Read Home and Community-based Services Billing and Payment Guidelines Frequently Asked Questions 2009 text version

Texas Department of Aging and Disability Services

HOME AND COMMUNITY-BASED SERVICES (HCS)

BILLING AND PAYMENT GUIDELINES Revised 2009

QUESTIONS AND ANSWERS

Questions and Answers ­ HCS Billing Guideline Revision 2009

Home and Community-Based Services (HCS) BILLING AND PAYMENT GUIDELINES QUESTIONS AND ANSWERS Revised Effective September 1, 2009

Due to the recent changes in the HCS billing guidelines, we have updated our Questions and Answers document. We have also included additional questions from stakeholder meetings held in the fall of 2009. The questions included here are those asked most often during the meetings and those that address fundamental issues related to reimbursable HCS waiver services. The questions and answers cover a wide scope of billing, service definition, and provider certification points relevant to all HCS providers. Please note in particular the following new or significantly updated questions and answers: General Questions: # 1, #24, #25 Nursing: #6, #8, #9, #17, #18 Specialized Therapies: #4 Case Management: #6 Residential Assistance: #27 Some of the most significant changes effective September 1, 2009 are: Additional activities that may be billed under Nursing Services; Addition of Specialized Nursing service component for individuals requiring tracheostomy or ventilator care; and Additional activities that may be billed under Specialized Therapies. HCS providers with additional questions should call (512) 438-5359 and leave a brief message with contact information. Calls are returned within 2 business days.

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General Questions

1. Q: When are providers going to be responsible for following the new guidelines? A: The guideline revisions were released in October 2009. However, providers may submit claims for additional billable services for nursing and professional services effective as of September 1, 2009. 2. Q: How will DADS schedule billing and payment reviews? A: Several strategies are used to determine when program providers undergo billing and payment reviews. Priorities are established based on certification survey outcomes; results of previous billing and payment reviews; complaints from any source; billing patterns identified through the automated enrollment and billing system; and routinely scheduled reviews. Currently, each HCS contract is subject to routine review every two years with high-risk providers being reviewed more frequently. 3. Q: Is scheduling coordinated so that a provider will not have billing reviews and a certification review conducted at the same time? A: Billing and payment reviews are scheduled independently so it is possible, although unlikely, that a program provider could undergo both a billing review and a certification review during the same week.

4. Q: May a home that is owned by an individual's parent or other family member be leased by the individual's program provider to be used as a 3 or 4-bed home? A: Yes. The family members could not reside in the home or provide Residential Support Services or Supervised Living if they are a relative of the individual. See Attachment B of the billing guidelines. 5. Q: If a provider does the exact same thing with an individual everyday can that part of the written narrative/summary be preprinted? A: Under no circumstances is it acceptable to preprint any part of a written narrative or written summary. A written narrative and written summary must be created in full within a reasonable amount of time after the service has been delivered. Regardless of how routine the care of an individual may be, written documentation (daily narratives/weekly summaries) must reflect unique, individualized, and accurate information regarding the actual service provided for a specific date and time. Service providers should remain aware of and always document anything occurring which is out of the ordinary. In doing so, written documentation will contain unique Page 3 of 33

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Questions and Answers ­ HCS Billing Guideline Revision 2009 information that will distinguish service provided during one day, week, or other service event from service provided during a different day, week or service event. Written narratives/summaries may be typed, but must still include the signature of the service provider performing each service event. Written documentation that is duplicated or copied verbatim, whether handwritten or typed, is subject to recoupment. 6. Q: What is the difference between a "detailed unique description," required of a written narrative, and a "general unique description," required of a written summary? A: Single service event narratives must contain detailed information about the services provided, where weekly summaries can contain more general information about the service. Both types of written documentation must be unique, in that each note must contain specific information about that particular day or week of service. Single service event narratives, for instance, must include information about not only the routine activities an individual performs every day, but also should include specifics about behavioral incidents; unusual occurrences; activities; training objectives performed and the results of that training; and details about the individual's mood, demeanor, reactions to the events of the day and interactions with the service provider. Even though weekly narratives may be more general, they still must contain some of the same information that distinguishes any one week of service from that of other weeks. 7. Q: What is a "reasonable" time frame for completing service delivery documentation (daily narratives/weekly summaries? A: To ensure that accurate information is recorded, it is recommended that providers of services requiring daily documentation complete those service delivery documents prior to leaving at the end of their shifts. Weekly written summaries should be completed as soon as possible after the week has ended. Case managers, nurses, and other professionals should also write their written documentation in a timely fashion so as to record the most accurate details possible. All documentation must be completed prior to billing for the service. 8. Q: Does the place of service need to be written out in the narrative? A: No, as long as it is included in the documentation of service delivery.

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9. Q: If service delivery documentation is typed, should the signature on the written narrative/summary be dated for the day the service was provided or the day it was signed? A: Some providers may choose to have both the date the service was provided and the date the written documentation was signed. However, for billing purposes, the documentation must be dated for the day the service was provided, regardless of when the documentation is manually signed. All documentation must be signed prior to billing for the service. If the documentation is revised for any reason, the additional changes must be signed or initialed and dated. 10. Q: May service delivery documentation be written in a language other than English? A: Service delivery documentation may be written in any language; however, the program provider is required to translate the information into English using a staff member that is fluent in the language used to write the written narratives/summaries. 11. Q: May service delivery documentation contain a begin time and duration of service in lieu of an end time? A: While it is preferable to have begin and end times, written narrative/summary which have both the begin time and duration from which the end time can be calculated are acceptable. 12. Q: May a weekly narrative/summary make reference to a separate document, such as the Individual Service Plan (ISP) or Interdisciplinary Team (IDT) meeting minutes? A: Yes. However, the written narrative/summary or separate document must contain all of the necessary elements of the written narrative/summary required to bill the service component as specified in the billing guidelines. Providers may wish to attach the separate document to the written narrative/summary to help ensure the necessary information is documented. 13. Q: In a written narrative/summary, may an individual be referred to by a nickname in lieu of a legal name? A: Yes, as long as the name used has been established as an "otherwise known as" in other documentation, such as the ISP, and it is clear to whom the written narrative/summary is referring.

