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

2. 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.

3. 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.

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

5. 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.

6. 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

7. Service Record – School Based Nursing Services Billing Form
Medicaid Number
Last Name
First Name  
Doe
Shamus
WVEIS Number
Date of Birth
Provider Name
Mary Smith
County
School
Month/Year
59 
501
Sept/2019

8. 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.

9. 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.

10. 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.

11. 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.

12. 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.

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

14. 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.

15. 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.

16. 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).

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

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

19. 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.

20. Signature and Credentials
_____________________ ______________ Signature/Credentials Date

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

22. 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.

23. Ashley Torres RN – School Health Coordinator Office of Special Education ext

24. Kelley Johnson – Coordinator Office of Special Education kelley
Kelley Johnson – Coordinator Office of Special Education ext WVDE Medicaid Website: