HCS BILLING GUIDELINES

Transcription

1 HCS BILLING GUIDELINES You can find the newest version on the DADS website: 1

2 General Information Department of Aging and Disability Services (DADS) rules at 40 TAC set forth requirements for Home and Community-based Services (HCS) Program providers to receive payment for HCS Program services. Specifically, 40 TAC 9.170(d) requires a program provider to prepare and submit service claims in accordance with the HCS Program Billing Guidelines. Also, Sections II. H. and II. T. of the HCS Program Provider Agreement require program providers to comply with the HCS Program Billing Guidelines. In addition, 40 TAC 9.170(k) sets forth circumstances under which a program provider will not be paid or Medicaid payments will be recouped from the program provider. 2

3 General Requirements Applicable Service Components Specialized Therapies Audiology; dietary; occupational therapy; physical therapy; behavioral support; social work; and speech and language pathology. Day Habilitation Nursing Registered; Licensed Vocational; Specialized Registered; and Specialized Licensed Vocational. Residential Assistance Foster/Companion Care; Residential Support; Supervised Living; and Supported Home Living. Respite Supported Employment Adaptive Aids Minor Home Modifications Dental Treatments 3

4 Specific Requirements 21

5 Specialized Therapies 22

6 Specific Requirements Specialized Therapies Audiology services Dietary services Occupational therapy services Physical therapy services Psychology services Social work services Speech and language pathology services 23

7 Specific Requirements Specialized Therapies Billable Activity The only billable activities for the specialized therapies service component are: interacting face-to-face or by video conference or speaking by telephone with an individual, based on the specialized therapies subcomponent provided, to conduct assessments or provide services within the scope of the service provider's practice; interacting face-to-face or by video conference or speaking by telephone with a person regarding a specialized therapies subcomponent provided to an individual, but not with: a staff person who is not a service provider; or a service provider of any nursing service component (registered nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational nursing), or specialized therapies; writing an individualized treatment plan for an individual's specialized therapies which, for behavioral support services, is a behavior support plan; reviewing documents, except for a written narrative or written summary of a service component as described in Section 3820, to evaluate the quality and effectiveness of an individual's specialized therapies; 24

8 Specific Requirements Specialized Therapies Billable Activity training the following persons on how to provide specialized therapies treatment, including how to document the provision of treatment: a service provider of foster/companion care, residential support, supervised living, supported home living, day habilitation, respite, supported employment or employment assistance; or a person other than a service provider who is involved in serving an individual; reviewing documents in preparation for the training described in the bullet above; participating in a service planning team meeting; participating in the development of an implementation plan; participating in the development of an IPC; and 25

9 Specific Requirements Specialized Therapies Billable Activity for behavioral support services, in addition to the activities listed above: assessing the targeted behavior so that a behavior support plan may be developed; training of and consulting with an individual, family member or other persons involved in the individual's care regarding the implementation of the behavior support plan; monitoring and evaluating the effectiveness of the behavior support plan; modifying, as necessary, the behavior support plan based on the monitoring and evaluation of the plan's effectiveness; and educating an individual, family members or other persons involved in the individual's care about the techniques to use in assisting the individual to control maladaptive or socially unacceptable behaviors exhibited by the individual. 26

10 Specific Requirements Not Billable as Specialized Therapies The following are examples of activities that are not billable for the specialized therapies service component: providing services outside the scope of the service provider's practice; providing services that are performed by a service coordinator or were performed by a former case manager; scheduling an appointment; transporting an individual; traveling or waiting to provide a specialized therapies subcomponent; training or interacting about general topics unrelated to a specific individual, such as principles of behavior management, or general use and maintenance of an adaptive aid or equipment; creating written documentation as described in Section 4260; reviewing a written narrative or written summary of a service component as described in Section 3820; and 27

11 Specific Requirements Not Billable as Specialized Therapies The following are examples of activities that are not billable for the specialized therapies service component (continued): interacting with: a staff person who is not a service provider; or a service provider of any nursing service component (registered nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational nursing) or specialized therapies, if not during a service planning team meeting or during the development of an IPC or an implementation plan. Activities in Section 3300 The activities listed in Section 3300, Activity Not Billable, are not billable for the specialized therapies service component. Activities Not Listed in Section 4220 Any activity not described in Section 4220, Billable Activity, is not billable for the specialized therapies service component. 28

12 Specific Requirements Examples of Activity Not Billable providing services outside the scope of the service provider's practice; providing services that are performed by a service coordinator or were performed by a former case manager; scheduling an appointment; transporting an individual; traveling or waiting to provide a specialized therapies subcomponent; training or interacting about general topics unrelated to a specific individual, such as principles of behavior management, or general use and maintenance of an adaptive aid or equipment; creating written documentation as described in Section 4260; reviewing a written narrative or written summary of a service component as described in Section 3820; and interacting with: a staff person who is not a service provider; or a service provider of any nursing service component (registered nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational nursing) or specialized therapies, if not during a service planning team meeting or during the development of an IPC or an implementation plan. 29

13 Specific Requirements Specialized Therapies Written Documentation Except as provided in Section 4270, Insurance Co-payment and Deductible (see No. 1, Item c and No. 2, Item c), a program provider must have written documentation to support a service claim for specialized therapies that: meets the requirements set forth in Section 3800, Written Documentation; includes the exact time the service event began and the exact time the service event ended documented by the service provider making the written service log; and for any activity performed by multiple service providers at the same time for the same individual, includes a written justification in the individual's implementation plan for the use of multiple service providers. 30