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14. Q: Are daily foster/companion care narratives required? A: No, program providers still have the option of having their foster/companion care providers write either daily narratives or weekly summaries. 15. Q: During a billing and payment review, will written narratives/summaries from different service components be compared for overlapping service times? A: This is always a possibility. 16. Q: May a program provider bill from service delivery logs without having the written narrative/summaries? A: While it is permissible for a program provider to bill from service delivery logs, the written narrative and written summary are also required for documentation of service delivery. During a billing and payment review, any services billed for which written narratives or summaries are not available will be subject to recoupment. 17. Q: Are original service notes required or will photocopies be accepted? A: Photocopies of original service notes will be accepted as documentation for billing and payment reviews. The content of such notes, however, must reflect unique and accurate information pertaining to services provided for specific dates. Identical photocopied notes covering multiple dates of service will not be accepted. 18a. Q: If an individual has an LAR, are both the LAR and individual required members of the IDT? A: Yes. 18b. Q: How does the HCS provider maintain evidence of having convened the IDT? A: The provider may ask members to sign a dated signature sheet to indicate attendance during an IDT meeting. However, this is not a requirement. The provider may also document participating members for any IDT.

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Questions and Answers ­ HCS Billing Guideline Revision 2009 19. Q: When service provider professionals are sharing pertinent information about a specific individual is the service billable? A: Even though the exchange of information may be vital to the welfare of the individual served; case managers, nurses, counselors, and therapists (whether employed or contracted) may not bill when discussing issues of a specific individual if contact occurs outside the context of an IDT meeting. 20. Q: May a program provider bill foster/companion care services when the foster/companion care provider is traveling out of the country with the individual and continues to provide foster/companion care services? A: When a foster/companion care provider travels outside of the United States and continues to provide foster/companion care to an individual, the program provider may bill for no more than 14 consecutive days of foster/companion care services. This 14-day period begins with the first night the individual does not stay in his or her residence and continues through the 14th night the individual is out of his or her residence. After the 14th night, the program provider is no longer eligible to bill for foster/companion care. Individuals who are receiving Supplemental Security Income (SSI) and are out of the country for more than a full calendar month are no longer eligible to receive SSI benefits and consequently also lose their Medicaid eligibility. Upon returning home, an individual must be in the country for 30 consecutive days before they are eligible to re-apply for SSI. Individuals receiving foster/companion care services who travel within the United States may do so for 14 consecutive days, with or without the foster/companion care provider, and the foster/companion care provider may be reimbursed for foster/companion care services during this time period. When a foster/companion care provider travels within the United States with the individual to whom he or she is providing foster/companion care, reimbursement for foster/companion care services is not subject to this 14-day rule. However, when services are provided in this manner (either the individual traveling up to 14 days in the United States without the foster/companion care provider, or traveling for an unspecified period of time within the United States with the foster/companion care provider) the program provider is responsible for monitoring the individual's health, safety, welfare and the quality and quantity of services provided. A plan must be in place to ensure these follow-up activities take place routinely while the individual is away from their residence. The only service for which the program provider may submit a claim during this period is foster/companion care, as no other service is provided and claims for case

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Questions and Answers ­ HCS Billing Guideline Revision 2009 management will not be reimbursed without the case manager having provided the individual with at least one face to face contact. 21. Q: Should services (e.g., personal care assistance) provided to a school age consumer during home schooling activities be considered Day Habilitation or Supported Home Living? A: Services provided to a school age consumer during home schooling activities or any other educational activities are not covered HCS waiver services. The services under the waiver are not intended to supplement services which are the responsibility of the state and local education agency. The parents' election of home schooling or private school education as an alternative to public school education does not change the intent of the waiver. In this case, the services being requested by the family would be available in the public school setting. 22. Q: If a consumer is not present at an IDT meeting based on the guardian's decision to exclude the consumer, may the specialized therapy providers and the nurses who attend the meeting bill individually for time spent participating in the IDT meeting? A: Yes. Although it is not recommended, the legally appointed guardian may determine that the individual should not be a participant in the IDT meeting. In these rare instances the IDT members may bill for the IDT participation. It is the legal guardian's right to exclude the individual if they feel that their participation would be negative. In some cases individuals may inhibit discussions if he or she has a behavioral or medical condition that would disrupt the meeting. However, efforts should be made to incorporate the individual into the meeting. It is in the provider's best interest to ensure guardianship papers are in order to eliminate any chance of possible recoupment. 23. Q: May services such as Supported Home Living be billed when a consumer is admitted to a hospital and the hospital requires someone from the provider agency remain with the consumer during the entire hospital stay? Could the provider submit billing claims for HCS services provided during the hospitalization if third party insurance rather than Medicaid pays for the hospital stay? A: When a consumer is hospitalized, the consumer must be temporarily discharged from the HCS waiver even if a non-Medicaid source pays for the hospitalization. The provider may not bill for any service during the period of time the consumer is temporarily discharged. Service providers sometimes choose to have staff remain with consumers who are hospitalized either because of the unique characteristics of the consumer or because the hospital staff are not trained to recognize the consumer's Page 8 of 33

