Deparrttmentt off Speciall Educatti ion MEDICAID SCHOOL BASED SERVICES FEE-FOR-SERVICE PROGRAM Billing Reference Guide Revision Date: 12/01/2011
TABLE OF CONTENTS Foreword... 1 Overview of School Based Services Program... 2 Individuals with Disabilities Education Act (IDEA) Assessment & IEP/IFSP Development, Review & Revision... 3 IDEA Assessment Services... 3 Provider Qualifications... 3 IDEA Assessments/Evaluations/Test... 4 Procedure Codes for IDEA Assessment (MET)... 5 Procedure Codes for IEP Participation... 6 Targeted Case Management... 7 Designated Case Management... 7 Reimbursement Requirements... 8 Examples of Reimbursable Services... 9 Examples of Services That Are NOT Reimbursable... 9 Billing Procedures... 10 Record Keeping Requirements... 11 Frequently Used Terms and Definitions... 12 Logging on to Remote Desktop... 13
FOREWORD This Medicaid School Based Services Billing Reference Guide was created to assist service providers with an understanding of the Medicaid School Based Services program. It contains specific information regarding billing procedures and documentation requirements. The information contained herein is based on the MICHIGAN MEDICAID PROVIDER MANUAL developed by the Michigan Department of Community Health (MDCH), Michigan s Medicaid agency. If you have any questions pertaining to the School Based Services Program and/or the billing procedures, please contact: Pam Manning, Medicaid Coordinator Van Buren Intermediate School District 701 S. Paw Paw Street Lawrence, MI 49064 (269) 539-5158 phone (269) 539-5009 fax pmanning@vbisd.org To assist a student or family to apply for Medicaid, please contact the Van Buren County Department of Human Services office: P.O. Box 7 57150 C. R. 681 Hartford MI 49057 (269) 621-2800 phone (269) 621-2927 fax 1
OVERVIEW OF MEDICAID SCHOOL BASED SERVICES PROGRAM Medicaid is a jointly funded Federal-State health insurance program for persons with low income and/or disabilities. School Based Services (SBS) allows reimbursement under the Medicaid program for services administered to students with special needs under the Individuals with Disabilities Education Act (IDEA) and is administered through the Intermediate School District. Coverage applies to individuals up to the age of 21 years who are enrolled in programs that require an Individualized Education Program (IEP) or an Individualized Family Service Plan (IFSP). Coverage is based on medically necessary, Medicaid-covered services already being provided in the school setting and enables these services provided to Medicaid-eligible beneficiaries to be billed to Medicaid. This ensures federal participation in the funding of these Medicaid covered services. Enrolled providers are required to establish an interagency agreement to facilitate coordination and cooperation with other human services agencies operating within the same service area. Medicaid services provided by the ISDs are to be provided as outlined in the IEP/IFSP treatment plan and are not expected to replace or substitute services already provided by other agencies. If services are being provided by another program, ISDs are expected to coordinate the services to prevent service overlap and to assure continuity of care to the Medicaid beneficiary. Medicaid covered services billed by ISDs include: Evaluations and tests performed for assessments Occupational Therapy Services Orientation and Mobility Services Assistive Technology Device Services Physical Therapy Services Speech, Language and Hearing Therapy Services Psychological, Counseling and Social Work Services Developmental Testing Services Nursing Services Personal Care Services Targeted Case Management (TCM) Services Specialized Transportation Services Special Education Transportation The personnel who service these students are as follows: Audiologists Occupational Therapists Physical Therapists Psychologists Registered Nurses Social Workers Speech Pathologists Teacher Consultants 2
Vision and Mobility Specialists Special Education Classroom Teachers Paraprofessionals The IEP/IFSP treatment plan must include the appropriate annual goals and short-term objectives, criteria, evaluation procedures, and schedules for determining whether the objectives are being achieved within an appropriate period of time (at least annually). All therapy services must be skilled (i.e. require the skills, knowledge, and education of a certified and registered occupational therapist, licensed physical therapist, CCC (Clinical Certificate of Competency) certified speech-language pathologist or licensed audiologist. INDIVIDUALS WITH DISABILITIES EDUCATION ACT (IDEA) ASSESSMENT & IEP/IFSP DEVELOPMENT, REVIEW & REVISION The Individuals with Disabilities Education Act (IDEA) Assessment is a formal evaluation that includes assessments, evaluations, tests and all related activities performed to determine if a student is eligible under provisions of the IDEA of 1990 as amended in 1997 and 2004 and are related to the evaluation and functioning of the student. These services are reimbursable only after they result in the implementation of an IEP/IFSP treatment plan. If an IEP/IFSP treatment plan is not implemented