14 Common Errors No begin and/or end times No location of service provided Reviewing or creating service delivery records Family paying for rate differential No Progress Note 31

15 Day Habilitation 32

16 Specific Requirements Day Habilitation Billable Activity The only billable activities for the day habilitation service component are: interacting face-to-face with an individual to assist the individual in achieving objectives to: acquire, retain or improve self-help skills, socialization skills or adaptive skills that are necessary to for the individual to successfully reside, integrate and participate in the community; reinforce a skill taught in school, specialized therapies; and develop opportunities for employment in the community (for example, completing a job application, assessing employment skills and training on employment-related issues); transporting an individual between settings at which day habilitation is provided to the individual; assisting an individual with his or her personal care activities if the individual cannot perform such activities without assistance; participating in a service planning team meeting; participating in the development of an implementation plan; and participating in the development of an IPC. 33

17 Specific Requirements Not Billable as Day Habilitation Travel time (except from one Day Habilitation site to another) Written documentation Reviewing records Drafting Implementation Plans Staff Training/Conferences Processing service claims Assisting an individual for the sole purpose of meeting vocational goals 35

18 Specific Requirements May not submit DH service claim for: An individual who refuses to participate An individual who is sleeping Assisting an individual in achieving goals not documented in their IP More than five units of service in a calendar week More than 260 units of service per IPC year Day habilitation that is funded by another source other than HCS 36

19 Specific Requirements Day Habilitation Unit of Service A unit of service for Day Habilitation is one day One-quarter unit of service if service is provided at least one and one-quarter hours of consecutive day habilitation on a calendar day One-half unit of service may be billed if service is provided for at least two and one-half hours on a calendar day. Two of the two and one-half hours must be consecutive. Three-quarters unit of service may be billed if service is provided for at least three and three-quarter hours on a calendar day. Two of the three and threequarter hours must be consecutive. One unit may be billed if service is provided for at least five hours on a calendar day. Two of the five hours must be consecutive. 37

20 Common Errors Individual sleeping Not signing individual out of Day Habilitation for other services provided (NU, SHL, etc.) No description of service provided (details about interactions, activities, behaviors, successes, refusals, etc.) Vocational Goals Sheltered Workshops No Progress Note 39

21 Supported Employment 40

22 Specific Requirements Supported Employment Supported employment is a service that assists an individual to sustain competitive, integrated employment. 41

23 Specific Requirements Supported Employment Billable Activity The only billable activities for the supported employment service component are: interacting face-to-face with an individual at the individual's work site to provide training, support and intervention necessary to sustain the individual's employment; interacting face-to-face or by telephone with an individual's employment supervisor as necessary to sustain the individual's employment; transporting an individual to and from the individual s work site; participating in a service planning team meeting; participating in the development of an implementation plan; and participating in the development of an IPC. 42

24 Specific Requirements Examples of Activities Not Billable under SE The following are examples of activities that are not billable for the supported employment service component: interacting with an individual prior to the individual's employment; conducting employment interest assessments, assisting with or arranging interviews, and completing job applications; interacting with an individual when the individual is not on duty; and transporting an individual to a job interview. 43

25 Specific Requirements Restrictions (SE): A program provider may not submit a service claim for supported employment provided to an individual: while the individual is employed by the program provider; in excess of 600 units of service (150 hours) per IPC year; or if supported employment is available to the individual through the public school system or the Department of Assistive and Rehabilitative Services. 44

26 Common Errors Training not occurring at the job site Pre-vocational training No Progress Note 46

27 Nursing 47

28 Specific Requirements Registered Nursing Billable Activity The only billable activities for the registered nursing service component are: interacting face-to-face with an individual who has a medical need for registered nursing, including: preparing and administering medication or treatment ordered by a physician, podiatrist or dentist; assisting or observing administration of medication; and assessing the individual's health status, including conducting a focused assessment or a comprehensive assessment; speaking by telephone with an individual who has a medical need for registered nursing, including assessing the individual's health status; interacting by video conference with an individual who has a medical need for registered nursing, including: observing administration of medication; and assessing the individual's health status, including conducting a focused assessment or a comprehensive assessment; 48

29 Specific Requirements Registered Nursing Billable Activity (cont.) at the time an individual receives medication from a pharmacy, ensuring the accuracy of: the type and amount of medication; and the dosage instructions; researching medical information for an individual who has a medical need for registered nursing, including: reviewing documents, except for a written service log or written summary log of a service component as described in Section 3820, to evaluate the quality and effectiveness of the medical treatment the individual is receiving; and completing a comprehensive assessment; 49

30 Specific Requirements Registered Nursing Billable Activity (cont.) training the following persons how to perform nursing tasks: a service provider of foster/companion care, residential support, supervised living, supported home living, day habilitation, respite, supported employment or employment assistance; or a person other than a service provider who is involved in serving an individual; reviewing documents in preparation for the training described in the bullet above; 50

31 Specific Requirements Registered Nursing Billable Activity (cont.) interacting face-to-face or by video conference or speaking by telephone with a person regarding the health status of an individual, but not with: a staff person who is not a service provider; or a service provider of: registered nursing; licensed vocational nursing unless supervised by the registered nurse; specialized registered nursing; specialized licensed vocational nursing unless supervised by the registered nurse; or specialized therapies; 51