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Questions and Answers ­ HCS Billing Guideline Revision 2009 special needs. It is questionable as to whether a hospital can make the consumer's treatment contingent on the presence of HCS staff. 24. Q: How may providers sign-up to get e-mail updates from DADS when new policy letters are issued or other alerts are posted to the DADS website? A: Signing up for e-mail updates via the "govdeliviery.com" system is a quick and easy way to stay up to date. The best part about the system is that there is no limit on the number of people who can receive these electronic updates... anyone in your agency can have access to this subscription and it's FREE!! All you need is a valid email address to sign up; all updates will be sent to that email address. Here's how it works: Go to the Department of Aging and Disability website www.dads.state.tx.us . At the bottom of the page click on the "E-mail updates" tab. Click on the "here" hyperlink in the sentence "If you want to subscribe to this page, click here."

You will then be redirected to the following page. https://service.govdelivery.com/service/multi_subscribe.html?code=TXHH SC&custom_id=307. Enter the e-mail address to which you would like DADS information and updates sent.

After entering your e-mail address, you will routed to a screen in which you can "check" boxes to indicate the categories of DADS information and

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Questions and Answers ­ HCS Billing Guideline Revision 2009 updates you would like to receive. To request updates for the HCS Program, at a minimum please check the boxes highlighted in yellow below, under the heading of "DADS Providers" and click to save these preferences. 25. Q: Will DADS provide training regarding changes to billing guidelines effective September 1, 2009? A: Yes, in addition to these updated questions and answers DADS is planning mini-training sessions to be held at local MRA offices. Please watch for e-mail announcements of these events.

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Nursing Questions - UPDATED 11/2009

1. Q: May nursing be billed for interaction between a nurse and other professional service providers employed or contracting with the program provider? A: Nursing contact with other professionals employed or contracting with the provider, including other nurses, is billable only if the interaction occurs within the context of an IDT meeting. Refer to the HCS Program Billing Guidelines to determine those nursing activities that may be billed. 2. Q: May the Nursing Practice Act be used as a guide for determining services billable under the nursing service component? A: No, because some of the activities required of nurses under the Nurse Practice Act are not considered billable activities under HCS billing guidelines. Refer to the HCS Program Billing Guidelines for determining which nursing activities may be billed.

3. Q: If a case manager and nurse make a face-to-face visit with the same individual at the same time can both contacts be billed? A: Yes. Both may be billed if the case manager provides adequate documentation of the face-to-face contact and the nurse also provides adequate documentation of a billable nursing activity performed during that time period. 4. Q: When writing a service note for nursing, can the nurse make reference to a doctor's written order or must the doctor's note be rewritten within the body of the nursing note? A: A nurse may refer to a doctor's order within the body of the written narrative without recopying the doctor's order. However, the nursing note must contain all aspects of a billable written narrative as stipulated in the billing guidelines. 5. Q: May nursing be billed for staff training? A: Yes, but only if the training covers nursing related information specific to an individual. Billing and Payment review staff may require a roster to subsidize the written narrative to justify the billing of this activity.

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Questions and Answers ­ HCS Billing Guideline Revision 2009 6. Q: How do we document the accumulation of nursing time for billing purposes? A: Service events for nursing may be accumulated for an individual during the same calendar day regardless of whether one nurse or multiple nurses performed the billable activity and regardless of whether the billable activity took place at one or more places of service. Place of service codes and staff IDs used for billing may be chosen at the discretion of the program provider. Nursing services provided over two or more calendar days may not be accumulated for billing purposes. Each nursing service event for an individual must be documented with exact begin and end times (rounding of time is not allowed). The program provider must choose from one of the following options to bill their nursing time: Treat each service event separately and bill according to the conversion table in Attachment C of the HCS Billing Guidelines. Accumulate or add the time for all nursing service events for the individual on one calendar day and bill according to the conversion table in Attachment C of the billing guidelines. Determine for each service event to bill separately or accumulate the time for two or more service events and bill according to Attachment C. The accumulation of multiple nursing types is also permitted. However, the program provider must bill the lower rate when accumulating nursing services. For example if you have an RN that performs 5 minutes of nursing duties and an LVN that provides 3 minutes, you may bill for 1 unit under the LVN rate when accumulation is used. The billable time must reach at least eight minutes, or have an accumulation of nursing service on the same calendar day that reaches at least eight minutes 7. Q: May a program staff nurse bill for nursing services for communication with a nurse from a doctor's office about medical issues concerning an individual? A: Yes. A nurse communicating with a doctor or nurse employed by a doctor's office regarding an individual's specific medical condition may bill nursing services for those service events. Contact made for the purpose of scheduling an appointment is not billable. The billable time must reach at least eight minutes, or have an accumulation of nursing service on the same calendar day that reaches at least eight minutes.

