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Personal Care Assistant Services. Local Education Agency Medicaid Provider Manual. Purpose. Common Acronyms Provider Participation Requirements Covered Services Documentation Requirements. Commonly Used Acronyms. VDOE - Virginia Department of Education

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Personal care assistant services l.jpg

Personal Care Assistant Services

Local Education Agency Medicaid Provider Manual


Purpose l.jpg
Purpose

  • Common Acronyms

  • Provider Participation Requirements

  • Covered Services

  • Documentation Requirements


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Commonly Used Acronyms

  • VDOE - Virginia Department of Education

  • DMAS - Department of Medical Assistance Services

  • CMS - Centers for Medicare & Medicaid Services


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Commonly Used Acronyms cont.

  • EPSDT - Early & Periodic Screening, Diagnosis, and Treatment

  • CHIP – Federal Child Health Insurance Program

  • FAMIS – Family Access to Medical Insurance Security Program – Virginia’s CHIP program

  • FAMIS Plus – Children’s Medicaid in Virginia


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Commonly Used Acronyms cont.

  • IEP - Individualized Educational Program

  • GAF - Global Assessment of Functioning

  • LEA - Local Education Agency

  • POC - Plan of Treatment/Plan of Care

  • PCP - Primary Care Physician

  • PCA – Personal Care Assistant

  • QMR - Quality Management Review



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Categories of Services

  • Nursing

  • Occupational Therapy

  • Physical Therapy

  • Speech Language Pathology

  • Psychology (Behavioral)


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Nursing PCAs

  • Must meet minimum qualifications for unlicensed assistive personnel as required by the Department of Education, Virginia School Health Guidelines, VDH and VDOE, 1999 (page 63)

    www.doe.virginia.gov/support/health_medical/virginia_school_health_guidelines/developing_program_infrastructure.pdf


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Nursing PCAs cont.

  • Must receive training for assisting with meeting the specific health needs of the student as outlined in the following:

    • Virginia School Health Guidelines Manual,

    • Specialized Health Care Procedures Manual,

    • Manual for the Training of Public School Employees in the administration of Medication, and


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Nursing PCAs cont.

  • Manual for training of Public School Employees in the Administration of Insulin and Glucagon.

  • VDOE training publications may be found on the VDOE website at

    www.doe.virginia.gov/support/health_medical/index.shtml


  • Nursing pcas cont11 l.jpg
    Nursing PCAs cont.

    • Must be identified in the student’s IEP.

    • Must be included in the Plan of Care (POC) prepared by the licensed registered nurse (RN).

    • Personal care assistants for nursing services must be supervised by a RN.

    • ADL and IADL services do not require physician order.


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    PCAs for Practitioners of the Healing Arts

    • Specific services must be ordered by a Department of Medical Assistance Services (DMAS) qualified practitioner of the healing arts acting within the scope of their licensure


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    PCAs for Practitioners of the Healing Arts cont.

    • Personal care assistants for the healing arts must be trainined and supervised by a DMAS qualified practitioner of the healing arts (OT, PT, SLP, Psychiatrist, Psychologist).


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    PCAs for Practitioners of the Healing Arts cont.

    • Board of Physical Therapy (18 VAC 112-20-10 et seq.)

      • Licensed PT can supervise support personnel who are designated routine tasks related to physical therapy; however…supervision must be direct.


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    PCAs for Practitioners of the Healing Arts cont.

    • OT - Board of Medicine (18VAC85-80-110-111 )

      • Unlicensed occupational therapy personnel may be supervised by an OT or a COTA.

      • An occupational therapist may provide clinical supervision for up to six occupational therapy personnel…


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    PCAs for Practitioners of the Healing Arts cont.

    • Board of Audiology & Speech Language Pathology

      • 18VAC30-20-240 Supervision of unlicensed assistants

        • A SLP…shall ensure that ‘PCA’ perform only those activities …which are appropriate with their level of training.

        • The identity of the ‘PCA’ shall be disclosed… prior to treatment and…made a part of…the file.


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    PCAs for Practitioners of the Healing Arts cont.

    • Board of Psychology (18VAC125-20-10 )

      • …monitors the performance of the person supervised and provides regular, documented individual consultation, guidance and instruction with respect to the skills and competencies of the person supervised.


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    Provider Requirements cont.

    • The DOE training manuals may be found on the DOE website at under the ‘Board of Education Guidance Documents’

      www.doe.virginia.gov/boe/guidance/index.shtml


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    Covered ServicesChapter IV

    Services to assist the child with disabilities in self-sufficiency, communications, and mobility skills.


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    Nursing PCAs

    • Must be identified in the student’s IEP.

    • Must be included in the Plan of Care (POC) prepared by the licensed registered nurse (RN).

    • Personal care assistants for nursing services must be supervised by a RN.

    • ADL and IADL services do not require physician order.


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    Covered Services

    • Services provided by the assistant are related to the child’s physical and behavioral health requirements, including:

      • assistance with eating, dressing, hygiene, activities of daily living, bladder and bowel needs;

      • use of adaptive equipment;

      • ambulation and exercise;


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    Covered Services cont.

    • behavioral issues; and

    • other remedial services to promote reduction of a child’s disabilities.

    • monitoring of a health related service

      • i.e.: bus driver aide or monitoring the need for suctioning


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    Authorization for Services

    • Services must be authorized by the current Individualized Education Program (IEP)

      • The student shall have a current order from a physician, physician assistant or nurse practitioner for specialized nursing procedures (i.e. tube feedings, catheterizations, and seizure monitoring)

      • The service cannot be provided by a parent or a step-parent



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    Documentation Requirements

    • Documentation must be in accordance with requirements of individual licensing board within DHP, VDOE and DMAS.

    • Quality management reviews follow requirements noted in Chapter VI of the DMAS LEA Provider manual.


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    Documentation Requirements

    • DMAS forms are recommended and available online http://dmasva.dmas.virginia.gov under Search Forms / Local Education Agency.

      • May be completed electronically and printed out to place in record.


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    Documentation Requirements

    • Records must be made available to authorized state and federal personnel and include:

      • Current IEP pages which document actual services;

      • Need for assessment must be documented when it does not result in determination that services are indicated in the IEP (such as on Present Level of Performance or Considerations Page)


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    PCA Plan of Care DMAS 46

    • Developed by a licensed practitioner of the healing arts within the scope of their license.

    • A separate plan of care should be developed per discipline based on the services needed.


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    PCA Plan of Care cont.

    • If percentages are used for measuring goals, percentages should change based on student’s progression, not a set time frame.

    • IEP may serve as POC only if it includes all elements of the POC.


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    PCA Plan of Care cont.

    • The plan of care developed by the qualified provider should be consistent with the health conditions and functional limitations documented on the individual’s IEP.


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    PCA Plan of Care cont.

    • Medical condition and diagnosis being address

      • Specific to needs identified in assessment

    • Goals and objectives

    • Treatment intervention and which goal addressed


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    PCA Plan of Care cont.

    • Type, amount and frequency of service

    • Anticipated duration of service

    • Signed and dated by individual performing service

    • Reviewed at least annually


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    PCA Service Log – DMAS 37

    • Progress notes/Student Log - DMAS

      • DMAS qualified provider must initial, sign and date each form. Entries must be initialed and dated by responsible provider of service each time service is provided.

      • Providers requiring supervision require documentation of supervision per requirements of licensing board, VDOE and DMAS.


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    PCA Service Log cont.

    The personal care assistant shall document:

    • On a daily basis for non-nursing services

    • For nursing assistants the documentation is per occurrence

    • Date and amount of time


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    PCA Service Log cont.