32 Specific Requirements Registered Nursing Billable Activity (cont.) interacting face-to-face or speaking by telephone with a pharmacist or representative of a health insurance provider, including the Social Security Administration, about an individual's insurance benefits for medication if the registered nurse justifies, in writing, the need for the registered nurse to perform the activity; instructing a service provider, except a service provider of registered nursing or specialized registered nursing, on a topic that is specific to an individual such as choking risks for an individual who has cerebral palsy; supervising a licensed vocational nurse regarding an individual's nursing services or health status; instructing, supervising or verifying the competency of an unlicensed person in the performance of a task delegated in accordance with rules of the Texas Board of Nursing at 22 TAC, Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions) or the Human Resources Code, , as applicable; 52

33 Specific Requirements Registered Nursing Billable Activity (cont.) participating in a service planning team meeting; participating in the development of an implementation plan; and participating in the development of an IPC. 53

34 Specific Requirements Licensed Vocational Nursing Billable Activity interacting face-to-face with an individual who has a medical need for licensed vocational nursing, including: preparing and administering medication or treatment ordered by a physician, podiatrist or dentist; assisting or observing administration of medication; and conducting a focused assessment of the individual's health status; speaking by telephone with an individual who has a medical need for licensed vocational nursing, which may include conducting an assessment of an individual if: the assessment is conducted using protocol approved by DADS; and the licensed vocational nurse has been trained by a registered nurse on using the protocol; 54

35 Specific Requirements Licensed Vocational Nursing Billable Activity (cont.) interacting by video conference with an individual who has a medical need for licensed vocational nursing, including: observing administration of medication; and conducting a focused assessment of the individual's health status; at the time an individual receives medication from a pharmacy, ensuring the accuracy of: the type and amount of medication; and the dosage instructions; 55

36 Specific Requirements Licensed Vocational Nursing Billable Activity (cont.) researching medical information for an individual who has a medical need for licensed vocational nursing, including: reviewing documents, except for a written service log or written summary log of a service component as described in Section 3820, to evaluate the quality and effectiveness of the medical treatment the individual is receiving; and completing a focused assessment; training a service provider of residential assistance, day habilitation, respite or supported employment, or a person other than a service provider who is involved in serving an individual, regarding how to perform nursing tasks; reviewing documents in preparation for the training described in the bullet above; 56

37 Specific Requirements Licensed Vocational Nursing Billable Activity (cont.) researching medical information for an individual who has a medical need for licensed vocational nursing, including: reviewing documents, except for a written service log or written summary log of a service component as described in Section 3820, to evaluate the quality and effectiveness of the medical treatment the individual is receiving; and completing a focused assessment; training a service provider of residential assistance, day habilitation, respite or supported employment, or a person other than a service provider who is involved in serving an individual, regarding how to perform nursing tasks; reviewing documents in preparation for the training described in the bullet above; 57

38 Specific Requirements Licensed Vocational Nursing Billable Activity (cont.) interacting face-to-face or by video conference or speaking by telephone with a person regarding the health status of an individual, but not with: a staff person who is not a service provider; or a service provider of any nursing service component (registered nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational nursing) or specialized therapies; interacting face-to-face or speaking by telephone with a pharmacist or representative of a health insurance provider, including the Social Security Administration, about an individual's insurance benefits for medication if the licensed vocational nurse justifies, in writing, the need for the licensed vocational nurse to perform the activity; 58

39 Specific Requirements Licensed Vocational Nursing Billable Activity (cont.) instructing a service provider, except a service provider of registered nursing or specialized registered nursing, on a topic specific to an individual such as choking risks for an individual who has cerebral palsy; participating in a service planning team meeting; participating in the development of an implementation plan; and participating in the development of an IPC. 59

40 Specific Requirements Specialized Registered and Licensed Vocational Nursing Follow respective sections only for an individual who has a tracheostomy or is dependent on a ventilator. & 60

41 Specific Requirements Examples of Non-Billable Activities: performing or supervising an activity that does not constitute the practice of licensed vocational nursing, including: performing an activity that constitutes the practice of professional nursing and must be performed by a registered nurse; transporting an individual; waiting to perform a billable activity; and waiting with an individual at a medical appointment; making a medical appointment; instructing on general topics unrelated to a specific individual, such as cardiopulmonary resuscitation, or infection control; preparing a treatment or medication for administration and not interacting face-to-face with an individual; storing, counting, reordering, refilling or delivering medication except as allowed in the fourth bullet of Section ; creating written documentation as described in Section ; 61

42 Specific Requirements Examples of Non-Billable Activities: reviewing a written service log or written summary log of a service component as described in Section 3820; interacting with: a staff person who is not a service provider; or a service provider of any nursing service component (registered nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational nursing), or specialized therapies, if not during a service planning team meeting or during the development of an IPC or an implementation plan; and performing an activity for which there is no medical need. 62

43 Specific Requirements Nursing Rule of Thumb: If it does not require a nursing license to perform a task, it is not billable. 63

44 Specific Requirements Nursing Unit of Service 15 Minute of Service A service claim cannot be made for a fraction of a unit of service Accumulation of Service Times Can be accumulated for nursing provided to one individual on a single calendar day 64

45 Common Errors Billing for creating and reviewing service records. No medical necessity shown when residential staff calls nurse to administer over the counter medication to individual No medical necessity for follow-up phone call Billing for services without Face-to-Face, Telephone or Video conferencing contact Providing any activity not requiring a nursing license One note used for multiple service events No Progress Note 68

46 Residential Assistance 69

47 Specific Requirements Residential Assistance Residential Location Own Home/Family Home if no foster/companion care, residential support or supervised living is provided to the individual Foster/Companion Care is not owned or leased by the program provider, a service provider provides care to the individual; and the care provider and the individual have the same address 70

