health related handbook 2012-2013 - · pdf fileeffort to recover costs for health ......

Prince George's County Public Schools

HEALTH RELATED SERVICES MEDICAID BILLING HANDBOOK 2012-2013

Prince George's County Public Schools Medicaid Billing Office

14201 School Lane, Trailer # C05-451 Upper Marlboro, MD 20772

301.952.6349 (PH) ∙ 301.780.5925 (FAX)

http://www1.pgcps.org/medicaid/

TABLE OF CONTENTS

Medicaid Program Background & Description .......................................................... 1 Overview of Medicaid Billing Eligibility Requirements .............................................. 2 Overview of Health Related Medicaid Billing Requirements .................................... 2 Billing Process and Documentation Requirements ................................................... 2 Speech and Language Services ................................................................................. 5 Speech and Language Sample Documentation ..................................................... 10 Nursing Services .......................................................................................................... 15 Nursing Services Sample Documentation ................................................................ 19 Psychological Services ............................................................................................... 24 Psychological Services Sample Documentation .................................................... 29 Occupational & Physical Therapy ............................................................................. 34 Occupational & Physical Therapy Sample Documentation .................................. 38 Audit Requirements .................................................................................................... 45 Billing Calendar ........................................................................................................... 48

Sasscer Administration Building ▪ Trailer # C05‐451 ▪ 301‐952‐6349 ▪ Fax 301‐780‐5925 ii

Please go to our website for the most current information and forms.

http://www1.pgcps.org/medicaid/

Sasscer Administration Building ▪ Trailer # C05‐451 ▪ 301‐952‐6349 ▪ Fax 301‐780‐5925

Medicaid Program Background & Description On July 1, 1988, President Ronald Reagan signed Public Law PL 100-360, the Medicare Catastrophic Coverage Act. This law permits local education agencies to recover costs from public health insurance for services identified in a child’s Individualized Education Plan (IEP). These services include speech pathology, audiology, occupational therapy, physical therapy, nursing, social work, and psychological services for screening, evaluation and treatment services. Additionally, local education agencies are allowed to submit claims for IEP coordination services (case management) as well as specialized transportation services for Medicaid eligible special education students. The Federal Government and the United States Congress have encouraged school systems to use all available federal funding, including Medical Assistance to finance special education and health related services. As a result, in 1994, Prince George's County Public Schools system began a system wide effort to recover costs for health related services, and IEP coordination services for Medicaid eligible students. Currently, there are over 4,600 Medicaid eligible special education students in Prince George's County Public School system. These students constitute 31% of the Special Education population and 3.7% of all students attending Prince George County Public Schools. Medicaid reimbursement funds support and expand existing programs and provide funding for staff, specialized supplies and equipment that enhance the learning experience for all special education students.

MBO Program Mission The mission of the Medicaid Billing Office is to recover funds for health related and IEP coordination services provided to Medicaid eligible special education students in order to expand and enhance the services offered to all PGCPS special education students.

MBO Program Goals Our goal is for the Medicaid Billing Office to operate with integrity, excellence and

professionalism and to provide quality service that is effective, efficient accountable to all stakeholders;

To increase and maximize efforts to recover Medicaid revenue in order to enhance services provided to PGCPS Special Education Department

To improve efforts in order to meet regulatory compliance in accessing Medicaid reimbursement funds;

To increase children and youth’s access to comprehensive health services through the PGCPS school-based Medicaid reimbursement program;

To increase collaboration among schools, families, and state agencies, where each partner has a defined role and demonstrates commitment and accountability to the Special Education students of PGCPS;

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To develop and implement a long-range plan for helping to ensure sustainability of a comprehensive Medicaid reimbursement program

Overview of Medicaid Billing Eligibility Requirements In order for PGCPS system to receive Medicaid reimbursement, the services billed must:

Be provided to a Medicaid eligible student under the age of 21 Be provided to a student with an active IEP/IFSP, Be provided by a qualified practitioner (possess proper licensure/certification) Address a student’s physical, mental or emotional disability Be consistent with the intent of the IEP/IFSP identified services and planned goals Have documentation that supports that the services billed relate directly to the

IEP/IFSP Parental consent for PGCPS to release information in order to bill Medicaid for health related and IEP coordination services must be obtained prior to billing.

Overview of Health Related Medicaid Billing Requirements The following are health related services that PGCPS currently provides to some special education students: PGCPS health related service providers must document each contact per month as prescribed in the student’s IEP. The following types of services are billable; face-to-face direct service, one-on-one direct screenings, evaluations, and treatments.

Billing Process for Health Related Service Providers On a monthly basis, the Medicaid Billing Office generates color-coded, pre-printed Monthly Service Record Billing Forms. Monthly Service Record billing forms are forwarded to the Medicaid Coordinators who disseminate the forms to the assigned health-related service providers.

Speech/Language Pathology Audiology Services Nursing Services Nutrition Occupational Therapy Physical Therapy Psychological Services

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Health-related providers:

Complete the Health Related Services Monthly Service Record billing forms on time. All forms should be forwarded to the Medicaid Billing Office by the 5th of the following month. Health Related Service Providers should keep detailed documentation of each individual session or encounter on the Related Services Log in Maryland Online. Each note must include the goal, describe the nature or extent of services provided and include a statement about the student’s progress.

Ensure that your billing is consistent with the Service Description on the IEP.

In order to receive reimbursement for MA billable services, (Speech, OT, PT) the

IEP must contain either, a daily, weekly or monthly prescription of services. (See MSDE Technical Bulletin 21 August 2010) For Nursing Services the IEP must contain a daily prescription of services.

For the exceptions to the service description of daily, weekly and monthly, the therapist must provide the reason or explanation for the use of the frequencies quarterly and yearly in order for Medicaid to be able to bill for IEP Service Coordination. For quarterly and yearly frequencies, Medicaid may not bill for the related service, but may bill for the IEP Service Coordination if the IEP has an appropriate explanation.

Medicaid regulations stipulate that health-related services must contain face-to-face contact with the student.

Monitor the session number on the Monthly Service Record (e.g., Session 1 of 10)

in order to prevent over billing for prescribed services.

Copies of all supporting documentation (MD Online IEP Related Service logs, treatment flow sheets (Nursing), copies of evaluations) should be stapled to all billing forms prior to submission to the Medicaid Billing Office.

When submitting billing for multiple months, supporting documentation will need

to accompany each Monthly Service Record. For example, do not send one service log for 3 months of billing.

Documentation Requirements Acceptable documentation describes a specific service that relates directly to the IEP. The provider must detail the intent of the encounter and a description of the specific skills being addressed.

Related service logs should state the goal; describe the service rendered and

the student’s response to the service or treatment (progress).

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Related Service log notations should include the date of service, time started

and time ended, the type of service (e.g., group therapy, individual therapy, and make-up session), progress code, service location and the initials of the person providing the service.

For Makeup sessions please use the “MU” code on the Related Services Log for the type of session and place the date of the session that was missed in the Description of Service area.

DO NOT USE DITTO MARKS ON THE MEDICAID MONTHLY SERVICE RECORD.

If the student did not receive service during the month, please indicate that on the form and return it to the Medicaid Billing Office by the 5th of the following month (Sasscer Administration Building ▪ Trailer # C05-451).

All health related billed services must be prescribed as a direct service on the student’s IEP!

