RELATED SERVICES ESY Service Nature ESY Location ESY Service Description ESY Begin Date ESY End Date ESY Provider(s): (P)=Primary, (O)=Other Summary of Service Physical Therapy Outside General Education Number of Sessions: 1 Length of Time (Select the length of time, in 15 minute increments, that the service is provided during each session): 0 Hr.10 Min. Frequency: Monthly 07/06/ /30/2013 P) Physical Therapist (O) Physical Therapy Assistant Total service Monthly 0 Hr. 10 Min. Nursing Services Outside General Education Number of Sessions: Length of Time (Select the length of time, in 15 minute Frequency: Weekly 07/01/ /31/2013 P) Nursing Total service eekly 07/07/

27 PSYCHOLOGICAL SERVICES 24

28 Psychological Services The services below are only billable under the following conditions for students receiving Medicaid: The service is a face-to-face encounter with the student. The service is specified in the IEP, or approved by a multidisciplinary team as documentation in or in the Discussions and Documentation area in the MD On-Line IEP. The One Time Only Evaluation/Assessment is a face-to-face service to determine if the student needs services. (The result of the assessment is not relevant- student may or may not be in special education.) Psychological Consultations- A psychological consultation may include classroom observations, parent/teacher conferences with the student being present. Psychological Evaluations/Assessments/Screenings- This is the application of psychological tests, techniques, etc., to measure the intelligence, personality, aptitudes, interests or achievement of individuals or group of individuals Individual Psychotherapy- Therapeutic Behavior Services Crisis Intervention Services Group Therapy- A trained clinician facilitates the group process and structure to alter the individuals feelings, behaviors, and attitudes. This type of intervention includes both process oriented groups as well as psycho-educational groups. Psychological Services Provider Credentials Are you qualified to bill? A psychologist shall possess the following licensure: DHMH Licensed Psychologist Psychological Services Clarifications Special Clarification/Notices For one time only psychological assessments/evaluations, you may bill whether the student is recommended for special education services or not. When sending the Medicaid billing forms, please attach a parent 25

29 permission form, and provide the student s Medicaid number on the billing form. Please indicate the date the student was assessed in the beginning of the report. Sign and date all psychological assessments. For all other services, please remember to attach to the Monthly Service Record, and a related service log as it relates to the IEP. Make sure the billed service is specified as a direct service in the IEP Except for the one time only assessment/evaluation. 26

30 Instructions for Completing Monthly Service Record Billing Form for Psychological Services Note: Demographic student information and most provider information are preprinted on the Health Related Services Monthly Service Record billing form on a monthly basis. However, if you have new students begin with step #1 of the billing instructions below. If you have received a pre-printed form, begin with step # 3 of the billing form instructions. 1. Complete the child s student number, name, date of birth, and school. Use only one form per child. Also, complete the therapy, provider and certification sections of the form. USE ONLY ONE FORM PER PROVIDER (therapist, teacher, etc.). FORMS MAY BE PHOTOCOPIED. 2. Leave the DIAGNOSIS code BLANK. 3. Write in the DATE OF SERVICE of the face-to-face encounter beginning with month, day, and year. 4. Write in the ENCOUNTER CODE for each encounter per child. An encounter is defined as a face-to-face event relating to, or directly involving a service such as screening, assessment, or treatment. The procedure code for this encounter would be: 51 Individual Therapy min 51 Individual Psychotherapy min 52 Individual Psychotherapy min 53 Individual Psychotherapy min 54 Family Therapy 55 Group Psychotherapy 5. In the COMMENTS section: Please write, see attached documentation or Write a brief description of the nature of the encounter provided. 6. SIGN & PRINT YOUR NAME. The Health Related Services Monthly Service Record form must have an ORIGINAL SIGNATURE. Nicknames and abbreviations will not be accepted. 7. If the student did not receive service during the month, please indicate that on the form and return it to the Medicaid Billing Office (Sasscer Administration Building, Trailer # C05-451) 8. SUBMIT FORMS by the 5 th of each MONTH to: Medicaid Billing Office, Sasscer Administration Building, Trailer # C