48 Specific Requirements Residential Assistance Residential Location 3-Person Home the individual s residence is a 3-person residence and a service provider provides residential support or supervised living to the individual 4-person Home the individual s residence is a 4-person residence and a service provider provides residential support or supervised living to the individual (one must be RSS) 71

49 Supported Home Living 72

50 Specific Requirements Supported Home Living Billable Activity Interacting face-to-face with the individual: to assist with activities of daily living to assist with ambulation and mobility to reinforce counseling and therapy subcomponents to assist with administration of medication or tasks delegated by an RN to conduct habilitation activities to secure transportation for the individual to supervise the individual s safety and security interactions regarding an incident directly affecting the individual's health or safety; performing allowable non-face-to-face activities participating in a service planning team meeting; participating in the development of an implementation plan; and participating in the development of an IPC. 73

51 Specific Requirements Supported Home Living claims may not be submitted for: An individual whose IPC does not have a residential location of own home/family home the sole activity of supervising the individual's safety and security Transporting an individual from one DH or SE site to another supporting home living provided to an individual: in a residence in which residential support or supervised living is provided to another individual; by a service provider who is simultaneously providing residential support, supervised living or foster/companion care to another individual; if the day habilitation service component is simultaneously provided to the individual by another service provider; or if the respite service component is simultaneously provided to the individual by another service provider. 74

52 Specific Requirements Supported Home Living Unit of Service 15 Minute of Service may not include fraction of service Calculating transportation use Method A or Method B (can only use one method on a single calendar day) 75

53 Transportation Method A Individual Departure Time Arrival Time A. Dorothy N. Kansas 7:00am 9:00am B. Dorothy N. Kansas 3:00pm 4:30pm a. Transportation time of 120 minutes (7:00am-9:00am) with 6 passengers (Dorothy + 5 others) and 1 service provider for Trip A SERVICE TIME = (1 X 120) 6 = 20 minutes b. Transportation time of 90 minutes (3:00pm-4:30pm) with 5 passengers (Dorothy + 4 others) and 1 service provider SERVICE TIME = (1 X 90) 5 = 18 minutes 20 min + 18 min = 38 minutes (accumulation) According to Attachment C: 38 minutes = 3 Units Billed (accumulation) 1 Unit (20 min) + 1 Unit (18 min)= 2 Units Billed (no accumulation) 79

54 Transportation Method B Individual Departure Time Arrival Time Dorothy N. Kansas 7:00am 9:00am Little B. Blue 7:15am 9:00am Mary Q. Contrary 7:30am 9:00am Transportation time for Dorothy N. Kansas: a. Transportation time of 15 minutes (7:00am-7:15am) with one passenger (Dorothy only) and 1 service provider SERVICE TIME = (1 X 15) 1 = 15 minutes b. Transportation time of 15 minutes (7:15am-7:30am) with two passengers (Dorothy and Little) and 1 service provider SERVICE TIME = (1 X 15) 2 = 7.5 minutes c. Transportation time of 15 minutes (7:30am-9:00am) with three passengers (Dorothy, Little and Mary) and 1 service provider SERVICE TIME = (1 X 90) 3 = 30 minutes 15 min min + 30 min = 52.5 minutes According to Attachment C: 52.5 minutes = 3 Units 80

55 Common Errors Overlapping times with other services Transportation method completed incorrectly Time not divided evenly between two or more individuals receiving services at the same time Non-qualified Service Provider (Proof of residence, etc.) No justification for receiving SHL in DH facility No begin and/or end times on documentation No location of services provided on documentation No Progress Note 81

56 Foster Care 82

57 Specific Requirements Foster Care Requirements of Setting The program provider may not lease or own the residence The individual receiving care must have a residence in which no more than three persons receive: foster/companion care, a non-hcs Program service similar to foster/companion care; and If the individual is a minor, the parent or stepparent may not provide this service 83

58 Specific Requirements Foster Care Requirements of Setting The service provider must have the same residence as the individual; and Ensure that foster/companion care is provided to an individual when necessary 84

59 Specific Requirements Foster Care Unit of Service Unit of service is one day May not be for more than one day May not have a fraction of a unit of service 85

60 Specific Requirements Foster Care Billable Activity Assisting the individual with activities of daily living (bathing, dressing, personal hygiene, eating, meal planning and preparation and housekeeping) Assisting the individual with ambulation and mobility Reinforcing any counseling and therapy subcomponent provided to the individual Assisting with the administration of the individual s medication or to perform a task delegated by an RN 86

61 Specific Requirements Foster Care Billable Activity Conducting habilitation activities that train the individual to: Develop or improve skills that allow the individual to live more independently Develop socially valued behaviors Integrate into community activities Use natural supports and typical community services available to the public Participate in leisure activities 87

62 Specific Requirements Foster Care Service Claim for an Individual on a Visit with Family or Friend A program provider may submit a service claim for an individual who is on a visit with a family member or friend away from their residence if the visit is for at least a calendar day. If the visit is for more than 14 consecutive calendar days, the program provider may submit a service claim for only 14 calendar days of the visit. 89

63 Specific Requirements Foster Care Service Claim for an Individual on a Visit with Family or Friend Written Documentation Written documentation must include the individual s name, the dates the individual was visiting the family member or friend, the location of the visit and the date and signature of the service provider. 90

64 Common Errors Failure to discharge individual while in the hospital Weekly summary exceeds seven days Not documenting location information No Progress Note 91