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SPEECH & LANGUAGE SERVICES

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Speech & Language Services

The following Speech/Language services are reimbursable by Medicaid: Speech/Language Diagnostic Evaluation- This is a comprehensive evaluation, which

determines the child’s strengths and needs in the area of communication to ascertain any weaknesses that may impede educationally on the child.

Speech/Language Therapy-Individual- Speech/Language therapy involves on-going intervention which may consist of direct contact, or classroom services, with the child

Speech/Language Therapy-Group- Speech/Language Group therapy involves ongoing intervention, which may consist of, direct contact or classroom services, in a group setting.

Speech & Language Credentials

Are you qualified to bill? A speech language pathologist shall possess the following: A current Maryland Department of Health and Mental Hygiene (DHMH) license;

Are you qualified to bill for IEP Coordination? In order to bill for IEP Coordination services: A SLP must have a current MSDE issued teaching certificate (Conditional, Standard,

Advanced professional certification)

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Note: Demographic student information and most provider information are pre-printed on the Health Related Services Monthly Service Record billing form on a monthly basis. However, if you have new students begin with step #1 of the billing instructions below. If you have received a pre-printed form, begin with step # 3 of the billing form instructions.

1. Complete the child’s student number, name, date of birth, and school. Use only one form per child. Also, complete the therapy, provider and certification sections of the form. USE ONLY ONE FORM PER PROVIDER (therapist, teacher, etc.). FORMS MAY BE PHOTOCOPIED.

2. Leave the DIAGNOSIS code BLANK.

3. Write in the DATE OF SERVICE of the face-to-face encounter beginning with

month, day, and year.

Write in the ENCOUNTER CODE for each encounter per child. An encounter is defined as a face-to-face event relating to, or directly involving a service such as an evaluation, or treatment. For example, a speech language pathologist conducted an evaluation of a student. The procedure code for this encounter would be: 42 Speech/Language Evaluation Individual

42 Speech/Language Evaluation Individual 43 Speech/Language Therapy Individual 46 Speech/Language Therapy Group

Student must be present for all Medicaid billable services.

4. Document the session number. Do not bill for more sessions than those indicated

in the IEP. For example, if the IEP stipulates 6 times a month, only submit billing each month for 6 times during the month. Do not put non billable dates on the Monthly Service Record. (absentee dates, IEP meetings, indirect service dates)

5. In the COMMENTS section:

Please write “see attached log”, one time. Attach a copy of the MD Online Service Log or a copy of the evaluation.

6. SIGN & PRINT YOUR NAME. The Health Related Services Monthly Service Record

form must have an ORIGINAL SIGNATURE. Nicknames and abbreviations will not be accepted.

7. If the student did not receive service during the month, please indicate that on

the form and return it to the Medicaid Billing Office (Sasscer Administration Building, Trailer C05-451).

Instructions for Completing Monthly Service Record Billing Form for Speech & Language Services

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8. SUBMIT FORMS by the 5th of the following MONTH to: Medicaid Billing Office, Sasscer Administration Building, Trailer # C05-451.

9. File a copy of the Monthly Service Record and the log in the student’s LAF folder each month.

VERY IMPORTANT POINTS TO REMEMBER

Services must be delivered in accordance with the IEP/IFSP and must be related to an identified health problem. Please do not bill in excess of the service description indicated on the IEP.

MSDE requires that the frequency of service on the IEP must be detailed as daily, weekly or monthly. Yearly and quarterly frequencies are no longer billable for Medicaid billing purposes. If “yearly” and “quarterly” are the best description for the frequency of the service, make sure to enter a professional explanation for the specialized frequency of service so that Medicaid can bill for IEP Service Coordination.

List your current MD License. Sign at the top of the log (marked “Provider Signature”) and initial each entry on

the MD Online Related Services Logs. Please remember that the Medicaid Monthly Service Record form is an official

document. Your signature is attesting to the accuracy of the information that is being provided. Therefore, you should carefully review the form to make sure the student was not absent on the date of service listed on the form.

Submit one MD Online Service Log for each billing month. Staple MD Online Service Logs to the Health Related Services Form. Attach copies of evaluations when billing Code 42- Speech and Language

Evaluation Individual. Place the dates of the assessments and testing in the beginning paragraphs of the evaluation. (example: "John was tested on 9/7/12 and 9/8/12.")

PLEASE DO NOT LIST DATES THE STUDENT WAS ABSENT ON THE BILLING FORM. PLEASE DO NOT BILL FOR IEP MEETINGS ON MONTHLY SERVICE RECORD FORMS. PLEASE DO NOT BILL FOR CONSULTATIONS WITH OTHER PROVIDERS, OR OTHER

MEMBERS OF THE IEP TEAM ON THE MONTHLY SERVICE RECORD FORM. PLEASE BE TIMELY WITH YOUR SUBMISSION OF FORMS. FORMS ARE DUE THE 5th OF

THE FOLLOWING MONTH. Please indicate if the session was a make-up session by denoting M/U on the

service log. You must also identify the date of the missed session in the Description of Service on the Related Service log.

Related service logs should state the goal; describe the service rendered and the student’s response to the service or treatment (progress).

If the student no longer receives Speech/Language services, please check the “Service is no longer prescribed on the IEP” box on the Monthly Service Record form and return it to the Medicaid Billing Office.

If the student did not receive services in the billing month, please check the “No billable services provided this month” box and return it to the Medicaid Billing Office.

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When submitting billing for multiple months, supporting documentation will need to accompany each Monthly Service Record. For example, do not send one Related Service Log for 3 months of billing.

Ditto marks are not permitted on the billing form Please make sure that the Medicaid Office is aware of students who are

“speech only students”; their only special education service is speech.

The Health Related Monthly Service Record form is located on our website at the following address: http://www1.pgcps.org/medicaid

Special Notice to SLP’s Maryland Senate Bill 600 require local boards of education to reimburse audiologists and speech language pathologists for their licensing fees if they (1) provide audiology and speech language services on a third-party basis in schools; and (2) are licensed by the State Board of Audiologists and Speech-Language Pathologists (We currently reimburse licensing fees for DHMH licensing only). During SY 2012- 2013, speech language pathologists will complete licensing fee reimbursement in I-expense in Oracle. The funding strand is: 0100 0 206 3015 5828 0000 5688 FEES FINES AND LICENSES 44215 13 Please contact your supervisor or the Special Education Office if you have any problems filing for reimbursement.

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SPEECH AND LANGUAGE SAMPLE FORM

& MD ON-LINE IEP DOCUMENTATION

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Monthly Service Record SY 2012-2013SERVICE MONTH

Health Related Services

Speech Therapy

STUDENT NAME STUDENT #

DIAGNOSIS CODE MEDICAID # DOB

SCHOOL PROVIDER

Services must be provided in accordance to the IEP (Frequency of service) and must be listed on the IEP as a direct service.Please remember to attach supporting documentation.Please remember to SIGN the form.NO DITTO MARKS

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

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DATE OF SERVICE ENCOUNTERCODE COMMENTS

PROVIDER SIGNATURE (Required) PRINT NAME DATE

42 Speech/Language Evaluation Individual43 Speech/Language Therapy Individual46 Speech/Language Therapy Group

SESSION#

No billable service provided this monthService is no longer prescribed on the IEPProvider is not licensed

NO SERVICE?