    • Procedure

    • Comments

      • N = Normal

      • V = variance from normal or standard. Include written explanation in ‘Comment’ section

    • Initials of the assistant

    • Documentation of supervisory visit signed by applicable supervisor


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    Supervision

    • Supervision provided by the appropriate qualified provider.

    • Supervisory visits are required as often as needed to ensure both quality and appropriateness of services.

    • Review the child’s progress and make any adjustment to goals or treatment modalities.


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    Supervision cont.

    • Supervising licensed provider must document supervisory visits with student and PCA at a minimum of every 30 to 90 calendar days, or as often as needed.

    • Purpose is to ensure quality and appropriateness of services being provided.


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    Supervision cont.

    • Condition of the child as well as qualified provider’s license requirements determines whether the supervision is direct versus indirect and the frequency of supervision visits.


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    Supervision cont.

    • An on-site visit must be conducted at least every 90 calendar days.

    • Supervisor shall identify any gaps in aide’s ability to function competently and shall provide training as indicated.


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    Billing

    • A unit of services equals 15 minutes for no more than 8.5 hours a day

    • The number of units billed is not to exceed the number of units in a day that the student is in the care of the school


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    Billing cont.

    • While more than one assistant may attend the student during a school day, the unit for a particular period of the day shall not be billed for the services of more than one assistant.


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    Billing cont.

    • If the total number of units billed ends up with a fraction of a unit, round to the nearest unit

      • 50 minutes of care / 15 = 3.33 = 3 units

      • 100 minutes of care / 15 = 6.66 = 7 units

    • Regular school year is 180 days

      • May vary among school divisions

    • Services during the summer school sessions are billable as well.


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    Resources

    • Amy Edwards

      Medicaid in Schools Specialist, DOE

      804-692-0150

      [email protected]

    • Ashley Barton, LCSW

      Maternal & Child Health Specialist, DMAS

      804-371-7824

      [email protected]


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    School Health Medical Evaluations

    Local Education Agency Medicaid Provider Manual


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    Child Focused IEP

    • Medical Evaluations should determine:

      • If the child’s IEP is appropriate to meet the health needs of the child; or

      • If there are medical services required for the student to receive a free and appropriate education


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    Providers of Medical Evaluations

    • Medical evaluation services are covered as physicians’ services

    • Persons performing these services must be licensed practitioners (physicians, physician assistants, and nurse practitioners) acting within the scope of practice


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    Providers Requirements, cont.

    • Schools must enroll as a health services provider

      • Have a school provider agreement completed and on file with DMAS

      • Provide DOE Medicaid Specialist (Amy Edwards) with copy of practitioner’s license requesting to provide medical evaluation services

      • Practitioner may be either employed or contracted with the school


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    Covered Services

    • Identifying the nature or extent of a recipient’s medical or other health related condition;

    • May be face-to-face, chart review or telephonic consultation;

    • Review of a recipient’s initial IEP as necessary to determine the medical necessity for the medical/mental health related services designated by the IEP team;


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    Covered Services, cont.

    • Annual review of a recipient’s IEP as necessary to determine continuing medical necessity for the medical/mental health related services designated by the IEP team;

    • Review of additional documents related to at recipient’s medical/mental health status either for consultative purposes or to determine medical necessity for services;


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    Covered Services, cont.

    • Participating in meetings with IEP providers or families to provide medical input concerning a recipient’s disability and medical/mental health-related services needed;


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    Covered Services, cont.

    • Coordinating medical/mental health related services rendered outside the school setting. For example, talking to a recipient’s primary care physician about medication needs; and

    • Completion of referral reports and documentation relative to the IEP.


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    Medical Evaluation Billing

    • Code: T1024

    • Maximum Interim Rate: $96.51

    • Unit: Per encounter


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    Documentation Requirements

    • Positive and negative examination findings;

    • Diagnostic tests ordered and the results of the tests;

    • Diagnoses;


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    Documentation Requirements cont.

    • An indication of whether further treatment is needed;

    • Referrals, including the name of the referring physician; and

    • Any recommended IEP changes.


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