65 Residential Support Services 92

66 Specific Requirements Residential Support Requirements of Setting The residence must be a Three or Four person residence The program provider may not have the same residence as the individual The service provider must be available to provide residential support to an individual as needed; and The service provider must be present and awake in the residence when the individual is present in the residence 93

67 Specific Requirements Residential Support Billable Activity assisting the individual with activities of daily living; assisting the individual with ambulation and mobility; reinforcing any specialized therapies subcomponent provided to the individual; assisting with the administration of the individual's medication or to perform a task delegated by a registered nurse in accordance with rules of the Texas Board of Nursing at 22 TAC, Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions) or the Human Resources Code, , as applicable; conducting habilitation activities that train the individual; securing transportation for or transporting the individual; and supervising the individual's safety and security. 94

68 Specific Requirements Residential Support Unit of Service Unit of service is one day A service claim may not be for more than one day A service claim may not include a fraction of a unit of service 95

69 Specific Requirements Residential Support Service Claim for an Individual on a Visit with Family or Friend A program provider may submit a service claim for an individual who is on a visit with a family member or friend away from their residence if the visit is for at least a calendar day. If the visit is for more than 14 consecutive calendar days, the program provider may submit a service claim for only 14 calendar days of the visit. 97

70 Specific Requirements Service Claim for an Individual on a Visit with Family or Friend Written Documentation Written documentation must include the individual s name, the dates the individual was visiting the family member or friend, the location of the visit and the date and signature of the service provider. 98

71 Common Errors Failure to discharge individual while in the hospital Not providing location codes Not providing staff signatures Not showing night shift coverage activities 99

72 Supervised Living 100

73 Specific Requirements Supervised Living Requirements of Setting The residence must be a 3 or 4-person residence The service provider must be available to provide residential support to an individual as needed; and The service provider must be present in the residence when the individual is present in the residence 101

74 Specific Requirements Supervised Living Billable Activity assisting the individual with activities of daily living; assisting the individual with ambulation and mobility; reinforcing any specialized therapies subcomponent provided to the individual; assisting with the administration of the individual's medication or to perform a task delegated by a registered nurse in accordance with rules of the Texas Board of Nursing at 22 TAC, Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions) or the Human Resources Code, , as applicable; conducting habilitation activities that train the individual; securing transportation for or transporting the individual; and supervising the individual's safety and security

75 Specific Requirements Supervised Living Unit of Service Unit of service is one day A service claim may not be for more than one day A service claim may not include a fraction of a unit of service 103

76 Specific Requirements Supervised Living Service Claim for an Individual on a Visit with Family or Friend A program provider may submit a service claim for an individual who is on a visit with a family member or friend away from their residence if the visit is for at least a calendar day. If the visit is for more than 14 consecutive calendar days, the program provider may submit a service claim for only 14 calendar days of the visit

77 Specific Requirements Service Claim for an Individual on a Visit with Family or Friend Written Documentation Written documentation must include the individual s name, the dates the individual was visiting the family member or friend, the location of the visit and the date and signature of the service provider

78 Common Errors Failure to discharge consumer while in the hospital Not providing location No Progress Note 107

79 Respite 108

80 Specific Requirements Respite is the temporary provision of assistance and support necessary for an individual to perform personal care, health maintenance and independent living tasks, participate in community activities, and develop, retain and improve community living skills; and provides relief for a caregiver of the individual who: has the same residence as the individual; routinely provides assistance and support necessary for an individual to perform personal care, health maintenance and independent living tasks, participate in community activities, and develop, retain and improve community living skills; is temporarily unavailable to provide such assistance and support; and is not a service provider of foster/companion care, residential support or supervised living to the individual

81 Specific Requirements Respite Room and Board- If respite is provided in a setting other than the individual's residence, the program provider must provide room and board to the individual free of charge

82 Specific Requirements Respite Billable Activity interacting face-to-face with an individual to: assist the individual with activities of daily living; assist the individual with ambulation and mobility; reinforce any specialized therapies subcomponent provided to the individual; assist with the administration of the individual's medication or to perform a task delegated by a registered nurse in accordance with rules of the Texas Board of Nursing at 22 TAC, Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions) or the Human Resources Code, , as applicable; conduct habilitation activities that teach the individual; secure transportation for the individual; supervise the individual's safety and security; and transport the individual, except from one day habilitation site to another; 111

83 Specific Requirements Respite Billable Activity interacting face-to-face or by telephone with an individual or an involved person regarding an incident that directly affects the individual's health or safety; and performing activities that does not involve interacting face-to-face with an individual described in Section

84 Specific Requirements Respite must be provided: Residence If an individual receives respite in a residence, the residence must be: the individual's residence; a three-person residence; a four-person residence; or the residence of another person (other than a three-person residence or a four-person residence) in which no more than three persons are receiving HCS Program services or a non-hcs program service similar to HCS Program services. Non-residence If an individual is receiving respite during an overnight stay in a setting that is not the residence of any person, no more than six persons receiving HCS Program services or a non-hcs Program service similar to HCS Program services may be in the setting

85 Specific Requirements Submitting a Service Claim for Respite Respite Provided in an Individual's Residence If a program provider provides respite in an individual's residence, the program provider may submit a service claim for no more than 96 units of service (24 hours) in one calendar day. Respite Provided in Location Other Than the Individual's Residence If a program provider provides 10 hours or more of respite to an individual in one calendar day in a location other than the individual's residence, the program provider may submit a service claim for no more than 40 units of service