UNITSOFFICE

USE ONLY

#SESSIONS LENGTH OF TIME FREQUENCY BEGIN DATE END DATE

0911Return all signed forms to: Medicaid Billing Office • Sasscer Administration Building, C05-451 • For Assistance, call: 301-952-6349

Please do NOTlist dates that the

student wasabsent

Remember to put the date ofthe missed session in the

Description of Service on theRelated Services log

October 2012

Janna Doe 200000315.3 00000000002 12/1/2000Musical ES Marge Simpson

2 30 Weekly 3/8/2012 3/19/2013

10/9/2012 43 143 2 Make-Up Session10/9/2012

Marge Simpson Marge Simpson 10/30/2012

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Related Services Log Notes

Services (from IEP)(Service Nature, number of sessions, length of time, frequency, begin/end dates

Provider Name: Position:

Student's Name:Unique Student ID:

School:Student's DOB:

FOR MA USE ONLY MA#: Date of parental consent for MA Billing: Diagnostic Code: Provider Name: Position: Provisional

Other Certified Licensure

___________________________________ Provider Signature

___________________________________ Supervisor Signature (if service provider is not credentialed)

Date Length of Session

Type of Session/ AbsenceCode

Description of Service Provided and Related Goal Progress Code

Service Location

Initials

Start time:

End time:

Start time:

End time:

Start time:

End time:

Service Description: Provide detailed description of assessment or services/treatment (must be at least two sentences)Progress Code: (P) Progress has been made and if the current rate of progress continues the goal should be achieved by the end of the duration of the IEP; (S) Someprogress has been made, but it may not be sufficient to achieve the goal by the end of the duration of the IEP; (N) Progress is not sufficient to achieve the goal by theend of the duration of the IEP Service Location: School, Home, Other (specify) Type of Session: (I) Individual, (G) Group, (Ind) Indirect, (M/U) Make-up session, (MT) Music Therapy, (AT) Art Therapy Absence Code: (A) Student absent, (B) school closed, (C) student unavailable, (D) clinician/therapist absent, (E) clinician/therapist unavailable e.g., IEP team meeting Note: Absences for codes C through E must be rescheduled

MA ONLY:Initials: Service Provider and Supervison (if Service Provider is not credentialed)

Marge Simpson Speech-Language PathologistJanna Doe 200000

Musical ES 12/1/2000

Marge Simpson✔

10/9/12

10:00

10:30I

Goal:Janna will answer detail questions. Description: Janna was able to correctly respondto 2/3/ questions from "The Drinking Gourd". She is making some progress in this area.

S School MS

10/9/12

1 : 0

1 : 0M/U

Goal:Janna will answer detail questions. Description:Janna was able to correctly respond to 2/3/ questionsfrom"A is for Arizona".This is a m/u from 9/7/12 S School MS

Signature REQUIRED

Remember to INITIAL

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Development)

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Special Education - Classroom Instruction: Janna will receive 27 hours and 30 minutes of Classroom Instruction for the remainder of this school

year and during the 2012-2013 school year.

Related Services - Occupational Therapy: Jannawill receive 30 minutes once a week of occupational therapy services during the 2012-2013 school

year. Service will consist of pull out and inside classroom sessions. Adaptive equipment will be tried as needed.

Related Services - Other Therapies (Music): Janna will receive 1 hour of Music from the general education music teacher, inside of the general

education setting, beginning March 19, 2012.

Related Services - Other Therapies (Motor Development): Janna will receive 1.0 hour of Motor Development for the remainder of this year and during

the 2012-2013 school year.

Related Services - Speech/Language Therapy as a Related Service: Speech-language therapy services for 2012-2013 academic year for 30 minutes 2x

weekly to be provided by a Speech-Language Pathologist. Services may be provided in the classroom or on a pull-out on an as needed basis. Services

may include observations, IEP meetings, parent/teacher consultation.

SPEC

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Num

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:4 Hrs.35 Min.

Freq

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07/06/2013

07/30/2013

(P)

Special Education

Classroom Teacher

(O)

Instructional

Assistant

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18

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12

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Documentation Examples for Speech‐Language Pathology Services

IEP Goal: Amy will use her augmentative communication skills to respond to questions and initiate conversation. (Goal is directly from the IEP.) ‐ 4/1/05 S/L therapy to stimulate greetings using the Dynavox. Using verbal reinforcement from the clinician, Amy returned 3 greetings. She is making adequate progress. ‐ 4/8/05 Language therapy to increase verbal interaction. Using question prompts, Amy responded to 8 out of 10 questions. She is improving in this area. IEP Goal: Increase speech intelligibility (Goal is directly from the IEP.) ‐ 12/11/11 Speech/ Language Treatment. Used visual cues given by clinician, to increase correct production. Allen produced /s/, /z/ in the initial position 40% of the time. His progress is slow but consistent. ‐ 2/9/12 Speech/Language Treatment. Used oral reading to improve, self monitoring. Allen self corrected /s/, /z/ 80% of the time. He is making adequate progress. IEP Goal: Increase number of fluencies by 50% in controlled settings. (Goal is directly from the IEP.) ‐ 2/1/12 S/L Therapy. Used modeling to elicit smooth easy beginnings during oral reading. John displayed an average of 4 dysfluencies during one minute readings. John is not making progress at this time. IEP Goal: John will become a more intelligible, spontaneous communicator (Goal is directly from the IEP.) ‐ 2/1/12: Therapy. Used tape recorder to help John identify what parts of speech are disrupted. John identified 60% of disruptions. John is making adequate progress. ‐ 2/8/12: Therapy. Utilized relaxation techniques to reduce overall body tension. John identified relationship between tension and speech production. He is making some progress.

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NURSING SERVICES

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Nursing Services

The following are services that are reimbursable by Medicaid and must be reflected in the student’s IEP.

Nursing Assessment Nursing Treatment

Nursing Credentials

Are you qualified to bill? A nurse shall be a Registered Nurse (RN) or Licensed Practical Nurse (LPN) licensed to practice the state of Maryland.

Requirements for Billing Nursing Services

■ Nursing Services must be documented as a related service in the IEP. ■ Nursing Services must be delivered in accordance with the IEP/IFSP. ■ Nursing Services must be related to an identified health problem. ■ Nursing Services must be ordered by a licensed prescriber, except for a nursing assessment, which results in a change of nursing care plan. ■ Nursing Services must be indicated in the nursing care plan which must be reviewed every 60 days or more frequently when a student’s medical condition changes.

Billable Nursing Services ■ Urinary Catheterizations ■ Gastrostomy Tube Feedings ■ Endotracheal Suctioning/Tracheotomy ■ Ostomy Care ■ Wound/Decubitus Care

Please Note: Medicaid does not reimburse for the following services: Peak flow monitoring, administration of medication, blood glucose monitoring, nebulizer treatments and oxygen administration. Medicaid does not reimburse for the student’s self administration of any medical service.

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1. Complete the child’s student number, name, date of birth, and school. Use only one form per child. Also, complete the therapy, provider and certification sections of the form. FORMS MAY BE PHOTOCOPIED.




4. Write in the ENCOUNTER CODE for each encounter per child. An encounter is defined as a face-to-face event relating to, or directly involving a service such as assessment, or treatment. For example, a nurse administered a gastric tube feeding to a student. The procedure code for this encounter would be:

99- Nursing Services.