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Questions and Answers ­ HCS Billing Guideline Revision 2009 8. Q: Is time spent reviewing an original doctor's order or a change in a doctor's order considered billable under the nursing service component? A: Yes. Reviewing paperwork is billable under nursing services as long as it is for quality assurance of medical services. This includes review of documentation such as lab work, physicians' orders, and other medically necessary documentation the nurse needs to review to ensure an individual is receiving necessary medical services. A nurse may bill for writing one annual report, but no other written reports are billable. The billable time must reach at least eight minutes or have an accumulation of nursing service on the same calendar day that reaches at least eight minutes. The review of service documentation other than for a medically related purpose is not billable. Review of written narratives of written summaries is not considered a billable service. 9. Q: Is time spent reviewing a medication administration record (MAR) billable under the nursing service component? A: Yes, if it is to monitor medication accuracy, side effects, to improve staff training, or for a medical reason that is specific to an individual. 10. Q: Is doing a self-administration of medication (SAM) assessment considered billable under the nursing service component? A: Yes, but it must be documented as a face-to-face contact in the service note. 11. Q: May nursing be billed for time spent preparing medications for administration, such as setting up a 7-day med-minder? A: This activity is not considered billable unless done while interacting faceto-face with the individual for whom the medications are being prepared. In that case, it would be considered self-administration of medication (SAM) training and should be documented as a training objective in the ISP and also documented as a face-to-face contact in the written narrative. 12. Q: May nursing be billed for a staff nurse interacting with a staff psychiatrist regarding the psychiatric/behavioral issues of a particular individual? A: Interaction with a psychiatrist (i.e.; an M.D.) is billable because a psychiatric service is not billable through the HCS waiver program. The Page 13 of 33

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Questions and Answers ­ HCS Billing Guideline Revision 2009 same type of interaction with a program psychologist would not be billable, unless it occurs within the context of an IDT meeting. 13. Q: May nursing be billed if issues with the reordering of a medication require that the doctor be contacted? A: Yes. The actual time spent speaking with the physician or physician's nurse is billable if the program provider's nurse also documents the immediate medical necessity of the service. 14. Q: May a staff nurse bill for interacting with a home health nurse, hospice nurse, or school nurse about a specific individual's medical issues? A: Yes, as long as the home health, hospice or school nurse is not employed or contracted by the program provider. Otherwise, the interaction is not billable regardless of the content of the discussion, unless it occurs within the context of an IDT meeting. 15. Q: Is the documentation of a nurse's delegation of duties to nonnursing staff required to be in an individual's record? A: No, but it may be requested during a billing and payment review or a certification review, conducted by Waiver Survey and Certification. 16. Q: May nursing be billed if a nurse accompanies an individual to the emergency room? A: The nurse could bill while sharing information with the hospital staff, but transportation or wait time is not billable. 17. Q: If an individual is receiving specialized vocational nursing or specialized registered nursing because they have a tracheostomy or are dependent on a ventilator, may all their nursing service be billed at the specialized rate? A:. Yes, the provider has the option to bill any nursing service provided to individuals with a ventilator or tracheostomy at the specialized LVN rate or the specialized RN rate. The provider may also bill at the lower LVN or RN rate if they so choose.

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18. Q: May any of the nursing services be billed for reviewing documentation to write an annual treatment plan? A. Yes, any of the nursing service components may be billed for reviewing medical documentation to prepare an annual treatment plan or annual nursing report. The nurse providing the service may bill for writing that annual report. The documents could include lab work, MARs, doctor's orders or discharge reports from a hospital stay. A nurse may not bill for reviewing service records (also known as progress notes, written narratives or written summaries) for any of the services provided from the other HCS services categories. A nurse may not bill for updates to the annual plan, as it is to be billed only once per IPC year.

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Specialized Therapies

1. Q: Do therapists need to justify the length of service being billed? A: Yes. The length of service billed must be justified by the billable activities described in the service note. The billing time must match the length of time one would reasonably expect it would take to complete such activities. 2. Q: May a therapy service be billed during the same time period as supported home living (SHL)? A: Yes. SHL may be billed if the SHL provider is waiting to provide return transportation for the individual who is receiving a therapy service, or if a SHL provider is needed to provide support to the individual during a therapy session. Therapy services that involve assessing or observing the individual at the same time SHL training occurs may be billed simultaneously with SHL. 3. Q: Do therapy notes need to be detailed or can they be brief and refer to assessments? A: Therapy notes can make reference to assessments already in place, but the notes must contain all of the necessary requirements of a written narrative as described in the billing guidelines. 4. Q: May service providers of specialized therapies bill for reviewing documents to do an annual report/treatment plan? A: The service provider of specialized therapies may bill for review documents that are relative to their specialties. However, consistent with nursing services providers may not bill for the review of service providers service records (written narrative/weekly summary) and can bill only once within an IPC year for the writing of the report. Providers may also review documents monthly to improve patient care or identify areas for staff training.

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Case Management

1. Q: May someone employed as a case manager for one program provider also be employed as a supported home living provider for another program provider? A: Yes. A case manager may also provide other services for another program provider. However an individual cannot receive case management services from the same individual providing supported home living. 2. Q: Does someone have to be employed by the program provider to provide case management services? A: Yes. A provider of case management services must be an employee of the program provider. 3. Q: May a case manager provide services to an individual during the same time period that nursing services are being provided to the same individual? A: Yes. A case manager may provide case management services to an individual at the same time a service provider of any other service component or subcomponent provides a service to the same individual. If the case management activity requires that the other service be interrupted or that the individual be removed from the service delivery area, however, then billing for the other service component must be suspended for the duration of the case management activity. 4. Q: May case management be billed during the same time period as day habilitation? A: Yes. A case manager could provide case management services by observing and accessing an individual while they are actively participating in day habilitation activities. To bill for case management requires a face to face contact with the individual. When the provision of case management activities requires the interruption of day habilitation services, day habilitation may no longer be billed. When the individual is no longer actively participating in day habilitation activities, they must be clocked out of day habilitation for the duration of the case management activity.