86 Common Errors Location of service not on documentation Billing more than 10 hours for respite occurring out of the individuals home Individual lives alone without a live-in caregiver No begin and/or end times Non Qualified Service Provider (Proof of residence, etc.) Not providing location information No Progress Note 116

87 Billing & Payment Review Protocol 117

88 Billing and Payment Review Conducted by DADS Billing and Payment staff Review of authorization and written documentation of service delivery maintained by program provider 118

89 Purpose: To determine whether the program provider is in compliance with the HCS Program Billing Guidelines Outcome: DADS will recoup non-verified claims that were not supported by authorization and/or written documentation and may require a corrective action plan (CAP) by the program provider. 119

90 Types of Reviews: Routine Once every 2 years, all services are reviewed with the number of individuals reviewed and review period determined by previous error rates or number of individuals served Special As determined by DADS, result of a complaint, referral or billing anomalies 120

91 Routine or special review can be either: On-site conducted at provider s place of business Desk conducted at DADS Headquarters (documentation submitted by mail ) 121

92 Samples are chosen based upon documentation error rate: Error Rate = non-verified dollars divided by the total amount billed during the review period 122

93 Example of Error Rate: Non-Verified Claims Total...$15, Total Claims Billed...$125, $15, $125, =.1226 Error Rate: 12.26% 123

94 BPR sample size: Error Rate Less Than Ten Percent (10%): Provider serves more than 10 individuals 5 + 5% reviewed Provider serves less than 10 individuals All reviewed 124

95 BPR sample size-- Error Rate More Than Ten Percent (10%): Provider serves more than 10 individuals % reviewed Provider serves less than 10 individuals All reviewed 125

96 BPR sample size Never Reviewed: Provider serves more than 10 individuals % Provider serves less than 10 individualsup to 5 126

97 On-site Reviews: Notification: Routine: At least fourteen(14) days notice by phone and followed by a faxed letter. Individual sample list from outside of Waiver Contract Area (WCA) of review location provided two business days prior to Entrance Conference. Special: Will be conducted without notice. 127

98 On-site Reviews: List of individuals within the review location s WCA are identified at Entrance Conference. PROVIDERS ARE NOT PERMITTED TO CREATE ANY DOCUMENTATION AT ANY TIME WHILE REVIEW IS IN PROGRESS 128

99 Error Sheet Forms 129

100 Refuting On-site Reviews Refuting is conducted while on-site. DADS will not accept additional documentation or refute any unverified claims after the Exit Conference. 130

101 Demand for Payment-on-site review: Following the Exit Conference, generally within 30 days, DADS will send a certified letter (Demand for Payment) to the provider detailing any unverified claims. The letter includes the amount to be recouped, any required corrective action and notice of the right to request an Administrative Hearing. 131

102 On-Site Review: Request for Administrative Hearing (appeal) Must be made within 15 calendar days from receipt of certified green card from Demand for Payment letter 132

103 Payment of unverified claims: Recoupment is done electronically through the automated billing system (CARE) Please do not send checks. 133

104 Desk reviews: Notification: Telephone and Certified Mail 134

105 Timeframe to Provide Documentation-desk review 14 calendar days from receipt of certified green card from notification letter. Documentation received after 14 days has elapsed will not be accepted and all services requested will be subject to recoupment. 135

106 Results-desk review: Provider notified of results in certified letter Refuting-desk review: Additional documentation must be submitted within 14 calendar days of receipt of certified green card from results letter Late submissions are not accepted 136

107 Demand for Payment-desk review: Certified letter notifies provider of final account of unverified claims after considering refuting documentation (if any submitted) 137

108 Desk Reviews: Request for Administrative Hearing (appeal): Must be made within 15 calendar days from receipt of certified green card from Demand for Payment letter 138

109 Payment of unverified claims: Recoupment is done electronically through the automated billing system. Please do not send checks. 139

110 Misti J. Ackermann, Billing & Payment Manager

111 2011 Billing Guidelines Guidelines: csbg/index.htm Guideline Changes: csbg/rmemo/11-1.htm

112 Section Title Change 2000 Definitions Adds definitions for competitive employment, comprehensive assessment, focused assessment, integrated employment, service coordination and service coordinator General Requirements Updated references Service Claim for Day Habilitation for Individual Receiving Supported Employment Deleted Service Claim for Foster/Companion Care, Residential Support or Supervised Section 3240 is renumbered to Living for Individual on a Visit with Family or Friend 3430 Relative, Guardian or Managing Updates information in the first paragraph and deletes outdated information. Conservator Qualified as Service Provider Minute Unit of Service Defines person under No. 2, Service Time Daily Unit of Service Updates billable units of service Billing Service Components Provided at the Same Time and Billing Day Habilitation Provided at the Same Time as Service Coordination Revises section heading Service Coordination and Day Habilitation Provided at the Same Time Adds new section General Requirements Adds new information and deletes outdated material Written Service Log and Written Updates section title; adds new information; deletes outdated material. Summary 3850 Example Forms Updates title and adds new information General Description of Service Component Defines specialized therapies subcomponents Billable Activity Updates billable activities for the specialized therapies Activity Not Billable Updates examples of non-billable activities Unit of Service Adds service time information Written Documentation Updates documentation required to support a service claim for specialized therapies Requirements of Setting Adds retirement age as justification for providing day habilitation at the individual s residence Unit of Service Updates billable units of service Written Documentation Deletes outdated information and clarifies required documentation to support a service claim for day habilitation.