99 Nursing-all services

5. In the COMMENTS section:

Attach a copy of the detailed Nursing notes (i.e., Treatment Flow Sheet)

including the start and end time of the billable service.

6. If the student did not receive service during the month, please indicate that on the form and return it to the Medicaid Billing Office (Sasscer Administration Building, Trailer # C05-451).


form must have an ORIGINAL SIGNATURE. All Nurses who have an entry on the Treatment Flow Sheet must sign the flow sheet and the Medicaid Monthly Service Record. (Billing form). Nicknames and abbreviations will not be accepted.

8. SUBMIT FORMS by the 5th of each MONTH to: Medicaid Billing Office, Sasscer

Administration Building, Trailer # C05-451. Place copies of billing forms and Treatment Flow Sheets in the student’s LAF file.

Instructions for Completing Monthly Service Record Billing Form for Nursing Services

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VERY IMPORTANT POINTS TO REMEMBER Services must be delivered in accordance with the IEP/IFSP and must be related

to an identified health problem. Please do not bill in excess of the Service Description indicated on the IEP.

The current service description (IEP prescription) on the IEP is printed on the Monthly Service Record form after the demographic information on preprinted Medicaid forms. Please contact the students’ case manager if the service description is incorrect.

List your Certification/License on the billing form. Nursing services are billed in 15 minutes increments/units. PGCPS can receive

reimbursement for up 8 units (2 hours) of service per day for nursing services provided to Medicaid eligible students.

Nursing services should be described as “Daily” in the related services section of the IEP.

Physician’s Orders are submitted once a year to the Medicaid billing office. Please resubmit the order to Medicaid if the order changes during the year.

Health Care Nursing Plan documents should be created and sent to the Medicaid Billing Office at the beginning of the school year. Then Health Care Nursing Plans are reviewed, signed, dated and submitted to the Medicaid Billing Office every 60 days.

Please remember that the Medicaid Health Related Services form is an official document. Your signature is attesting to the accuracy of the information that you are providing. Therefore, you should carefully review the form to make sure the student was not absent on the date of service listed on the form.

PLEASE DO NOT LIST DATES THE STUDENT WAS ABSENT ON THE BILLING FORM. PLEASE DO NOT BILL FOR IEP MEETINGS ON A HEALTH RELATED SERVICES FORM. PLEASE DO NOT BILL FOR CONSULTATIONS WITH OTHER PROVIDERS, OR OTHER

MEMBERS OF THE IEP TEAM ON THE HEALTH RELATED SERVICES FORM. PLEASE BE TIMELY WITH YOUR SUBMISSION OF FORMS. FORMS ARE DUE THE 5th OF

THE FOLLOWING MONTH. Please indicate the start and end time of every billable service. If the student no longer receives Nursing services, please check the “Service is

no longer prescribed on the IEP” box on the health related service form and return it to the Medicaid Billing Office.

If the student did not receive services in the billing month, please check the “No billable service provided this month.” box and return it to the Medicaid Billing Office.

When submitting billing for multiple months, supporting documentation will need to accompany each Monthly Service Record. For example, do not send one Treatment Flow Sheet for 3 months of billing.

Ditto marks are not permitted on the billing form or on the Treatment Flow Sheet. The Health Related Monthly Service Record form is located on our website at the following address: http://www1.pgcps.org/medicaid

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NURSING SERVICES SAMPLE FORM


19


Health Related ServicesM E D I C A I D B I L L I N G O F F I C E

Nursing



SCHOOL PROVIDER


1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16



99 Nursing-all services (per 15 min)

SESSION#


NO SERVICE?

UNITSOFFICE

USE


INTERNAL USE ONLY

DO Date________________

HCP Date_______________

0712Return all signed forms to: Medicaid Billing Office • Sasscer Administration Building C05-451 • For Assistance, call: 301-952-6349


student wasabsent

SignatureREQUIRED

September 2012

Hannah Montana 200001315.3 00000000001 12/1/2000

Della Reese ES RN

1 30 Min Daily 2/17/2012 2/16/2013

99 1 See Nursing Notes9/9/20129/10/2012 99 2 See Nursing Notes

Marge Simpson Marge Simpson 9/29/2012

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PRINCE GEORGE’S COUNTY PUBLIC SCHOOLS

OFFICE OF HEALTH SERVICES Individual Health Care Plan

Student: __________________________ Date of Birth: ________ Parent/Guardian: _______________________ Phone: Home _____________________ Work ___________ Emergency Contact: ____________________________ Phone: ______________________ Health Care Provider

Phone

Nursing Diagnosis

Nursing Goals

Individual Concerns Nursing Interventions

Individual Care Plan Initiated by

Date

21

Dietary Recommendations

Activity Limitations

Physician’s Signature Date

Health Services Coordinator (Nurse) Phone

Physician’s Name Phone

Physician’s Address

Prince George’s County Public SchoolsDEPARTMENT OF HEALTH SERVICES

PHYSICIAN’S ORDER FORSPECIALIZED SCHOOL HEALTH SERVICES

(Catheterization)

PS-158APGIN 7540-3462 (9/06) White Copy: School Canary Copy: Coordinator Pink Copy: Parent Goldenrod Copy: Physician

Ref

erra

lPG

CPS

Pare

nt In

form

atio

n

Describe treatment/procedure to be administered.

CLEAN INTERMITTENT CATHETERIZATION AT SCHOOL

Frequency:

Times:

Special Instructions:

Equipment/supplies necessary for procedure Catheter size: , wipes, lubricant, receptacle for urine. Special equipment:

Patient Name (Last, First, Middle Initial) Date of BIrth Race

Patient Address Sex ❏ M ❏ F Phone No.

Parent or Guardian Relationship to child Phone No.

School Presently Attending Phone No.

Diagnosis/Pertinent History (Use back as needed) Treatment Start Date

Treatment End Date

● I Understand that I must supply the school with the equipment/supplies listed above. Date● I hereby authorize the treatment/procedure described above to be administered by Prince George’s County Public School’s staff to my child as directed by my child’s physician.● I understand that the physician will be called if a question arises about my child’s procedure.

Signature of Parent/Guardian Date

RN Signature Date

Pare

nt/G

uard

ian

Phys

icia

n’s

Ord

ers

Name of Student School Year

General

Education

Sess

ions

:1

(Sel

ect

the

leng

th o

f ti

me,

in 1

5 m

inut

e in

crem

ents

, th

at t

he

serv

ice

is p

rovi

ded

duri

ng e

ach

sess

ion)

:0 Hr.30 Min.

Daily

(O)

Other Service

Provider- School Nurse

tim

e:Daily

2 H

rs.

30

Min

.N

Nursing Services

Outside

General

Education

Num

ber

of

Sess

ions

:51

Leng

th o

f Ti

me

(Sel

ect

the

leng

th o

f ti

me,

in 1

5 m

inut

e in

crem

ents

, th

at t

he

serv

ice

is p

rovi

ded

duri

ng e

ach

sess

ion)

:0 Hr.30 Min.

Freq

uenc

y:Daily

02/17/2012

02/16/20113 P) Nurse Tot

al s

ervi

ce

tim

e:Weekly

2 H

rs.

30

Min

.