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5. Q: May case management be billed for any activity that does not include face to face contact with the individual? A: No. Billing for this service component is based on face-to-face contact with an individual who is awake, although case management providers are required to perform multiple functions, including contact with LARs and facilitating/participating in IDT meetings. Any month of service for which there is no written documentation of a face-to-face contact with the individual served is subject to recoupment. 6. Q: When will responsibility for case management transfer from HCS program providers to the Mental Retardation Authority (MRA)? A: DADS will publish ongoing communications regarding this legislatively mandated transfer. This transition is scheduled to be effective June 2010.

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Day Habilitation

1. Q: May day habilitation be billed for the same time period as a therapy for the same consumer? A: If a licensed therapist performs a therapy service while an individual is in the day habilitation setting, the individual must be clocked out of the day habilitation activity for the duration of the therapy unless the therapy activity involves observation or assessment that can be done while the individual is still actively engaged in day habilitation activities. Any activity which does not constitute day habilitation may not be counted toward time for day habilitation billing. 2. Q: Are two consecutive hours required to bill for a ½, ¾ or 1 unit of day habilitation billing? A: Yes. An individual must spend at least two consecutive hours actively engaged in billable activity to bill for a full day or partial day of day habilitation. Any time the individual is not present or available for day habilitation activities, including therapy sessions, medical appointments, illness, etc., the clocked time for day habilitation billing must be suspended. If the remaining blocks of time do not contain at least one period of two consecutive hours, day habilitation may not be billed for that day. Day habilitation logs must contain exact begin and end times; rounding is unacceptable. EXAMPLES: 4 hours, 55 minutes (with 2 consecutive hours) counts as .75 unit, not 1 3 hours, 28 minutes (with 2 consecutive hours) counts as .5 unit, not .75 1 hour, 59 minutes is not billable 3. Q: May day habilitation be billed during the time a consumer is being administered medications? A: Yes, but only in cases where the medications can be administered with no interruption to the day habilitation activities. Day Habilitation may not be billed when medications, treatments, or therapies administered by licensed personnel require more extended time periods to administer or require that the individual be removed from the day habilitation area.

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Questions and Answers ­ HCS Billing Guideline Revision 2009 4. Q: If an individual sleeps or refuses to participate in day habilitation activities can the time they are present be counted toward day habilitation billing? A: Day Habilitation may not be billed for the time an individual is asleep. There are circumstances where an individual's refusal to participate in day programming may be billed. For example, day habilitation may be billed if repeated attempts are clearly documented throughout the day to involve the individual in appropriate activities and there is also documentation of steps taken by the IDT to address the problem or to evaluate the appropriateness of day habilitation activities. Such documentation would be considered on a case by case basis during a billing and payment review. If sleeping or refusal to participate only occurs during part of the day, the time the individual actually participates may be counted. Documentation must include the exact length of time the individual participates in the day habilitation program. 5. Q: Is the address alone sufficient for description of day habilitation location? A: Along with the address, include some brief information about the specific type of location and name of the building, workshop, or residential site, etc. This information may be preprinted on the service log forms. If the day habilitation is community based include the location of the activities. 6. Q: If the day habilitation activity includes community inclusion in multiple locations, do all the locations need this level of description? A: Include the separate locations visited in the body of the written narrative or summary. 7. Q: How many goals and objectives are required for day habilitation? A: There is no set number of goals required but formally defined day habilitation activities should be sufficient to justify the amount of time spent in day habilitation. If a training objective is something that can be completed during a short time period, it is necessary to also have other goals that can be addressed over a longer period of time during the day habilitation hours. Goals do not have to be formal but must justify the outcomes that the individual will receive from the provision of this service.

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8. Q: May day habilitation be billed for prevocational activities such as training on how to fill out applications or training on interviewing techniques? A: This type of activity is acceptable for day habilitation as long as such goals and objectives are defined in the day habilitation section of the ISP and the individual is not employed. 9. Q: May day habilitation be provided in the home? A: Yes, but only if justified by significant behavioral or medical issues which contraindicate participation in day habilitation activities outside the home and are sufficiently documented in the ISP. When day habilitation is provided in the home the goals and objectives must be unique and different than those addressed in residential training. 10. Q: May Day Habilitation be provided in the home when an individual who lives in a rural area is unable to attend a Day Habilitation due to distances required to transport the individual? A: No. Day Habilitation could not be provided in the home, but could be provided in the community. The ISP should clearly define appropriate day habilitation activities and locations of where services are provided. Written narratives or summaries must include each site visited in the community. The documentation should clearly identify sufficient activities to justify the full time period for which day habilitation is billed. For instance, nonspecific statements such as "went shopping" or "saw a movie" would not provide enough detail to justify a full day of day habilitation. Transportation is not billable when day habilitation is provided in the community as it is already included in the day habilitation rate. This service also requires different goals and objectives from those addressed in residential training and must be documented separately from the residential service component.