113 4390 Submitting a Service Claim for Deleted. Individuals Receiving Supported Employment 4420 Billable Activity Updates billable activities for the licensed registered nursing service component Activity Not Billable Updates text Unit of Service Adds No. 3, Service Time Written Documentation Deletes outdated information Billable Activity Updates billable activities for the licensed vocational nursing service component Activity Not Billable Updates examples of non-billable activities Unit of Service Adds No. 3, Service Time Written Documentation Deletes outdated information Billable Activity Updates billable activities for the specialized registered nursing service component Activity Not Billable Updates text Unit of Service Adds No. 3, Service Time Written Documentation Deletes outdated information Billable Activity Updates bill activities for the specialized licensed vocational nursing service component Activity Not Billable Updates text Unit of Service Adds No. 3, Service Time Written Documentation Deletes outdated information Supported Home Living Subcomponent Updates rule citations; adds new requirements; deletes outdated information Foster/Companion Care Subcomponent Updates rule citations; clarifies requirements for service provider; updates text in No. 5, Restrictions Regarding Submission of Claims for Foster/Companion Care; and clarifies required documentation in No. 8, Written Documentation Residential Support Subcomponent Deletes text under No. 1(d), Service Provider Shifts; updates rule citations under No. 2, Billable Activity; updates information in No. 5, Restrictions Regarding Submission of Claims for Residential Support; adds new bullet under No. 8, Written Documentation; and makes minor wording changes to No. 9, Submitting a Service Claim for an Individual on a Visit with Family or Friend Supervised Living Subcomponent Updates rule citations under No. 2, Billable Activity; updates information in No. 5, Restrictions Regarding Submission of Claims for Supervised Living; adds new bullet under No. 8, Written Documentation; and makes minor wording changes to No. 9, Submitting a Service Claim for an Individual on a Visit with Family or Friend General Description of Service Updates information in No. 1, Temporary Provision of Assistance, and No. 2, Room and Board. Component 4620 Billable Activity Updates rule citations Restrictions Regarding Submission of Adds reasons for which a program provider may not submit a service claim. Claims for Respite 4690 Written Documentation Deletes a bulleted item and makes minor wording changes General Description of Service Updates definition of supported employment. Component 4730 Billable Activity Adds transporting individual to and from the individual s work site as a billable activity for the supported employment service component Activity Not Billable Adds transporting an individual to a job interview as a non-billable activity.

114 4760 Restrictions Regarding Submission of Deletes outdated information. Claims for Supported Employment 4770 Unit of Service Adds No. 3, Service Time 4780 Written Documentation Updates information Submitting a Service Claim for Day Deleted. Habilitation 6160 Required Documentation for an Adaptive Updates section reference and removes prior approval requirement. Aid 6170 Prior Approval Deleted Authorization for Payment Updates section number; adds new information and deletes outdated text Payment Limit Deletes outdated information Required Documentation for a Minor Removes prior approval requirement. Home Modification 6260 Prior Approval Deleted Authorization for Payment Updates section number; adds new information and deletes outdated material. Appendix I Billing and Payment Review Protocol Updates information. Appendix Example of Service Delivery Log with Deletes appendix and reserves it for future use. IV Written Narrative Appendix Billable Adaptive Aids Updates abbreviations and number codes. VII Appendix Instructions for AA/MHM Request for Deletes appendix and reserves it for future use. VIII Prior Approval Appendix Billable Minor Home Modifications Updates abbreviations. X Form Dental, Instruction Home and Community-based Services/Texas Home Living Dental Summary Sheet Deletes outdated information and adds instruction for signature/date line. s Form MHM-AA, Instruction s Home and Community-Based Services/Texas Home Living Minor Home Modification/Adaptive Aids Summary Sheet Deletes outdated information, updates references and adds instruction for signature/date line.

115 Changes to Billing Guidelines Section Definition Additions Competitive employment Employment that pays an individual at or above the greater of: (A) the applicable minimum wage; or (B) the prevailing wage paid to individuals without disabilities performing the same or similar work. Comprehensive Assessment: An extensive evaluation of an individual's health status that: (A) addresses anticipated changes in the conditions of the individual as well as emergent changes in the individual's health status; (B) recognizes changes to previous conditions of the individual; (C) synthesizes the biological, psychological, spiritual and social aspects of the individual's condition; (D) collects information regarding the individual's health status; (E) analyzes information collected about the individual's health status to make nursing diagnoses and independent decisions regarding nursing services provided to the individual; (F) plans nursing interventions and evaluates the need for different interventions; and (G) determines the need to communicate and consult with other service providers or other persons who provide supports to the individual.

116 Changes to Billing Guidelines Section Definition Addition Focused Assessment: An appraisal of an individual's current health status that: (A) contributes to a comprehensive assessment conducted by a registered nurse; (B) collects information regarding the individual's health status; and (C) determines the appropriate health care professionals or other persons who need the information and when the information should be provided. Integrated employment Employment at a work site at which an individual routinely interacts with people without disabilities other than the individual's work site supervisor or service providers.