Disc

ussi

on o

f se

rvic

e(s)

del

iver

y (f

or a

ll se

rvic

es):

Special Education - Classroom Instruction: After evaluation the team decided that services and supplementary aides will be provided in the

classroom on a consultative basis

Special Education - Physical Education: Starting on February 6th,2009 Hanna will receive Adapted Physical Education services by an Adapted

Physical Education teacher over a period of 36 weeks. The service will be delivered 2 times per week for a total of 60 minutes. We will be

following the Adapted Physical Education curriculum and framework through out the academic year. S. Wolff, Motor Specialist.

Related Services - Physical Therapy: Hanna will receive 10, 15 minute sessions of Physical Therapy to train the staff on proper use and

positioning of her assigned adapted equipment and to monitor and make adjustments to her equipment as needed.

Related Services - Nursing Services ): Hanna will be g-tube fed daily in the nurses office.

REL

AT

ED S

ERV

ICES

ESY

Ser

vice

Nat

ure

ESY

Loc

atio

nES

Y S

ervi

ce D

escr

ipti

onES

Y B

egin

D

ate

ESY

End

Dat

eES

Y P

rovi

der(

s):

(P)=

Prim

ary,

(O

)=O

ther

Sum

mar

yof

Ser

vice

Physical Therapy

Outside

General

Education

Num

ber

of

Sess

ions

:1

Leng

th o

f Ti

me

(Sel

ect

the

leng

th o

f ti

me,

in 1

5 m

inut

e in

crem

ents

, th

at t

he

serv

ice

is p

rovi

ded

duri

ng e

ach

sess

ion)

:0 Hr.10 Min.

Freq

uenc

y:Monthly

07/06/2013

07/30/2013 P)

Physical Therapist

(O)

Physical Therapy

Assistant

Tota

l ser

vice

ti

me:

Monthly

0 H

r.10

Min

.

Nursing

Services

Outside

General

Education

Num

ber

of

Sess

ions

:

Leng

th o

f Ti

me

(Sel

ect

the

leng

th o

f ti

me,

in 1

5 m

inut

e

Freq

uenc

y:Weekly

07/01/2013

07/31/2013 P) Nursing

To

tal s

ervi

ce

tim

e:eekly

Nam

e:H

anna

Mon

tana

Agen

cy:Prince George's

IEP

Team

Mee

ting

Dat

e: 02/17/20012

07/0

7/2012

23


PSYCHOLOGICAL SERVICES

24


Psychological Services

The services below are only billable under the following conditions for students receiving Medicaid:

The service is a face-to-face encounter with the student. The service is specified in the IEP, or approved by a multidisciplinary team

as documentation in or in the Discussions and Documentation area in the MD On-Line IEP.

The One Time Only Evaluation/Assessment is a face-to-face service to determine if the student needs services. (The result of the assessment is not relevant- student may or may not be in special education.)

Psychological Consultations- A psychological consultation may include classroom observations, parent/teacher conferences with the student being present.

Psychological Evaluations/Assessments/Screenings- This is the application of psychological tests, techniques, etc., to measure the intelligence, personality, aptitudes, interests or achievement of individuals or group of individuals

Individual Psychotherapy- Therapeutic Behavior Services Crisis Intervention Services Group Therapy- A trained clinician facilitates the group process and

structure to alter the individuals’ feelings, behaviors, and attitudes. This type of intervention includes both process oriented groups as well as psycho-educational groups.

Psychological Services Provider Credentials

Are you qualified to bill? A psychologist shall possess the following licensure:

DHMH Licensed Psychologist

Psychological Services Clarifications

Special Clarification/Notices

For one time only psychological assessments/evaluations, you may bill whether the student is recommended for special education services or not. When sending the Medicaid billing forms, please attach a parent

25


permission form, and provide the student’s Medicaid number on the billing form.

Please indicate the date the student was assessed in the beginning of the report.

Sign and date all psychological assessments. For all other services, please remember to attach to the Monthly

Service Record , and a related service log as it relates to the IEP. Make sure the billed service is specified as a direct service in the IEP

Except for the one time only assessment/evaluation.

26



1. Complete the child’s student number, name, date of birth, and school. Use only one form per child. Also, complete the therapy, provider and certification sections of the form. USE ONLY ONE FORM PER PROVIDER (therapist, teacher, etc.). FORMS MAY BE PHOTOCOPIED.




4. Write in the ENCOUNTER CODE for each encounter per child. An encounter is defined as a face-to-face event relating to, or directly involving a service such as screening, assessment, or treatment. The procedure code for this encounter would be: 51 Individual Therapy 20-30 min

5. In the COMMENTS section: Please write, “see attached documentation” or Write a brief description of the nature of the encounter provided.



7. If the student did not receive service during the month, please indicate that on

the form and return it to the Medicaid Billing Office (Sasscer Administration Building, Trailer # C05-451)

8. SUBMIT FORMS by the 5th of each MONTH to: Medicaid Billing Office, Sasscer

Administration Building, Trailer # C05-451

Instructions for Completing Monthly Service Record Billing Form for Psychological Services

51 Individual Psychotherapy 20-30 min 52 Individual Psychotherapy 45-50 min 53 Individual Psychotherapy 75-80 min 54 Family Therapy 55 Group Psychotherapy

27


VERY IMPORTANT POINTS TO REMEMBER

Services must be delivered in accordance with the IEP/IFSP and must be related to an identified health problem. Please do not bill in excess of the prescription indicated on the IEP.

Please indicate your MD State License Please indicate the start and end time of your session(s) in your notes/log

for each service date. Provide a date next to signature on all psychological assessments. Staple supporting documents to the Health Related Services Form. When using a MD-Online Service Log, provide one for each billing month. Please remember that the Medicaid Health Related Services form is an official

document. Your signature is attesting to the accuracy of the information that you are providing. Therefore, you should carefully review the form to make sure the student was not absent on the date of service listed on the form.

PLEASE DO NOT LIST DATES THE STUDENT WAS ABSENT ON THE BILLING FORM PLEASE DO NOT BILL FOR IEP MEETINGS ON A HEALTH RELATED ENCOUNTER FORM. PLEASE DO NOT BILL FOR CONSULTATIONS WITH OTHER PROVIDERS, OR OTHER

MEMBERS OF THE IEP TEAM ON THE HEALTH RELATED ENCOUNTER FORM. PLEASE BE TIMELY WITH YOUR SUBMISSION OF FORMS. FORMS ARE DUE THE 5th OF


related service log. If there are the same dates listed twice and one is not denoted as a make-up session, we will not be able to receive reimbursement for both dates of service. You must also put the date the session was originally scheduled in the description of the session.

If the student no longer receives Psychological services, please check the “Service is no longer prescribed on the IEP” box on the health related services form and return it to the Medicaid Billing Office.

If the student did not receive services in the billing month, please check the “No billable service provided this month” box and return it to the Medicaid Billing Office.


Ditto marks are not permitted on the billing form

The Health Related Monthly Service Record form is located on our

website at the following address: http://www1.pgcps.org/medicaid/

28


PSYCHOLOGICAL SERVICES SAMPLE FORM


29


MEDICAID BILLABLE SERVICES FOR PSYCHOLOGICAL SERVICES Required Attachments SY 12-13

Billable Services What Should Go On the Billing Form? Required Attachments

ONE TIME ONLY - ASSESSMENT/EVALUATION

The date of service, the encounter code, and written in the comment section, “See attached.” Sign and date the billing form.