within one (1) year of the date of service, then none of the services provided are covered. IDEA Assessment Services IDEA assessments are evaluations, tests and related activities performed to determine if an individual is eligible for special education or early intervention services under the provisions of the Individuals with Disabilities Education Act of 1990. These services are related to the evaluation and re-evaluation of the functioning of the individual. Comprehensive evaluations must occur annually, and re-evaluations are performed when a change or decrease in function occurs. Services are reimbursable only after they result in the implementation of an IEP/IFSP. If an IEP/IFSP is not implemented within one year of the date of service, then these services are not covered. Professional evaluations performed as part of the IDEA assessment may be billed using the appropriate evaluation/assessment codes (Specific procedure codes are listed on Page 5). Provider Qualifications Qualified staff may bill for assessments, tests, and evaluations performed for the IDEA Assessment. To be covered by Medicaid, the staff must have the following credentials: An occupational therapist currently registered in Michigan (OTR); A licensed physical therapist (LPT) in Michigan; (1) A speech-language pathologist or audiologist possessing a current Certificate of Clinical Competence (CCC); (2) an appropriately supervised speech-language 3
pathologist (SLP) and/or audiology candidate (i.e., in his/her clinical fellowship year or having completed all requirements but has not obtained a CCC). All documentation must be reviewed and signed by the appropriately-credentialed supervising SLP or audiologist; (3) a Master s Degree in Speech and Language Pathology with a minimum of 300 clock hours of supervised practicum experience; or (4) a person employed as a teacher of the speech and language impaired who met the requirements of the Michigan Special Education Rules before the effective date of the Rules amended August 13, 1980. A fully licensed psychologist (Doctoral level) in Michigan; A limited-licensed psychologist (Master s level) under the supervision of a licensed psychologist; A Michigan-licensed professional counselor; A school psychologist with a Master s degree in psychology with a minimum of 500 clock hours of supervised internship; A social worker with a Master s degree from a graduate school of social work and a minimum of 500 clock hours of supervised practicum; A physician or psychiatrist (M.D. or D.O.) with a current State of Michigan license to practice; A registered nurse (RN) with a Michigan license; Orientation and mobility specialist certified by the Association for the Education and Rehabilitation of the Blind and Visually Impaired; A teacher consultant with a Master s degree in education or a field of study related to special education, and a minimum of three years teaching experience, not less than two years of which must be in teaching special education IDEA Assessments/Evaluations/Tests Qualified staff may bill for three distinct types of assessments/evaluations/tests as follows. All activities, such as meetings and written reports related to the assessment/evaluation/test, are an integral part or extension of the service and are not separately reimbursable. The HT Modifier is used with the procedure code when billing for an evaluation, assessment or test performed for the IDEA Assessment. Each qualified staff bills using the appropriate procedure code below followed by the HT modifier. The date of service is the date of determination of eligibility for special education services (MET meeting date). The TM Modifier is used with the procedure code when billing for the IEPT meeting to develop, review and revise the IEP/IFSP treatment plan. Each qualified staff bills using the appropriate procedure code below followed by the TM modifier. The date of service is the date of the IEPT meeting. Each qualified practitioner involved in the IDEA assessment process may record both the HT and the TM modifiers if they participate in both the MET and the IEPT meetings. Evaluations, assessments or tests may be provided that are NOT related to the IDEA assessment (the MET) or the IEP/IFSP treatment plan development, review and revision. Each qualified staff member records these activities using 4
the appropriate procedure code with no modifier. The date of service is the date the evaluation, assessment or test was completed. Procedure Codes for IDEA Assessment (MET) The following procedure codes may be used to bill for evaluations, assessments or tests and related meetings and documentation in preparation for (and including) the MET. Each qualified staff bills using the appropriate procedure code below followed by the HT modifier. The date of service is the date of determination of eligibility for special education or Early On services (the MET meeting date). NOTE: The procedure code with HT modifier is recorded only ONCE per MET and includes all preliminary evaluations, report writing and meetings. DO NOT record evaluations or reports for the MET as a separate encounter. Procedure Code Description Qualified