117 Changes to Billing Guidelines Section 3000 Supported Employment/Day Habilitation Division of Time Between Individuals Service Coordination & Day Habilitation Written Documentation for non-nursing services Other Changes to Section 3000

118 Changes to Billing Guidelines Section 4000 Specialized Therapies Definitions Video Conference Day Habilitation In-Home Exception Time Change Supported Employment Dual Billing Removal Nursing (See Next Slides) Residential Services (See Next Slides) Respite Clarification Supported Employment Transportation included

119 Changes to Billing Guidelines Section 4400 Nursing Services Registered Nursing Assessments & Comprehensive Assessments Medication Review Insurance Provider Communication Supervising LVN (RN can only bill) Licensed Vocational Nursing Focused Assessments Medication Review Insurance Provider Communication

120 Changes to Billing Guidelines Section 4500 Residential Services Foster Care & Supervised Living No Significant Changes Residential Support Services Service Provider Shifts Off Duty Requirement No Shifts of More than 24 Hours Supported Home Living Safety & Supervision No Volunteer Hour Limit

121 Changes to Billing Guidelines Section 6000 Adaptive Aids Prior Approval Removal Authorization for Payment Requirements Minor Home Modifications Prior Approval Removal Authorization for Payment Requirements

122 Changes to Billing Guidelines Other Changes Guideline Format Billing and Payment Review Process Form Updates 2122 Service Delivery Log with Written Narrative/Written Summary 2124 Community Support Transportation Log 4116-Dental Dental Summary Sheet 4116-MHM-AA Minor Home Modification/Adaptive Aids Summary Sheet 4117 HCS Supported Employment Service Delivery Log 4118 HCS Respite Service Delivery Log 4119 HCS Residential Support Services (RSS) and Supervised Living (SL) 4120 HCS Day Habilitation (DH) 4121 HCS Supported Home Living 4122 Foster/Companion Service Delivery Log

123 Vivian Griffor, Billing and Payment Team Leader 153

124 Documentation required before purchasing any AA/MHM: Written assessment Not required for AA under $500 or MHM under $1000 Individual and Program Provider Agreement Three Bids 3 bids are required no matter the cost need an explanation if 3 bids have not been obtained Proof of non-coverage by private insurance, Medicare, and Medicaid (AA only-as applicable) 154

125 The Written Assessment must: be based on a face-to-face evaluation be done in the home if a MHM is being requested be done by a qualified medical professional- See Appendix VII for Adaptive Aids & Appendix X for Minor Home Modifications include a description of AND a recommendation for the specific AA/MHM being requested 155

126 Assuming that a recommended item is a covered item **Obtaining an assessment that is not current **Obtaining an assessment that does not contain sufficient medical justification Assuming that a doctor s prescription is sufficient **Obtaining an assessment that is not legible **Obtaining an assessment done by an unauthorized professional 156

127 Individual and Program Provider Agreement Must consider the written assessment document any discussion about the recommended item(s) agree that the recommended item is necessary and should be purchased document their agreement in writing 157

128 Failure to include signatures Team meeting/staffing/individual and Program Provider Agreement Failure to document discussion of need for item requested 158

129 Bids : Three (3) bids are required, regardless of cost Bids must be comparable (for like or very similar items) Bids must state the total cost of the requested AA/MHM and, if it includes more than one AA/MHM, state the itemized cost of each AA/MHM listed by service code Bids must include the name, address and telephone number of the vendor/contractor 159

130 Exceptions to bid requirements: Less than three bids for an AA/MHM may be acceptable IF there is written justification stating the AA/MHM is available from only a limited number of vendors/contractors A single bid from the custom fitting vendor is acceptable for eyeglasses (220), hearing aids, batteries and repairs (260) and orthotic devices, orthopedic shoes, and braces (107) 160

131 Annual Vendor: Will there still be an Annual Vendor? Yes. A Program Provider: May be exempted from bid requirement for frequently purchased consumable items with an approval for Annual Vendor status Will submit application for Annual Vendor by January 31 for current calendar year 161

132 Failure to obtain three bids (no justification)* Obtaining bids that contain items not recommended in the assessment** Obtaining bids that contain items not covered on the waiver** Obtaining bids that are not for the same item or list of items** 162

133 Pursuing alternate funding sources: Written proof of non-coverage from Medicare/Medicaid must be obtained for any AA denoted with a (1) or (2) on the List of Billable (Reimbursable) Adaptive Aids 163

134 Obtaining a statement by a DME vendor that an item is not covered** Obtaining a denial letter that indicates that insufficient documentation was submitted with claim** Obtaining a Medicaid denial letter that indicates that consumer is eligible for Medicare (primary)** 164

135 Texas Department of Aging and Disability Services Home and Community-Based Services/Texas Home Living Minor Home Modification/Adaptive Aids Summary Sheet Form 4116-MHM-AA September 2011 Service Month and Year Component Code Contract No. Contact Person Area Code and Telephone No. September XXXX Ima Provider Name (Last, First, Initial) Client Care ID No. Service Date (MM,DD,YY) Prior Approval Tracking No. Minor Home Modification Service Description Service Code Dollars Spent Req. Fee Adaptive Aids Service Description 1. Anita N. Item /01/11 N/A Leg Brace 107 $ $ Total Service Code Dollars Spent Req. Fee I certify by submission of this form that it meets all requirements set forth in the Home and Community-Based Services/Texas Home Living Billing Guidelines. Ima Provider 9/22/11 Signature Date 165

136 Submit reimbursement claims (4116) to: DADS Provider Claims Services PO BOX MC W-400 Austin, TX For questions contact Provider Claims Services at option

137 Misti J. Ackermann Manager HCS Team Leaders Vivian Griffor -Adaptive Aids Contact Willie Mae Jones D. Sam Montgomery Virginia Sifuentes Julia Solis Cost Report Contact Karri Henager Jeff Rehagen Stephanie Santos-Vela Nikolaos Vekris Cost Report Contact Program Specialists Additional Information Billing and Payment & Hotline [ ] Fax Mailing Address Department of Aging and Disability Services Community Services, Billing and Payment PO BOX , Mail Code W-200 Austin, Texas