Attach the Medicaid parent permission form, the recommendation from the treatment team for the assessment, and a copy of the assessment. Sign and date the assessment.

PSYCHOLOGICAL CONSULTATION

The date of service, the encounter code, and in the comments section write, “The student is present for this consultation where the purpose is to …assess the effectiveness of his behavioral plan...” Sign and date the billing form.

Attach the portion of the IEP where the service is listed, recommended, or requested. Or attach the request for this service by the treatment team. Then attach the consultation report. Sign and date the consultation report.

EVALUATIONS/ASSESSMENTS AND SCREENINGS

The date of service, the encounter code, and in the comment section write, “Evaluation was requested by the treatment team to determine if the student may need more mental health services than are being provided.” Sign and date the billing form.

Attach the portion of the IEP where the service is listed, recommended, or requested. Or attach the request for this service by the treatment team. Also attach a copy of the assessment/screening. Sign and date the evaluation/assessment.

INDIVIDUAL PSYCHOTHERAPY

The date of service, the encounter code, and in the comment section, “Individual therapy conducted regarding aggressive tendencies and withdrawn characteristics.” Sign and date the billing form.

Attach a copy of the related service as prescribed in the IEP. Also attach a copy of the Related Services Log. Remember to initial each entry.

THERAPEUTIC BEHAVIOR SERVICES

The dates of service, the encounter code, and in the comment section write, “TBS services delivered in the initial phase where we are developing alternative behaviors to cursing and hitting.” Sign and date the billing form.


CRISIS INTERVENTION SERVICES

The dates of service, the encounter code, and in the comment section write, “Crisis intervention service conducted due to outburst and underlying depression.” Sign and date the billing form.


GROUP THERAPY The date of service, the encounter code), and in the comment section write, “Group therapy session regarding children of abuse.” Sign and date the billing form.


30

Monthly Service Record SY 201Ɩ-201ƗSERVICE MONTH





SCHOOL PROVIDER

� Services must be provided in accordance to the IEP (Frequency of service) and must be listed on the IEP as a direct service.

� Please remember to attach supporting documentation.� Please remember to SIGN the form.� NO DITTO MARKS

123456789

10111213141516



50 Psychiatric Diagnostic Interview51 Ind Psychotherapy 20-30 min 52 Ind Psychotherapy 45-50 min53 Ind Psychotherapy 75-80 min54 Family Psychotherapy 55 Group Psychotherapy

SESSION#


NO SERVICE?

UNITSOFFICE

USE



Monica Friends 200000

315.3 0000000000006 12/1/98

Chandler Heights MS Jennifer Anniston

9/9/12 51 N/A See Attached Treatment Notes/ Log

Jennifer Anniston Jennifer Anniston 9/29/12

Please do NOT listdates that the

student was absent

SignatureREQUIRED

6 30 min Monthly 3/11/2012 3/10/2013

31













Service Location

Initials

Start time:

End time:

Start time:

End time:

Start time:

End time:



Signature REQUIRED

Jennifer Anniston PsychologistMonica Friends 200000

Chandler Heights MS 12/1/2000

✔

Jennifer Anniston

9/9/2012

10:00

10:30I P

Goal: Monica will be able to control her anger when facedwith difficult situationsDescription: Student participated in individual counseling tolearn anger management. She is also learning social skills,understanding and communication of emotions

School JA

32

SPEC

IAL

EDU

CATI

ON

Serv

ice

Nat

ure

Loca

tion

Serv

ice

Des

crip

tion

Begi

n D

ate

End

Dat

ePr

ovid

er(s

):(P

)=Pr

imar

y, (

O)=

Oth

erSu

mm

ary

of S

ervi

ce

Classroom Instruction

(Identifying the number of

sessions for Classroom

Instruction is optional)

Outside

General

Education

Num

ber

of

Sess

ions

:5

Leng

th o

f Ti

me

(Sel

ect

the

leng

th o

f ti

me,

in 1

5 m

inut

e in

crem

ents

, th

at t

he

serv

ice

is p

rovi

ded

duri

ng e

ach

sess

ion)

:4 Hrs.40 Min.

Freq

uenc

y:Weekly

03/11/201

03/09/201

(P)

Special Education

Classroom Teacher

(O)

Special Education

Classroom Teacher

Tota

l ser

vice

ti

me:

Weekly

23

Hrs

.20

Min

.

Speech/Language Therapy

Outside

General

Education

Num

ber

of

Sess

ions

:3

Leng

th o

f Ti

me

(Sel

ect

the

leng

th o

f ti

me,

in 1

5 m

inut

e in

crem

ents

, th

at t

he

serv

ice

is p

rovi

ded

duri

ng e

ach

sess

ion)

:0 Hr.15 Min.

Freq

uenc

y:Weekly

03/11/201

03/09/201

(P)

Speech/Language

Pathologist

Tota

l ser

vice

ti

me:

Yearly

7 H

rs.

30

Min

.

REL

AT

ED S

ERV

ICES

Serv

ice

Nat

ure

Loca

tion

Serv

ice

Des

crip

tion

Begi

n D

ate

End

Dat

ePr

ovid

er(s

):(P

)=Pr

imar

y, (

O)=

Oth

erSu

mm

ary

of S

ervi

ce


Outside

General

Education

Num

ber

of

Sess

ions

:6

Leng

th o

f Ti

me

(Sel

ect

the

leng

th o

f ti

me,

in 1

5 m

inut

e in

crem

ents

, th

at t

he

serv

ice

is p

rovi

ded

duri

ng e

ach

sess

ion)

:0 Hr.30 Min.

Freq

uenc

y:Monthly

03/11/201

03/09/201

(P)

Psychologist

otal

ser

vice

ti

me:

Monthly

3 H

rs.

0 M

in.

Disc

ussi

on o

f se

rvic

e(s)

del

iver

y (f

or a

ll se

rvic

es):

Special Education - Classroom Instruction: Services will be provided by a special educator for 22 hours per week in a separate class in reading,

Nam

e:

Agen

cy:Prince George's

IEP

Team

Mee

ting

Dat

e: 03/10/20

07/0

1/2012

33


OCCUPATIONAL & PHYSICAL

THERAPY SERVICES

34


Occupational & Physical Therapy Services

The services below are only billable under the following conditions for students receiving Medicaid:

The service is a face-to-face encounter with the student. The service is specified in the IEP.

Billable Occupational & Physical Therapy Services

Occupational Therapy Evaluations and Re-evaluations Occupational Therapy Treatment Physical Therapy Evaluation and Re-evaluations Physical Therapy Treatment

Occupational & Physical Therapy Provider Credentials

Are you qualified to bill?

An occupational therapist shall be licensed to practice in the jurisdiction in which services are provided;

A physical therapist shall be licensed to practice in the jurisdiction in which

services are provided.

A physical therapist assistant will not be permitted to bill for PT services at this time due to the lengthy documentation of supervision that is required by Maryland and the Federal government.

35



1. Complete the child’s student number, name, date of birth, and school. Use only

one form per child. Also, complete the therapy, provider and certification sections of the form. USE ONLY ONE FORM PER PROVIDER (therapist, teacher, etc.). FORMS MAY BE PHOTOCOPIED.