Staff 96101 HT Psychological testing Psychologist H0031 HT Mental Health assessment Social Worker T1001 HT Nursing assessment/evaluation Registered Nurse V2799 HT Vision assessment and MET Orientation and Mobility Specialist 92506 HT Evaluation of speech, language, voice, communication and auditory processing, and/or aural rehabilitation status Speech Pathologist, Audiologist * 96110 HT Developmental testing, limited Psychologist, Social Worker, Teacher Consultant 96111 HT Developmental testing, extended Psychologist, Social Worker, Teacher Consultant 97001 HT Physical Therapy evaluation Physical Therapist * 97003 HT Occupational Therapy evaluation Occupational Therapist * *An occupational therapist, physical therapist, speech pathologist, and audiologist may participate in the IDEA Assessment for therapy and/or Assistive Technology Device services. 5
Procedure Codes for IEP Participation The following procedure codes may be used to bill for attendance at the IEPT meeting to develop, review and revise an IEP/IFSP. Each qualified staff bills using the appropriate procedure code below with the TM modifier. The date of service is the date of the IEPT meeting. NOTE: The procedure code with TM modifier is recorded only ONCE per IEP and includes all preliminary evaluations, report writing and meetings. DO NOT record evaluations or reports for the IEP as a separate encounter. Procedure Code Description Qualified Staff H0031 TM Mental Health Assessment Psychologist, Social Worker T1001 TM Nursing assessment/evaluation Registered Nurse T1024 TM IEP Participation (other than initial) Designated Case Manager T1017 TM Staff Case Management Teacher Consultant V2799 TM Vision assessment and MET Orientation and Mobility Specialist 92506 TM Evaluation of speech, language, voice, communication and auditory processing, and/or aural rehabilitation status Speech Pathologist, Audiologist * 97001 TM Physical Therapy evaluation Physical Therapist * 97003 TM Occupational Therapy evaluation Occupational Therapist * *An occupational therapist, physical therapist, and speech pathologist or audiologist may participate in the IEP for therapy and/or Assistive Technology Device services. 6
TARGETED CASE MANAGEMENT Targeted Case Management (TCM) (formerly known as service coordination) is a category of service which identifies and addresses special health problems and needs that affect the student s ability to learn, and ensures that the student receives effective and timely services appropriate to their needs. TCM is covered only when: There are other Medicaid-covered medical services in the IEP/IFSP treatment plan (i.e. occupational therapy; physical therapy; speech, language and hearing therapy; assistive technology device services; social work services; vision orientation and mobility training; nursing services; personal care services). Transportation by itself is not a qualifying Medicaid-covered service for billing TCM. A service provided on a consultative basis is not a qualifying Medicaidcovered service. Coordinating activities to assist students receiving special education or early intervention services to gain access to needed medical, social, educational, and other services. Designated Case Management (Procedure Code T2023) The Designated Case Manager is the person responsible for implementation of the IEP/IFSP treatment plan (most of the time it is the special education teacher). The Designated Case Manager must be an individual who meets one of the following criteria: A RN with a Michigan license; A baccalaureate degree with a major in a specific special education area; Has earned credit in course work equivalent to that required for a major in a specific special education area; or Has a minimum of three years personal experience in the direct care of an individual with special needs. Designated Case Management can only be provided when the student is receiving one or more of the following services: Occupational Therapy Physical Therapy Speech Therapy Orientation & Mobility Social Work Audiology Nursing Personal Care The following functions are the responsibility of the Designated Case Manager. A designated case management service consists of the activities performed during the month to complete each responsibility: 7
Assure that standard re-examination and follow-up of the student are conducted on a periodic basis to ensure that the student receives needed diagnosis and treatment; Assist families in identifying and choosing the most appropriate providers of case and services, scheduling appointments and helping families to maintain contact with providers; Follow-up to ensure that the student receives needed diagnostic and treatment services; Assure that case records are maintained and indicate all contacts with, or on behalf of, a student in the same manner as other covered services; Coordinate performance of evaluations, assessments and other services that the student needs; Prevention of duplication of services; Facilitation and participation in the development, review and evaluation of the IEP/IFSP treatment plan; and Activities that support linking and coordinating needed health services for the student. It is important