31 VERY IMPORTANT POINTS TO REMEMBER Services must be delivered in accordance with the IEP/IFSP and must be related to an identified health problem. Please do not bill in excess of the prescription indicated on the IEP. Please indicate your MD State License Please indicate the start and end time of your session(s) in your notes/log for each service date. Provide a date next to signature on all psychological assessments. Staple supporting documents to the Health Related Services Form. When using a MD-Online Service Log, provide one for each billing month. Please remember that the Medicaid Health Related Services form is an official document. Your signature is attesting to the accuracy of the information that you are providing. Therefore, you should carefully review the form to make sure the student was not absent on the date of service listed on the form. PLEASE DO NOT LIST DATES THE STUDENT WAS ABSENT ON THE BILLING FORM PLEASE DO NOT BILL FOR IEP MEETINGS ON A HEALTH RELATED ENCOUNTER FORM. PLEASE DO NOT BILL FOR CONSULTATIONS WITH OTHER PROVIDERS, OR OTHER MEMBERS OF THE IEP TEAM ON THE HEALTH RELATED ENCOUNTER FORM. PLEASE BE TIMELY WITH YOUR SUBMISSION OF FORMS. FORMS ARE DUE THE 5 th OF THE FOLLOWING MONTH. Please indicate if the session was a make-up session by denoting M/U on the related service log. If there are the same dates listed twice and one is not denoted as a make-up session, we will not be able to receive reimbursement for both dates of service. You must also put the date the session was originally scheduled in the description of the session. If the student no longer receives Psychological services, please check the Service is no longer prescribed on the IEP box on the health related services form and return it to the Medicaid Billing Office. If the student did not receive services in the billing month, please check the No billable service provided this month box and return it to the Medicaid Billing Office. When submitting billing for multiple months, supporting documentation will need to accompany each Monthly Service Record. For example, do not send one Related Service Log for 3 months of billing. Ditto marks are not permitted on the billing form The Health Related Monthly Service Record form is located on our website at the following address: 28

32 PSYCHOLOGICAL SERVICES SAMPLE FORM & MD ON-LINE IEP DOCUMENTATION 29

33 MEDICAID BILLABLE SERVICES FOR PSYCHOLOGICAL SERVICES Required Attachments SY Billable Services What Should Go On the Billing Form? Required Attachments ONE TIME ONLY - ASSESSMENT/EVALUATION PSYCHOLOGICAL CONSULTATION EVALUATIONS/ASSESSME NTS AND SCREENINGS INDIVIDUAL PSYCHOTHERAPY THERAPEUTIC BEHAVIOR SERVICES CRISIS INTERVENTION SERVICES GROUP THERAPY The date of service, the encounter code, and written in the comment section, See attached. Sign and date the billing form. The date of service, the encounter code, and in the comments section write, The student is present for this consultation where the purpose is to assess the effectiveness of his behavioral plan... Sign and date the billing form. The date of service, the encounter code, and in the comment section write, Evaluation was requested by the treatment team to determine if the student may need more mental health services than are being provided. Sign and date the billing form. The date of service, the encounter code, and in the comment section, Individual therapy conducted regarding aggressive tendencies and withdrawn characteristics. Sign and date the billing form. The dates of service, the encounter code, and in the comment section write, TBS services delivered in the initial phase where we are developing alternative behaviors to cursing and hitting. Sign and date the billing form. The dates of service, the encounter code, and in the comment section write, Crisis intervention service conducted due to outburst and underlying depression. Sign and date the billing form. The date of service, the encounter code), and in the comment section write, Group therapy session regarding children of abuse. Sign and date the billing form. Attach the Medicaid parent permission form, the recommendation from the treatment team for the assessment, and a copy of the assessment. Sign and date the assessment. Attach the portion of the IEP where the service is listed, recommended, or requested. Or attach the request for this service by the treatment team. Then attach the consultation report. Sign and date the consultation report. Attach the portion of the IEP where the service is listed, recommended, or requested. Or attach the request for this service by the treatment team. Also attach a copy of the assessment/screening. Sign and date the evaluation/assessment. Attach a copy of the related service as prescribed in the IEP. Also attach a copy of the Related Services Log. Remember to initial each entry. Attach a copy of the related service as prescribed in the IEP. Also attach a copy of the Related Services Log. Remember to initial each entry. Attach a copy of the related service as prescribed in the IEP. Also attach a copy of the Related Services Log. Remember to initial each entry. Attach a copy of the related service as prescribed in the IEP. Also attach a copy of the Related Services Log. Remember to initial each entry. 30

34 Psychological Services M E D I C A I D B I L L I N G O F F I C E Monthly Service Record SY SERVICE MONTH Health Related Services STUDENT NAME Monica Friends STUDENT # DIAGNOSIS CODE MEDICAID # DOB 12/1/98 SCHOOL Chandler Heights MS PROVIDER Jennifer Anniston #SESSIONS LENGTH OF TIME FREQUENCY BEGIN DATE END DATE 6 30 min Monthly 3/11/2012 3/10/2013 DATE OF SERVICE ENCOUNTER CODE UNITS OFFICE USE SESSION # COMMENTS 9/9/12 51 N/A See Attached Treatment Notes/ Log Please do NOT list dates that the student was absent NO SERVICE? No billable service provided this month Service is no longer prescribed on the IEP Provider is not licensed 50 Psychiatric Diagnostic Interview 51 Ind Psychotherapy min 52 Ind Psychotherapy min 53 Ind Psychotherapy min 54 Family Psychotherapy 55 Group Psychotherapy Services must be provided in accordance to the IEP (Frequency of service) and must be listed on the IEP as a direct service. Please remember to attach supporting documentation. Please remember to SIGN the form. NO DITTO MARKS Signature REQUIRED Jennifer Anniston Jennifer Anniston 9/29/12 PROVIDER SIGNATURE (Required) PRINT NAME DATE Return all signed forms to: Medicaid Billing Office Sasscer Administration Building, C For Assistance, call:

35 Related Services Log Notes Provider Name: Position: Student's Name: Unique Student ID: School: Student's DOB: FOR MA USE ONLY MA#: Date of parental consent for MA Billing: Diagnostic Code: Provider Name: Position: Certified Licensure Provisional Other Jennifer Anniston Provider Signature Jennifer Anniston Psychologist Monica Friends Chandler Heights MS 12/1/2000 Signature REQUIRED Supervisor Signature (if service provider is not credentialed) Services (from IEP) (Service Nature, number of sessions, length of time, frequency, begin/end dates Date Length of Session Type of Session/ Absence Code Description of Service Provided and Related Goal Progress Code Service Location Initials 9/9/2012 Start 10:00 End 10:30 I Goal: Monica will be able to control her anger when faced with difficult situations Description: Student participated in individual counseling to learn anger management. She is also learning social skills, understanding and communication of emotions P School JA Start End Start End Service Description: Provide detailed description of assessment or services/treatment (must be at least two sentences) Progress Code: (P) Progress has been made and if the current rate of progress continues the goal should be achieved by the end of the duration of the IEP; (S) Some progress has been made, but it may not be sufficient to achieve the goal by the end of the duration of the IEP; (N) Progress is not sufficient to achieve the goal by the end of the duration of the IEP Service Location: School, Home, Other (specify) Type of Session: (I) Individual, (G) Group, (Ind) Indirect, (M/U) Make-up session, (MT) Music Therapy, (AT) Art Therapy Absence Code: (A) Student absent, (B) school closed, (C) student unavailable, (D) clinician/therapist absent, (E) clinician/therapist unavailable e.g., IEP team meeting Note: Absences for codes C through E must be rescheduled MA ONLY: Initials: Service Provider and Supervison (if Service Provider is not credentialed) 32

36 Name: Agency: Prince George's IEP Team Meeting Date: 03/10/20 SPECIAL EDUCATION Service Nature Location Service Description Begin Date End Date Provider(s): (P)=Primary, (O)=Other Summary of Service Classroom Instruction (Identifying the number of sessions for Classroom Instruction is optional) Outside General Education Number of Sessions: 5 Length of Time (Select the length of time, in 15 minute increments, that the service is provided during each session): 4 Hrs.40 Min. Frequency: Weekly 03/11/201 03/09/201 (P) Special Education Classroom Teacher (O) Special Education Classroom Teacher Total service Weekly 23 Hrs. 20 Min. Speech/Language Therapy Outside General Education Number of Sessions: 3 Length of Time (Select the length of time, in 15 minute increments, that the service is provided during each session): 0 Hr.15 Min. Frequency: Weekly 03/11/201 03/09/201 (P) Speech/Language Pathologist Total service Yearly 7 Hrs. 30 Min. RELATED SERVICES Service Nature Location Service Description Begin Date End Date Provider(s): (P)=Primary, (O)=Other Summary of Service Psychological Services Outside General Education Number of Sessions: 6 Length of Time (Select the length of time, in 15 minute increments, that the service is provided during each session): 0 Hr.30 Min. Frequency: Monthly 03/11/201 03/09/201 (P) Psychologist otal service Monthly 3 Hrs. 0 Min. Discussion of service(s) delivery (for all services): Special Education - Classroom Instruction: Services will be provided by a special educator for 22 hours per week in a separate class in reading, 07/01/2 33

37 OCCUPATIONAL & PHYSICAL THERAPY SERVICES 34

38 Occupational & Physical Therapy Services The services below are only billable under the following conditions for students receiving Medicaid: The service is a face-to-face encounter with the student. The service is specified in the IEP. Billable Occupational & Physical Therapy Services Occupational Therapy Evaluations and Re-evaluations Occupational Therapy Treatment Physical Therapy Evaluation and Re-evaluations Physical Therapy Treatment Occupational & Physical Therapy Provider Credentials Are you qualified to bill? An occupational therapist shall be licensed to practice in the jurisdiction in which services are provided; A physical therapist shall be licensed to practice in the jurisdiction in which services are provided. A physical therapist assistant will not be permitted to bill for PT services at this time due to the lengthy documentation of supervision that is required by Maryland and the Federal government. 35