Write in the ENCOUNTER CODE for each encounter per child. An encounter is defined as a face-to-face event relating to, or directly involving a service such as screening, assessment, or treatment. The procedure code for a PT evaluation would be 10.

10 Physical Therapy Evaluation 11 Physical Therapy Re-Evaluation 12 Physical Therapy Individual 15 min 20 Occupational Therapy Evaluation 21 Occupational Therapy Re-Evaluation 22 Occupational Therapy Individual 15 min 23 Occupational Therapy Group

*Student must be present

4. In the COMMENTS section: Write “see attached log” once.



6. Attach a copy of the MD Online Related Service Log . 7. SUBMIT FORMS by the 5th of each MONTH to: Medicaid Billing Office, Sasscer

Administration Building, Trailer # C05-451. 8. File a copy of the Medicaid Billing form and the attachments in the student’s

LAF folder at the end of the year.

Instructions for Completing Monthly Service Record Billing Form for Occupational & Physical Therapy Services

36


VERY IMPORTANT POINTS TO REMEMBER Services must be delivered in accordance with the IEP/IFSP and must be related

to an identified health problem. Please do not bill in excess of the service description indicated on the IEP.

MSDE requires that the frequency of service on the IEP must be detailed as daily, weekly or monthly. Yearly and quarterly frequencies are no longer billable for Medicaid billing purposes. If “yearly” and “quarterly” are the best description for the frequency of the service, make sure to enter a professional explanation for the specialized frequency of service so that Medicaid can bill for IEP Service Coordination. Contact the Medicaid office if you have questions about this.

List your current MD License. Sign at the top of the log (marked “Provider Signature”) and initial each entry on

the MD Online Related Services Logs. Please remember that the Medicaid Monthly Service Record form is an official

document. Your signature is attesting to the accuracy of the information that you provided. Therefore, you should carefully review the form to make sure the student was not absent on the date of service listed on the form.

Submit one MD Online Service Log for each billing month. Staple MD Online Service Logs to the Health Related Service Form. Attach copies of evaluations when billing for Evaluations and Re-Evaluations.

Place the actual dates of the evaluation in the beginning of the document. PLEASE DO NOT LIST DATES THE STUDENT WAS ABSENT ON THE BILLING FORM. PLEASE DO NOT BILL FOR IEP MEETINGS ON MONTHLY SERVICE RECORD FORMS. PLEASE DO NOT BILL FOR CONSULTATIONS WITH OTHER PROVIDERS, OR OTHER

MEMBERS OF THE IEP TEAM ON THE MONTHLY SERVICE RECORD FORM. PLEASE BE TIMELY WITH YOUR SUBMISSION OF FORMS. FORMS ARE DUE THE 5th OF


service log. You must also identify the date of the missed session in the Description of Service on the Related Service log.

Related service logs should state the goal; describe the service rendered and the student’s response to the service or treatment (progress).

If the student no longer receives Speech/Language services, please check the “Service is no longer prescribed on the IEP” box on the Monthly Service Record form and return it to the Medicaid Billing Office.

If the student did not receive services in the billing month, please check the “No billable services provided this month” box and return it to the Medicaid Billing Office.


Ditto marks are not permitted on the billing form. The Health Related Monthly Service Record form is located on our website at the following address: http://www1.pgcps.org/medicaid

37


OCCUPATIONAL & PHYSICAL THERAPY SERVICES

SAMPLE DOCUMENTATION

38



Occupational Therapy



SCHOOL PROVIDER


1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16



20 Occupational Therapy Evaluation21 Occupational Therapy Re-Evaluation22 Occupational Therapy Individual Service (per 15 min)23 Occupational Therapy Group Service

SESSION#

No service provided this monthService is no longer prescribed on the IEPProvider is not licensed

NO SERVICE?

UNITSOFFICE

USE

#SESSIONS LENGTH OF TIME FREQUENCY BEGIN DATE END DATE07



student wasabsent



Winny T Pooh

October 2012

200002299.0 00000000000 12/1/2002

Sunshine Hills ES Mick E. Mouse

1 30 Min Weekly 11/11/2012 11/10/2013

22 310/8/201210/9/2012 22 2 Make-Up Session

Mick E. Mouse Mick E. Mouse 10/9/2012

39













Service Location

Initials

Start time:

End time:

Start time:

End time:

Start time:

End time:



Signature REQUIRED

Remember to Initial

Mick E. Mouse Occupational TherapistWinny T. Pooh 200002

Sunshine Hills ES 12/1/2002

✔

✔

Mick E. Mouse

10/8/2012

10:00

10:30I P

Goal: Student will be able to mark items with a pencil.Description: OT worked with student with different adaptedwriting materials with a slanted surface. Student had animproved grasp and was able to mark items on command.Making progress

School MEM

10/9/2012

10:30

11:00M/U P

Goal: Student will be able to mark items with a pencil.Description: This is a make-up session from 9/9/2012.Student was able to display a marked improvement with hergrasp of the pencil.

School MEM

40

SPEC

IAL

EDU

CATI

ON

Serv

ice

Nat

ure

Loca

tion

Serv

ice

Des

crip

tion

Begi

n D

ate

End

Dat

ePr

ovid

er(s

):(P

)=Pr

imar

y, (

O)=

Oth

erSu

mm

ary

of S

ervi

ce

Num

ber

of

Sess

ions

:Le

ngth

of

Tim

e(S

elec

t th

e le

ngth

of

tim

e,

in 1

5 m

inut

e in

crem

ents

, th

at t

he s

ervi

ce is

prov

ided

dur

ing

each

se

ssio

n):

Freq

uenc

y:To

tal s

ervi

ce

tim

e: Hrs

. M

in.

REL

AT

ED S

ERV

ICES

Serv

ice

Nat

ure

Loca

tion

Serv

ice

Des

crip

tion

Begi

n D

ate

End

Dat

ePr

ovid

er(s

):(P

)=Pr

imar

y, (

O)=

Oth

erSu

mm

ary

of S

ervi

ce

Num

ber

of

Sess

ions

:Le

ngth

of

Tim

e(S

elec

t th

e le

ngth

of

tim

e,

in 1

5 m

inut

e in

crem

ents

, th

at t

he s

ervi

ce is

prov

ided

dur

ing

each

se

ssio

n):

Freq

uenc

y:To

tal s

ervi

ce

tim

e: Hr. M

in.

Disc

ussi

on o

f se

rvic

e(s)

del

iver

y (f

or a

ll se

rvic

es):

Nam

e: ~

WAg

ency

:IE

P Te

am M

eeti

ng D

ate:

31

12

Win

nyT.

Poo

h

3/11/2012

3/11/2012

3/10/2013

3/10/2013



Physical Therapy



SCHOOL PROVIDER


1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16



10 Physical Therapy Evaluation11 Physical Therapy Re-Evaluation12 Physical Therapy Service (per 15 min)

SESSION#


NO SERVICE?

