1. Medicaid Billing Module Personal Care Services Billing Form

2. Changes to Personal Care Billing Personal Care will now be billed in 15-minute units. Maximum of 28 units per instructional day. Units must be documented with start and stop times. Extra minutes can be carried over to the next instructional day.

3. Personal Care Changes Billing form is a daily form per student. Form is two pages long. Personal Care Provider will be required to document start and stop times for each billable service throughout the school day.

4. Student Demographics Section Medicaid Number Last NameFirst NameCountySchoolProcedure Code T1019 SE WVEIS #Diagnosis CodeDate of BirthMonth/YearProvider Name (Printed) Personal Care must be identified on the Service Plan DATE OF SERVICE: ______________________________

5. Student Demographics Section On the top row enter the information as requested. County and school as the code numbers On the second row enter data as requested. Suggest printing a copy with all demographics completed except month/year. This will serve as a template for the school year. Print the name of the employee providing the personal care services. If two employees split the tasks with one student, each employee would complete a separate form for the services they provided.

6. Student Demographics Section Example Medicaid Number Last NameFirst NameCountySchoolProcedure Code 0000000001DoeJane058303T1019 SE WVEIS #Diagnosis CodeDate of BirthMonth/YearProvider Name (Printed) 999999999 01-01-1900August, 2015John Smith Personal Care must be identified on the Service Plan DATE OF SERVICE: ______________________________

7. Date of Service List the date the services were performed. List the same date on the second page. List the student’s name on the second page.

8. Data Entry Section This is divided into 5 categories of personal care activities. Total of 25 billable activities Minutes from all of the activities are combined to determine the number of units for the day.

9. Data Entry Section There is space for six start and stop times for each activity. If an activity occurs more than six times a day, add additional pages as needed. Document the start and stop times as soon as possible when the activities occur. Documenting quickly will ensure more accurate data. If a specific activity does not occur, leave those spaces blank.

10. Data Entry Self Help Skills CATEGORY/ACTIVITY START/END TIMES FOR EACH ACTIVITY For each time an activity is provided list the start and end time. If more than six in one activity use an additional form MINUTES Self Help SkillsStart Time | End Time | Start Time | End Time | Start Time | End Time | Start Time | End Time | Start Time | End Time | Start Time | End Time A. Grooming 8:00 | 8:10 | 1:00 | 1:10 | | | | | | | | 20 B. Bathing | | | | | | | | | | | C. Toileting 9:05 | 9:15 | 2:13 | 2:25 | | | | | | | | 22 D. Dressing | | | | | | | | | | | E. Laundry (Employee Doing) | | | | | | | | | | | F. Brushing Teeth 12:10 | 12:15 | | | | | | | | | | 5 G. Hand Washing 9:15 | 9:20 | 11:05 | 11:10 | 2:25 | 2:30 | | | | | | 15

11. Data Entry Non-Tech Physical Assistance Non-Tech Physical AssistanceStart Time | End Time | Start Time | End Time | Start Time | End Time | Start Time | End Time | Start Time | End Time | Start Time | End Time MINUTES A. Repositioning/Transfer | | | | | | | | | | | B. Walking | | | | | | | | | | | C. Medical Equipment (Adaptive) | | | | | | | | | | | D. Assistance with Medication | | | | | | | | | | | E. Range of Motion (ROM) (Per Phys. Order) | | | | | | | | | | | F. Vitals (Per Phys. Order) | | | | | | | | | | | G. Catheterization | | | | | | | | | | | H. Communication | | | | | | | | | | |

12. Data Entry Nutritional Support CATEGORY/ACTIVITY START/END TIMES FOR EACH ACTIVITY For each time an activity is provided list the start and end time. If more than six in one activity use an additional form MINUTES Nutritional Support Start Time | End Time | Start Time | End Time | Start Time | End Time | Start Time | End Time | Start Time | End Time | Start Time | End Time A. Meal Preparation | | | | | | | | | | | B. Feeding | | | | | | | | | | | C. Special Dietary Needs | | | | | | | | | | |

13. Data Entry Environmental Environmental Start Time | End Time | Start Time | End Time | Start Time | End Time | Start Time | End Time | Start Time | End Time | Start Time | End Time MINUTES A. Housecleaning | | | | | | | | | | | B. Laundry/Ironing (Supervision) | | | | | | | | | | | C. Making/Changing Bed | | | | | | | | | | | D. Dishwashing | | | | | | | | | | |

14. Data Entry Behavior Modifications Behavior Modifications Start Time | End Time | Start Time | End Time | Start Time | End Time | Start Time | End Time | Start Time | End Time | Start Time | End Time MINUTES A. Supervision of Non-Educational Time 7:45 | 8:00 | 11:10 | 12:10 | | | | | | | | 90 B. Redirection 9:30 | 9:40 | 9:55 | 10:00 | 1:15 | 1:20 | 1:30 | 1:39 | 1:50 | 1:55 | | 34 C. Positive Behavior Supports 1:55 | 2:15 | | | | | | | | | | 20

15. Data Entry Minutes Add up the total minutes per row and list in the Minutes column at the far right of the pages. If an activity does not have any start and stop times listed, place NA in the minute column for that row. In the carryover box enter any extra minutes from the previous day. The first day would be zero minutes. This carryover would be added to the minutes for the total minutes for the day. Add up the minutes from both pages and the carryover minutes. List under total minutes.

16. Unit Calculations CARRYOVER MINUTES FROM PREVIOUS INSTRUCTIONAL DAY 0

17. Unit Calculations TOTAL DAILY MINUTES 206DIVIDE BY 15 =TOTAL DAILY UNITS 13Carryover minutes for next instructional day 11

18. Calculations There were not any carryover minutes in our example. Total 206 minutes Divided by 15 minutes Equals 13 units Remainder of 11 minutes that will be entered into the carryover box on the next day’s data entry form.

19. Signature and Credential The provider signs the form The provider lists credential Credential is the employee designation such as Aide (I, II, III, IV), Autism Mentor, Paraprofessional, ECCAT(I,II,III), Braille Specialist, Sign Language Interpreter(I, II), Sign Support Specialist, or LPN.

20. Terry Riley – Coordinator Office of Special Education tjriley@k12.wv.us 304-957-9833 ext 53223 WVDE Medicaid Website: http://wvde.state.wv.us/osp/medicaid.html tjriley@k12.wv.us http://wvde.state.wv.us/osp/medicaid.html