Chapter 238 School-Based Health Services Nursing Services Billing Form Effective August 1, 2019

Consent to Bill Medicaid Prior to billing parents must provide written consent to release information and to bill for Medicaid reimbursement. Consent is valid for one calendar year from the signature date. Parents are to be provided an annual notice.

Plan of Care Services must be documented on the Plan of Care signed by the parent and therapist. Effective August 1, 2019 Service Care Plan is now called a Plan of Care. This provides more consistency and avoids a terminology conflict with private school service plans. There is not a need to have a new one signed if it says Service Care Plan The IEP Program has been adjusted to reflect the change in terminology. Specific ICD-10 diagnosis codes are required. ICD-10 codes must relate to the specific type of therapy being provided. Think of these more as treatment diagnosis codes. All appropriate diagnosis codes need to be listed on the Plan of Care. A global code such as Autism would not be appropriate. A copy of the nursing health care plan is to be included with the Plan of Care.

Physician Authorization Form Nursing services are not included on the Physician Authorization Form as doctor orders are provided in conjunction with nursing services.

Student Demographics Use the student’s real name as listed in WVEIS The diagnosis code is to be an ICD-10 code that matches the need for nursing services. County and school names can be written out or use the county and school WVEIS codes. For provider name print the name of the person providing the service.

Service Record – School Based Nursing Services Billing Form Medicaid Number Last Name First Name   WVEIS Number Date of Birth Provider Name County School Month/Year

Service Record – School Based Nursing Services Billing Form Medicaid Number Last Name First Name 03900000005  Doe Shamus WVEIS Number Date of Birth Provider Name 999999999 1-3-2008 Mary Smith County School Month/Year 59  501 Sept/2019

Diagnosis Codes Enter the specific ICD 10 Diagnosis Codes related to nursing services on the form starting with box number one. Enter the codes that are directly associated with the services/or assessments.

LIST ALL DIAGNOSIS CODES RELATED TO NURSING SERVICES ICD 10 Diagnosis Codes LIST ALL DIAGNOSIS CODES RELATED TO NURSING SERVICES 1. 2. 3. 4. 5. 6.

LIST ALL DIAGNOSIS CODES RELATED TO NURSING SERVICES ICD 10 Diagnosis Codes LIST ALL DIAGNOSIS CODES RELATED TO NURSING SERVICES 1. E10.9 2. T78.01XA 3. F90.1 4. J45.901 5. 6.

Nursing Service Procedure Codes Authorized Individual Nursing Services/Treatments: *Anaphylactic Reaction Assessment/Evaluation (T1001 SE) (2 Events/Calendar Year) Seizure Management (T1001 SE) (2 Events/Calendar Year) *Diabetic Management Manual Resuscitator (92950) (10/Calendar Year) * If providing services via Telehealth use an additional modifier of GT.

Nursing Service Procedure Codes The following procedures use T1000 SE code: Each of the following procedures can be billed, with a maximum of 10 units for each procedure per instructional day, (1 Unit = 15 minutes) Long Term Medication Administration Emergency Medication Administration Mechanical Ventilator *Inhalation Therapy Catheterization *Catheterization Self-Management *Subcutaneous Insulin Infusion-by Pump *Peak Flow Meter Ostomy Care *Measurement of Blood Sugar *Subcutaneous Insulin Infusion by Injection Oxygen Administration Enteral Feeding (tube feeding) Postural Drainage and Percussion Tracheostomy Care Oral Suctioning Anaphylactic Reaction Individual   * If providing services via Telehealth use an additional modifier of GT.

Nursing Service Changes *Diabetic Management – T1001 SE (2 Events/Calendar Year) *Catheterization Self-Management – T1000 SE (Units)

Nursing Telehealth Telehealth is now available for some procedures within T1000 SE: Inhalation Therapy – Available for self-administration only with RN or LPN at main site Catheterization Self-Management Measurement of Blood Sugar – Available for self-administration Subcutaneous Insulin Infusion by Pump – Available for self-administration Subcutaneous Insulin Infusion by Injection – Available for self-administration Peak Flow Meter Available only with RN or LPN at main site. If using Telehealth an additional modifier is required of GT. So the CPT code would be T1000 SE GT. It is very important to enter the modifiers in that order.

Nursing Telehealth Telehealth is now available for two procedures within T1001 SE: Anaphylactic Reaction Assessment/Evaluation – Available for self- administration only with RN or LPN at originating site Diabetic Management – Available for nurse supervision for self-administration If using Telehealth an additional modifier is required of GT. So the CPT code would be T1001 SE GT. It is very important to enter the modifiers in that order.

Enter Claim Documentation Use the CPT codes and caps from slide eleven to complete the claim documentation section of the billing form. In the first column list the service date. (If combining minutes from different days for a unit use the date the 15th minute occurred to complete the unit. No span dates are allowed.) Column two - enter one or more of the diagnosis code numbers that directly relates to the services. (examples 1, 1 & 3, 2) Column three - enter the CPT code including a GT modifier if being provided by telehealth. It is very important to enter the modifiers in the correct order. The SE modifier must come first. Example -T1000 SE GT. Columns four and five - enter the start and end time. In the last column enter the total number of units or event(s).

List Diagnosis Code Number(s) Claim Documentation Service Date List Diagnosis Code Number(s) Procedure code   Start Time End Time Units/Event

List Diagnosis Code Number(s) Claim Documentation Service Date List Diagnosis Code Number(s) Procedure code   Start Time End Time Units/Event

Third Party Billing At times a student may be eligible for Medicaid as the secondary insurance. Medicaid is the payer of last resort for direct services (OT, PT, Speech, Audiology, Psychological, and Nursing). If the student has special transportation services, the direct billing should be submitted. The claim will be denied but will justify claiming transportation billing for that instructional day. Medicaid will pay ancillary services (TCM, personal care aide and special transportation) as the secondary insurance. Occasionally a student may be eligible for Medicaid under two numbers. In this case district’s should always use the primary Medicaid number.

Signature and Credentials _____________________ ______________ Signature/Credentials Date

Signature and Credentials __Mary Smith ___ RN___ October 1, 2019 Signature/Credentials Date

Additional Documentation A copy of the student’s nursing notes for the month will also be required. A copy must be on file in the special education central office.

Ashley Torres RN – School Health Coordinator Office of Special Education atorres@k12.wv.us 304-558-2696 ext 53536 https://wvde.us/special-education/school-health/

Kelley Johnson – Coordinator Office of Special Education kelley Kelley Johnson – Coordinator Office of Special Education kelley.johnson@k12.wv.us 304-558-2696 ext 53539 WVDE Medicaid Website: https://wvde.us/special-education/Medicaid/