to note that: There is only ONE Designated Case Manager per student (implementer on the IEP) Designated Case Management is for the coordination of Medicaid-covered services only, not for educational activities or other direct services provided to the student Designated Case Management cannot be billed for students who do not receive a Medicaid-covered service per the IEP/IFSP REIMBURSEMENT REQUIREMENTS In order for school districts to receive reimbursement under the provisions of the School Based Services program, 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; or Be provided to a student who will have an IEP/IFSP within one year in the case of IDEA assessment services Be provided by a qualified practitioner based on SBS Policy Address a student s physical, mental or emotional disability Be consistent with the intent of the IEP/IFSP identified services and planned goals. Covered services do not require prior authorization by the Medicaid agency. However, physical therapy, occupational therapy and speech therapy require an annual physician s referral (prescription), which is currently obtained by Van Buren ISD s Special Education Department. 8
School Based Services that may be covered include: Evaluations and tests performed for assessments Therapy (occupational, physical, speech, language and hearing) Nursing Services Psychological and social work services Developmental testing IDEA assessment (coordination of the MET report and meeting) Special education transportation Assistive technology devices/services Vision, orientation and mobility services Targeted case management services Personal care services Examples of Reimbursable Services The following are reimbursable services when provided according to SBS program guidelines: Individual or group therapy and counseling Evaluations for medical services are covered when: - Performed as part of the IDEA Assessment - The student left and is re-entering special education or related programs - At any time when initiation, development, review or revision of the student s IEP/IFSP treatment plan will occur; and - When a change or decrease in function occurs Consultations with parent, guardian, or other professional about a student s services (these consultations are indirect services/case management) Equipment assessments and adjustments or repairs IEP/IFSP related activities Developmental testing (to determine if motor, speech, language, or psychological problems exist or to detect the presence of any developmental delays) Designated Case Management Case management activities (provided by the implementer of the IEP/IFSP), such as: arrange evaluations, link families with services/service practitioners, follow-up on treatment and diagnostic services; maintain case records; facilitate IEP/IFSP Crisis Intervention (psychologists and social workers only) Behavioral Intervention Plan meetings (billable under Targeted Case Management) Manifestation IEPs Special Education Transportation Nursing services Personal care services Examples of Services That Are NOT Reimbursable Academic instructional services provided directly to the student Group therapy involving more than 8 students 9
Attendance of the Designated Case Manager at the initial IEP Team meeting (once the DCM is identified in the IEP, any further meetings are covered) Services not related to the IEP Notes/meetings without any explanation of the purpose or its connection to the IEP IDEA assessments that do not result in implementation of an IEP/IFSP within one year Vocational or work skills services Report writing is included as part of an evaluation and is not separately reimbursable Services considered observational or stand-by in nature, including supervision of medication administration or other medical services First Aid Manifestations Reviews BILLING PROCEDURES Van Buren ISD utilizes TieNet, a comprehensive student management system, for Medicaid billing. Please refer to the Medicaid: Logging Encounters section contained in this document on Page 17 for specific instructions regarding logging Medicaid encounters in TieNet. Medicaid eligibility is checked every month. Medicaid eligible students are listed are your caseload in the far right hand column. Designated Case Managers should log Encounters only for those Medicaid eligible students who also receive a Medicaidcovered service (e.g. speech, OT, PT, SSW, S&L, PC, etc.). All other service providers should log Encounters for all Medicaid eligible students. It is recommended that service providers complete Encounters for the preceding month by the 10 th of the following month, so as to ensure a fluid billing process. For services that have time-specific procedure codes, the provider must indicate the actual begin and end time of the service. The record must indicate the specific findings or results of the diagnostic or therapeutic procedures. The student s school clinical record should include documentation of the implementation and coordination of services for the special education student. Please refer to the TIP Sheet specific to your discipline. When billing for evaluations not related to a MET or IEP, the date of service is the date the evaluation was completed. Services provided by substitute staff or staff on waivers are reimbursable only if the substitute meets the Medicaid certification requirements described in this document. Services provided by staff fully paid with federal funds are not reimbursable. Services provided to students in federally funded programs are reimbursable. 10