UNITSOFFICE

USE ONLY




student wasabsent



October 2012

Kenneth Babyface Edmonds 2000008299.0 00000000004 12/25/2001

West Beverly ES Karrie Underwood

6 15 Min Monthly 2/24/2012 2/24/2013

10/9/201210/12/201210/12/2012

12 312 412 2 Make-Up Session

Karrie Underwood Karrie Underwood 10/29/2012

42













Service Location

Initials

Start time:

End time:

Start time:

End time:

Start time:

End time:



Signature REQUIRED

Remember to Initial

Karrie Underwood Physical TherapistKenneth Babyface Edmonds 000008

West Beverly ES 12/25/2002

✔

✔

Karrie Underwood

10/9/2012

12:15

12:30I P School KU

10/12/2012

12:45

01:00

Goal: Kenneth will be able to sit and perform simple tasks.Description: Kenneth practiced sitting astride a bolster whileperforming reaching/pointing/grasping activities. He functionedwith his L hand 90% of the time, with his L hand/fingers extended.Tolerated well. Continue PT plan. Karrie Underwood PT #00000

I P School KUGoal: Kenneth will be able to sit and perform simple tasks.Description: Kenneth practiced sitting astride a bolster whileperforming reaching/pointing/grasping activities. He functionedwith his L hand 90% of the time, with his L hand/fingers extended.Tolerated well. Continue PT plan. Karrie Underwood PT #00000

10/12/2012

01:00

01:15M/U P School KU

Goal: Kenneth will be able to sit and perform simple tasks.Description: Kenneth practiced sitting astride a bolster whileperforming reaching/pointing/grasping activities. He functionedwith his L hand 90% of the time, with his L hand/fingers extended.Tolerated well. Continue PT plan. Karrie Underwood PT #00000

43

SPEC

IAL

EDU

CATI

ON

Serv

ice

Nat

ure

Loca

tion

Serv

ice

Des

crip

tion

Begi

n D

ate

End

Dat

ePr

ovid

er(s

):(P

)=Pr

imar

y, (

O)=

Oth

erSu

mm

ary

of S

ervi

ce

Num

ber

of

Sess

ions

:Le

ngth

of

Tim

e(S

elec

t th

e le

ngth

of

tim

e,

in 1

5 m

inut

e in

crem

ents

, th

at t

he s

ervi

ce is

prov

ided

dur

ing

each

se

ssio

n):

Freq

uenc

y:2

3To

tal s

ervi

ce

tim

e: Hrs

. M

in.

Num

ber

of

Sess

ions

:Le

ngth

of

Tim

e(S

elec

t th

e le

ngth

of

tim

e,

in 1

5 m

inut

e in

crem

ents

, th

at t

he s

ervi

ce is

prov

ided

dur

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44


AUDIT REQUIREMENTS

45


Audit Requirements

The Maryland Department of Health and Mental Hygiene (DHMH) along with Maryland State department of Education (MSDE), Division of Special Education/Early Intervention Service administer the statewide School Based Medicaid Reimbursement Program. MSDE has assembled an Interagency Monitoring Team to conduct audits statewide in order to determine if local educational agencies are in

compliance with COMAR 10.09.36, COMAR 10.09.50 COMAR 10.09.52 and COMAR 10.09.40 regulations. PGCPS system can be subject to audits from federal, state and local authorities at any time. Based on findings of audits conducted by the Interagency Monitoring Team, DHMH may request reimbursement for Medicaid school-based services in accordance with the terms of applicable federal regulations and state Medicaid rules. In order to meet the requirements for state and federal audits: Billing Records must contain:

Name of Medicaid Recipient Name of Provider Qualifications of Provider Date of Service Type and Description of Service

The audit file must contain:

A copy of the IEP or IFSP Notes of an IEP meeting if a child is not found to be eligible under IDEA. Notes of

the meeting with the multidisciplinary team and family if an infant or toddler is found not eligible under Part C of IDEA

Monthly Medicaid Encounter Form Record/copy of Provider Qualifications Notes of an emergency meeting when billing for an emergency IEP review and

ongoing care coordination during the same monthly period of time Transportation logs Documentation to support the services indicated on all billing forms

At a minimum, the record must contain a signed IEP or IFSP, name of recipient, recipient’s medical assistance number, type of service, date of service, name and signature of the provider (with credentials and co-signature as appropriate), description of the face-to-face health related service provided. Documentation must be maintained which shows that services provided to or on behalf of the student. This MSDE requires that, as a minimum, the supporting information/documentation should be and maintained for six (6) years.

46



THERAPY



SCHOOL PROVIDER

Services must be provided in accordance to the IEP (Frequency of service) and must be listed on the IEP as a direct service.

Please remember to attach supporting documentation. Please remember to SIGN the form. NO DITTO MARKS

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

DATE OF SERVICE ENCOUNTER CODE COMMENTS


10 Physical Therapy Evaulation11 Physical Therapy Re-Evaluation12 Physical Therapy Service20 Occupational Therapy Evaluation21 Occupational Therapy Re-Evaluation22 Occupational Therapy Service Ind

SESSION#


NO SERVICE?

UNITSOFFICE

USE ONLY


23 Occupational Therapy Service Group31 Audiological Evaluation42 Speech/Language Evaluation/Ind43 Speech/Language Therapy/Ind.46 Speech/Lang. Therapy/Group50 Psychiatric Diag Interview

51 Ind Psychotherapy52 Ind Psychotherapy53 Ind Psychotherapy54 Family Psychotherapy55 Group Psychotherapy99 Nursing Services


47

2012-2013 SCHOOL YEAR CALENDAR

DO NOT SUBMIT BILLING FOR THE

HIGHLIGHTED DATES !!!

AUGUST ‘12 S M T W Th F S

20 21 22 23 24

27 28 29 30 31

SEPTEMBER ‘12 S M T W Th F S

3 4 5 6 7

10 11 12 13 14

17 18 19 20 21

24 25 26 27 28

3 Labor Day

19 MSTA Convention

OCTOBER ‘12 S M T W Th F S

1 2 3 4 5

8 9 10 11 12

15 16 17 18 19

22 23 24 25 26

29 30 31

NOVEMBER ‘12 S M T W Th F S

1 2

5 6 7 8 9

12 13 14 15 16

19 20 21 22 23

26 27 28 29 30

21-23 Thanksgiving Break

24-31 Winter Break

DECEMBER ‘12 S M T W Th F S

3 4 5 6 7

10 11 12 13 14

17 18 19 20 21

24 25 26 27 28

31

JANUARY ‘13 S M T W Th F S

1 2 3 4

7 8 9 10 11

14 15 16 17 18

21 22 23 24 25

28 29 30 31

1 New Year’s Day 21 M.L. King Jr. Day

18 Presidents’ Day

FEBRUARY ‘13 S M T W Th F S

1

4 5 6 7 8

11 12 13 14 15

18 19 20 21 22

25 26 27 28

MARCH ‘13 S M T W Th F S

1

4 5 6 7 8

11 12 13 14 15

18 19 20 21 22

25 26 27 28 29

29 Spring Break

1-5 Spring Break

APRIL ‘13 S M T W Th F S

1 2 3 4 5

8 9 10 11 12

15 16 17 18 19

22 23 24 25 26

29 30

MAY ‘13 S M T W Th F S

1 2 3 6 7 8 9 10 13 14 15 16 17 20 21 22 23 24 27 28 29 30 31

28 Memorial Day

7 Last Day of School

JUNE ‘13 S M T W Th F S

3 4 5 6 7

10 11 12 13 14

17 18 18 20 21

24 25 26 27 28

PLEASE BE MINDFUL OF SNOW DAYS AND WEEKENDS!

48

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