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Supported Employment

1. Q: May supported employment service notes be combined with day habilitation notes? A: No. Both supported employment and day habilitation service components require separate written narratives or summaries to document the delivery of services. 2. Q: May supported employment be billed for an individual who is employed by the program provider? A: Generally, no. Under certain circumstances a variance may be granted. Please refer to 4.07 (F) "Restrictions Regarding Submissions of Claims for Supported Employment" in the HCS Program Billing Guidelines. 3. Q: May supported employment be billed if the SE provider discusses employment issues with the individual by telephone? A: No. The only billable contact between the individual receiving SE and the SE provider must occur face-to-face while at the work site or in the context of an IDT meeting. 4. Q: Is a program provider required to have specific written denial of funding for supported employment service from other sources, such as the Department of Assistive and Rehabilitation Services (DARS)? A: No, but efforts made to secure services through DARS should be documented and available. Supported Employment may not be billed when such services are available or being funded through another source, such as DARS. 5. Q: If the HCS provider assists consumers in setting up and operating their own business, can this activity be billed as Supported Employment? A: No. Consumer-operated businesses are considered "Affirmative Industries" and most likely, would not meet the criteria of "integration" included in the definition of the Supported Employment component. 6. Q: Does the ISP need to contain a plan for "fading" the supported employment service? A: Yes, there should be a plan for reducing/fading the amount of Supported Employment.

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Residential Assistance

1. Q: In the definition of "residence," what is meant by the term "bona fide"? A: Bona fide, in this case, would indicate that the individual truly does reside at a given address. An individual's "residence" must not only be his or her actual site of day-to-day living, but also be a place of permanent or continuous habitation for a sustained period of time. 2. Q: Is the 14-day allowance for vacation time counted per year or per incident? A: There is a 14-day allowance per incident. There is no limit to the number of vacation allowances per year as long as each occurrence does not exceed 14 days. The 14-day period begins with the first night the individual does not stay in their residence. After the 14th night, the program provider is no longer eligible to bill. 3. Q; How long must an individual be back in the home prior to taking an additional vacation allowance and what is considered the first day of the vacation period? A: The individual must spend the night at the SL/RSS/FC site before another allowable vacation period can begin. The first date in which the individual does not spend the night at his/her residence is counted as the first day of the vacation allowance period. 4. Q: Is it permissible for a program provider to charge a daily fee to the parent or family member who takes an individual out of the program for longer than 14 consecutive days to maintain their bed at the foster care or 3 or 4 bed residence? A: Yes. Program providers may wish to add a clause addressing absences exceeding 14 days in their service agreements with the consumer or LAR. 5. Q: If a provider is billing supported home living for transporting an individual to and from the day habilitation site, can they also bill respite for community integration? A: Yes. The provider could bill SHL and Respite on the same calendar day if the activities are not occurring simultaneously and if less than 10 hours of hourly respite are billed. 40 units (10 hours) of Respite and SHL units cannot be provided on the same calendar day.

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Questions and Answers ­ HCS Billing Guideline Revision 2009

6. Q: May supported home living and nursing be billed for the same consumer during the same time period? A: Yes, if the nurse and SHL provider are both actively providing a billable service and both are properly documented. EXAMPLE: The SHL provider assists the individual in complying with the nurse who is checking vital signs. This would also be allowable if the SHL provider is performing a non-face-to-face billable activity at the same time the nurse is performing a billable service with the individual. 7. Q: May supported home living be billed for job search activities? A: Yes. Assisting an individual with obtaining employment would be considered a billable activity under SHL if such activities are justified and identified as objectives in the ISP. 8. Q: May supported home living (SHL) be billed for the time a SHL transportation provider spends waiting for a consumer to complete business or errands? A: The time a SHL provider spends waiting for an individual to complete business that is essential for health and safety such as doctor visits, dental visits, and therapy appointments is billable as SHL. 9. Q: May supported home living be billed for the same time period that an HCS funded therapy or non-HCS funded therapy is being billed? A: HCS is billable if an SHL transportation provider is waiting to provide return transportation or the SHL provider is needed to provide support to the individual during therapy. SHL could also be billed if the provider is performing a billable non-face-to-face activity during the same time period a therapy service is provided. 10. Q: May the time an individual spends sleeping after a seizure be billed as supported home living? A: Yes, because the SHL provider is still required to monitor the individual for additional seizure activity or other problems until natural supports can take over.

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Questions and Answers ­ HCS Billing Guideline Revision 2009

11. Q: May SHL be billed when a service provider is on duty to provide services when the individual is sleeping? For example the individual may require diaper changes or repositioning, etc.? A: The actual time the individual is asleep is not billable. If a staff person came in periodically to change a diaper or reposition an individual, only the actual time they were performing these functions is billable. If the SHL staff member provided non-face to face services such as cleaning individual specific locations, preparing meals, or other approved indirect activities specifically for the individual, the program provider may bill for those services. All indirect services must be documented in the ISP prior to initiation of these service activities. 12. Q: May a foster/companion care provider also provide supported home living at the same time? A: No. One service provider may not provide different service components or subcomponents at the same time to the same individual. Additionally, SHL may not be provided to an individual by a service provider who is simultaneously providing, RSS, SL or FC to another individual. 13. Q: May one person simultaneously provide HCS foster/companion care to one individual and DFPS foster care to another individual in the same home? A: Yes. However, the maximum number of individuals living and receiving services in the home is three. In this example the HCS foster/companion care provider cannot be paid to provide either FC or SHL to the individual receiving DFPS foster care. 14. Q: May a grandparent, who has legal custody and is managing conservator for their minor grandchild, be that child's foster/companion care provider? A: No. Grandparents who have legally adopted a minor child are ineligible to be the foster/companion care provider to that individual.. Provider qualifications listed in the billing guidelines must be met.