RECORD KEEPING REQUIREMENTS Documentation must be maintained which shows that services provided to or on behalf of the student comply with MDCH rules. These rules state that, at a minimum, the following information should be documented and maintained for seven (7) years: The IEP/IFSP document with the goals and services identified and any addendum to the plan Relevant evaluations and assessments given to determine the need for services An encounter log notation including the date of service, the type of service (e.g. group therapy, evaluation) the level of service intervention, and the name of the person providing the service The actual begin and end time of the service for services that have timespecific procedure codes A daily progress note describing the direct service rendered and the student s response to the service or treatment A brief monthly summary/progress note summarizing the services provided during the month, using your daily notes, as well as the student s progress toward the goals defined in the IEP/IFSP. Also, include changes in medical or mental status and changes in treatment with rationale for change. A physician s prescription for physical therapy and occupational therapy and a physician s referral for speech, language and hearing services (required annually) Each practitioner, local school district, or intermediate school district should maintain additional documentation as necessary to support the provision of the service as required by their respective professional standards. 11
FREQUENTLY USED TERMS AND DEFINITIONS (Taken directly from the Medicaid Manual) HT Modifier (Multi-disciplinary team) The HT modifier is used when billing for an assessment, evaluation or test performed for the IDEA Assessment. Each qualified staff bills using the appropriate procedure code followed by the modifier HT. TM Modifier (Individualized Education Program [IEP]) The TM modifier is used when billing for the multi-disciplinary team assessment for the development, review and revision of an IEP/IFSP treatment plan. Each qualified staff bills for this assessment using the appropriate procedure code with the modifier TM. IDEA (Individuals with Disabilities Education Act) The federal statute, first enacted in 1975 and most currently amended in 2004, that requires public schools to determine whether a child has a disability, develop a plan that details the education and support services that the student will receive, provide the services and evaluate the plan at least annually. IDEA Assessment IDEA Assessment is a formal evaluation that includes assessments, evaluations, tests and all related activities performed to determine if an individual is eligible under provisions of the IDEA of 1990 as amended in 1997 and 2004 and are related to the evaluation and functioning of the individual. IEP (Individualized Education Program) A written plan for services for eligible students between the ages of 5 and 26. Medicaid funds are available to reimburse for health and medical services that are a part of a student s IEP. IFSP (Individualized Family Services Program) A written plan for a child with a disability who is between the ages of zero and five years, that is developed jointly by the family and appropriate qualified personnel, and is based on multi-disciplinary evaluation and assessment of the child s unique strengths and needs, as well as on a family-directed assessment of the priorities, resources and concerns. Medicaid funds are available to reimburse for health and medical services that are a part of a child s IFSP. SBS (School Based Services Program) A Michigan Medicaid program with two components, Fee-for-Service (FFS) and Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Administrative Outreach. All Michigan ISD, the DPS and the MSDB participate in the Fee-for-Service component. All ISDs and DPS participate in the EPSDT Administrative Outreach. Treatment Plan If an evaluation indicates that Medicaid-covered services are required, the qualified staff must develop and maintain a treatment plan for the student. The student s IEP/IFSP form may suffice as the treatment plan as long as the IEP/ISP contains the required components described under the Treatment Plan subsection. 12
Logging on to the Remote Desktop Load Internet Explorer by clicking on the icon. Once on Internet Explorer, go to the VBISD web site: www.vbisd.org Point to Special Education a dropdown will open. Click on Educator Resources. Click on Tienet on the left hand side and then select Log onto Tienet. You will be directed to this page. Before proceeding the first time, please read the information on the left. Your User ID is the letter u along with the first initial of your first name and then your last name. (example: ufirstnameinitiallastn ame) Your Temporary Password is: vanamazoo1 13