Home and Community-based Services Billing Guidelines

Changes for Fiscal Year 2010Misti J. Ackermann – Manager, Billing & Payment

Overview

Rate Re-Distribution & Setting

Requisition Fees

Daily Respite

Nursing Services and Specialized Nursing Services

Specialized Therapies

Contact Information

Rate Re-Distribution & Setting

What will be modified?All Rates

Delayed and ChangedAddition of Requisition Fees to HCSCost Caps

Will change based on the rate changes

Item Cost Requisition Fee$3,500 to $3,999.99 $258.27$4,000 to $4,499.99 $284.28$4,500 to $4,999.99 $309.90$5,000 to $5,499.99 $335.91$5,500 to $5,999.99 $361.92$6,000 to $6,499.99 $395.15$6,500 and over $428.76

Requisition Fees

What will the requisition fees be for HCS?Similar to TxHmL requisition fees

Item Cost Requisition Feeunder $500 10% of cost

$500 to $ 999.99 $ 80.04$1,000 to $1,499.99 $118.86$1,500 to $1,999.99 $131.67$2,000 to $2,499.99 $163.89$2,500 to $2,999.99 $196.50$3,000 to $3,499.99 $227.19

Proposed Requisition Fees – Adaptive Aids & Minor Home Modifications

Respite Services ~ Changes

Information Letter (IL 2009-65)Omission of Daily Respite

Rules do not change

Claim submission into Client Assignment and REgistration system (CARE) changes

Conversion of Daily to Hourly (prior to 9/1/09)

Information Letter (IL 2009-85)Removal of Daily Respite from CARE

IPC Renewal entries with effective dates on or after 9/1/09

IPC Revisions AFTER 8/31/09 – effective to be announced

“administrative revision per DADS”

Nursing Services ~ Changes CARE Entry

Information Letter (IL 2009-85)Nursing Service Unavailability in CARE

IPC Renewal entries with effective dates on or after 9/1/09

Nursing Service Available in CARE

IPC Renewals & Revisions AFTER 8/31/09 – effective date to be announced

“administrative revision per DADS”

B. Billable ActivityThe only billable activities for the nursing service component are:

interacting face-to-face or by telephone with an individual to provide professional or vocational nursing for which there is a documented or immediate medical necessity, including:

preparing and administering medication or treatment ordered by a physician, podiatrist, or dentist;

assisting or observing self-administration of medication; and

assessing an individual’s health status;

reviewing documents for the purpose of evaluating care, training or quality assurance pertaining to your level of skill and developing an annual nursing report;

interacting face-to-face or by telephone with a person, except a service provider of nursing, service coordination, or specialized therapies, regarding the health status of an individual;

writing an annual Individual Treatment Plan (ITP) for an individual;

instructing, verifying the competency of, or supervising an unlicensed person in the performance of a task delegated in accordance with rules of the Board of Nurse Examiners (22 TAC §225.1 et seq.); and

participating in an IDT meeting.

Nursing Services ~ Changes Proposed Billing Guidelines: §4.04 Nursing

Nursing Services ~ Changes Proposed Billing Guidelines: §4.04 Nursing

3. Examples of Non-billable Activities The following are examples of activities that are not billable for the nursing service component, regardless of whether the activities constitute the practice of nursing:

performing or supervising an activity that does not constitute the practice of nursing, including:

transporting the individual;

waiting to perform a billable activity; and

waiting with the individual at a medical appointment;

making a medical appointment;

training 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 the individual;

storing, counting, reordering, refilling, or delivering medication;

reviewing documentation that does not address documented or immediate medical necessity;

interacting with a service provider of nursing, or specialized therapies, if not during an IDT meeting; and

performing an activity for which there is no documented or immediate medical necessity.

A. General Description of Service ComponentThe specialized nursing service component is the provision of professional or vocational nursing for daily skilled nursing to cleanse, dress, and suction a tracheostomy or daily skilled nursing assistance with ventilator as ordered by a physician.

B. Billable ActivityThe only billable set of activities for the specialized nursing service component are:

Interacting face-to-face with an individual to provide professional or vocational nursing for tracheostomy or ventilator care

Specialized Nursing Services ~ New Proposed Billing Guidelines: §4.045 Specialized Nursing

B. Billable Activity

The only billable activities for the specialized therapies service component are:

interacting face-to-face or by telephone with an individual to conduct assessments or provide services within the scope of the service provider’s practice;

interacting face-to-face or by telephone with a person, except a service provider of nursing, case management, or specialized therapies, regarding a specialized therapies subcomponent provided to an individual;

performing one of the following activities that does not require face to face interaction with an individual;

writing an individualized treatment plan for your specialized service;

reviewing documents for the purpose of evaluating care, training or quality assurance pertaining to your specialized service;

participating in an IDT meeting; and

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 the individual, regarding how treatment that is within the scope of practice of the service provider of specialized therapies will be provided, including training to document the provision of treatment.

Specialized Therapies ~ Changes Proposed Billing Guidelines §4.02 Specialized Therapies

3. Examples of Non-billable Activities The following are examples of activities that are not billable for the specialized therapies

service component:

writing how treatment will be provided, such as a behavior intervention plan, menu, or schedule;

providing services outside the scope of the service provider’s practice;

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; and

interacting with another service provider of a specialized therapies subcomponent, or with a service provider of nursing or case management, if not during an IDT meeting.

Specialized Therapies ~ Changes Proposed Billing Guidelines §4.02 Specialized Therapies