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Questions and Answers ­ HCS Billing Guideline Revision 2009

15. Q: May a parent who is providing companion care to their adult child also be the day habilitation provider? A: Yes, there is no prohibition on a parent providing day habilitation service to their adult child. However, unless there is a compelling medical or behavioral issue, day habilitation service must be provided outside of the home. Goals, objectives/outcomes for day habilitation must meet to standards for day habilitation and must be documented separately from the foster care notes. Finally, the goals, objectives/outcomes for day habilitation must be distinct from the companion care objective and must be contained in the ISP. 16. Q: May a person receiving foster/companion care receive respite services in a 3 or 4-bed home? A: Individuals who receive HCS foster/companion care are not eligible to also receive respite as a waiver service. However, if a foster/companion care provider chooses to use a portion of the reimbursement received for this service to pay for respite care outside of the waiver, this service may be provided to an individual in an HCS 3- or 4-person residence as long as the total capacity of the home is not exceeded and other related program requirements are met. Please refer to Chapter 9, Subchapter D §9.174 (55) and (56). 17. Q: May respite ever be billed in excess of 10 hours? A: Yes. It is acceptable to bill respite up to 24 hours (96 units) per day in cases where the individual lives in a home with an unpaid caregiver (usually a parent or family member) and the respite service is provided in the individual's home by a qualified respite provider. 18. Q: If a foster/companion care provider is on vacation or otherwise unavailable, may foster/companion care be provided by the foster care provider's spouse or other family member? A: Yes, but only if the spouse or family member is also qualified as an HCS foster/companion care provider and the service provider has received specific training to meet the needs of an individual. The case manager and program provider must be notified of such an arrangement.

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Questions and Answers ­ HCS Billing Guideline Revision 2009

19. Q: May the parent of an adult individual be the foster/companion care provider? A: Yes, if it is documented that the IDT has determined the arrangement to be in the best interest of the individual and not based solely on the convenience of the parent. Parents, including adoptive parents and stepparents, may not serve as the foster/companion care provider or other service provider for their minor children. 20. Q: May a service provider's spouse live in a supervised living home? A: Program providers have the discretion to approve this type of arrangement. 21. Q: May an individual receiving supervised living (SL) or residential support services (RSS) ever be left unsupervised in the home? A: If an individual needs the level of supervision required by RSS (a residential support provider present in the residence and awake whenever an individual is present in the residence), he/she may never be left unsupervised, even for short periods of time. If an individual is receiving supervised living because it has been determined by the IDT that he/she does not require such close supervision, the IDT may identify and document in writing specific times and circumstances under which the individual may be left unsupervised. The program provider is ultimately responsible for the individual and any incident that occurs regardless of level of supervision at the time of occurrence. 22. Q: What is the intent behind the allowance of 5 extended shifts per month with Residential Support Services (RSS)? A: Unforeseen circumstances such as sudden illness, personal emergencies and inclement weather can arise which make it difficult, if not impossible, for a program provider to have a shift change on a given day. For this reason, up to five extended shifts per month per residence is allowed. Any staff person working an extended shift must then remain off the clock for a minimum of eight hours before working another shift of any length. At no time may one person work more than 24 consecutive hours and any person working an extended shift of any length must remain awake for the duration of the shift. This rule applies to both hourly and salaried staff members.

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Questions and Answers ­ HCS Billing Guideline Revision 2009 23. Q: Will there be any exceptions to the limit of five extended shifts? A: Natural disasters like major hurricanes or tornados or a sudden catastrophic event such as an act of war or terrorism would be considered on a case by case basis. Events such as staff suspensions for abuse/neglect allegations are not sufficient to warrant an exception to this limit. 24. Q: May respite be billed if an individual goes to camp? A: No. Only Day Habilitation may be billed in HCS when an individual attends camp. To bill for Day Habilitation the provider must be responsible for paying for the camp activities, and camp personnel must meet the minimum provider qualifications. The ISP must also contain goals and objectives relative to the day habilitation activities. 25. Q: Is the provider allowed to bill Respite for time spent by a consumer at a summer camp activity? A: No. This service could be considered billable under Day Habilitation when the HCS Provider pays for the summer camp activity, the summer camp personnel meet the minimum provider qualification, and the individual service plan contains goals and objectives relative to the day habilitation activities. 26. Q: May a provider bill 10 hours of out-of-home Respite on an hourly basis and then bill Supported Home Living for 14 hours to cover the remainder of the calendar day that Respite is provided? A: No. When out-of-home Respite is provided for 10 hours or more in calendar day, reimbursement is available in an amount equal to a 10 hour period. An individual receiving out-of-home Respite for 10 hours or more is not eligible to receive Supported Home Living on the same calendar day. 27. Q: Does a provider that provides out-of-home Respite have to provide more than 10 hours when they can only bill up to 10 hours? A: Yes, although there is no longer a separate category of daily respite on the IPC, individuals receiving program services are still eligible to receive the same annual amount of daily respite, hourly respite, or a combination of both. Daily respite may be received by an individual in a place outside of the individual's own or family home. Providers may bill 10 hours of respite to be reimbursed for the provision of daily respite. Depending upon the individual's need, daily respite must be provided for at least 10 hours, up to a 24 hour period per each claims submission of 10 respite units. Page 28 of 33

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Questions and Answers ­ HCS Billing Guideline Revision 2009

Revised November 2009

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Questions and Answers ­ HCS Billing Guideline Revision 2009

Adaptive Aid (AA), Minor Home Modification (MHM), and Dental (DE)

1. Q: How specific does medical justification need to be for an AA and MHM prior approval requests? A: Professional recommendations must be based on face-to-face assessments and must include information about an individual's medical and/or psychiatric diagnoses. The assessment must also include a description of conditions related to the diagnosis and how the adaptive aid will meet the needs of the individual. A description of the item and a recommendation for the item must also be included. Justification should be based on the needs of the individual rather than the needs or convenience of the caregiver. 2. Q: If an individual has private medical insurance, must a request be submitted to the private insurance carrier before being submitted for waiver approval? A: Any Medicaid waiver, including HCS, is always the payor of last resort. If an individual has private insurance and the adaptive aid is available from the insurance company, proof of non-coverage from the private insurance carrier must be included in the request for waiver funding for adaptive aids. If an individual is also covered by Medicare, a Medicare denial must accompany any request for an item denoted by a 1 or a 2 on the list of reimbursable adaptive aids in Attachment G, as these items are typically covered by both Medicare and Medicaid home health services. Medicaid denials are also required for items denoted by a 1 or a 2. 3. Q: Is a doctor's order or nursing recommendation required for approval of disposable gloves? A: No. If the item costs less than $500, the IDT can authorize the service. If the item costs more than $500, a doctor or nurse must conduct an assessment to authorize the service. 4. Q: May a request for eyeglasses include only one bid? A: Items requiring custom fitting such as eyeglasses, orthotic devices, and hearing aids may be approved with only one bid.

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Questions and Answers ­ HCS Billing Guideline Revision 2009

5. Q: What if the cost of eyeglasses is only partially covered by Medicaid? A: The difference in the cost of eyeglasses not covered by Medicaid may be paid by the waiver. While there is no set cap to the allowable amount for eyeglasses, items such as more expensive frames, special lenses, tinting, etc. still require medical justification based on the needs of the individual. It is recommended that a provider submit requests for prior approval in cases where there is some question as to the cost or justification. 6. Q: May the partial cost of other adaptive aids, besides eye glasses be covered by the waiver? A: No. Eye glasses are the only covered item under the waiver that Medicaid allows the individual to make partial payments for more expensive frames, lenses, etc. 7. Q: Do program providers need to get denials for items not denoted with a 1 or 2 on the list of billable adaptive aids? A: No, DADS is aware these items are not covered by Medicare or Medicaid. The exception to this is orthotic devices (code 107). These are typically covered by Texas Health Steps for children and Medicare for adults, so prior approval requests for these items need to contain written proof of non-coverage from Texas Health Steps (CCP) if the individual is under 21 years old or from Medicare (Palmetto GBA) if the individual is 21 years old or older and covered by a Medicare plan. 8. Q: If the doctor orders a nutritional supplement which is not listed in the Medicaid manual can it be covered on the waiver? A: No. All nutrition supplements covered by the HCS waiver must also be covered items through Medicaid and be listed in the Medicaid Provider Procedures Manual. 9. Q: May a minor home modification be done in a foster/companion setting? A: A recommended minor home modification can be done in any home which is the individual's primary residence. However, these modifications are subject to a lifetime cap of $7,500. The IDT should consider such factors as the permanence of the residential arrangement and projected needs of the individual over his/her life span.

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Questions and Answers ­ HCS Billing Guideline Revision 2009

10. Q: May a minor home modification be considered for prior approval without an in-home assessment by an OT or PT? A: An in home assessment is not required if the item costs less than $1,000.00. 11. Q: What if the individual lives in a rural area and the provider cannot secure three bids for a minor home modification? A: If sufficient efforts to secure bids have been documented, two comparable bids may be accepted. Only in extremely rare circumstances will a single bid be accepted for a minor home modification, as prices for these jobs can vary greatly and one bid gives no basis for comparison. 12. Q: Does the HCS waiver cover IV sedation under dental services for individuals who are minors? A: No. Dental services for individuals under the age of 21 are not covered on the waiver. Medically justified IV sedation is covered by Texas Health Steps.

13. Q: Where do we send our prior approval packets for Adaptive Aids and Minor Home Modifications? A: They can be faxed to (512) 438-2695 or mailed to: DADS Provider Services, Billing & Payment Attn: AA/MHM Committee PO BOX 149030, MC W-200 Austin, TX 78714-9030 Providers with questions concerning the prior approval of adaptive aids and minor home modifications may call (512) 438-5359 and leave their name, phone number, and a brief message. Calls will be returned within two business days.

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Questions and Answers ­ HCS Billing Guideline Revision 2009

14. Q: Where do we send our packets for reimbursement authorization? A: They should be mailed to: DADS P.O. Box 149030, MC W-400 Austin, Texas 78714-9030 Overnight mail should be sent to: DADS Attention: Flor Deleon 701 West 51st Street, MC W-400 Austin, Texas 78751 Providers with questions concerning reimbursement authorization should call (512) 438-2200, option #5 to speak to a representative. 15. Q: If an adaptive aid is not on the list of allowable aids, can the provider get special permission to purchase the aid? A: No. If the item is not on the list of billable adaptive aids the provider will not be reimbursed. Providers should contact DADS at (512) 438-5359 if there is any question as to whether an item is included on the list of billable adaptive aids. 16. Q: The list of allowable dental treatments does not include administration of sedatives. How is this billed? A: Reimbursement for the administration of routine sedatives necessary to complete dental treatment such as oral medications and shots is billable through the HCS program. When regular Medicaid benefits do not cover the cost of intravenous sedation, it may also be billed to the HCS waiver.

If you have further questions about the billing guidelines please call our Billing and Payment Hotline at (512)438-5359 and a member of our staff will return your call within two business days to assist with any questions. Thank you.

Revised November 2009

Page 33 of 33

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