Chapter 538 School-Based Health Services

1. Chapter 538 School-Based Health Services Medicaid Policy Update

2. Bureau of Medical Services(BMS) Policy Chapter 538 School Based Health Services - Revision 2019 • 1. Overview of requirements to bill that have not changed. • 2. Changes effective August 1, 2019 • 3. New billing forms • 4. Molina/DXC Portal.

3. Medicaid Arrest Reporting • Districts are still required to submit monthly to WVDE a statement indicating if any staff working with Medicaid who have been arrested for crimes listed in BMS Policy Section 538.4. • This includes those signing billing documents, listed on the PCG roster and those factored into the cost settlement. • Includes those providing contractual services. • Statements can be e-mailed to Kelley Johnson at kelley.Johnson@k12.wv.us • If a staff member has been arrested for one of these crimes, the district submits the name, crime and date to WVDE. It also is helpful to include the current status of the staff member/contractor.

4. Office of Inspector General (OIG) List of Excluded Individuals and Entities: • Persons on the OIG List of Excluded Individuals cannot provide Medicaid billable services. The list can be searched at the following link: https://exclusions.oig.hhs.gov/Default.aspx. Districts are responsible to ensure staff providing Medicaid services are not on the exclusion list. Districts need to search this list for any staff who will be submitting Medicaid billing and those providing Medicaid billable contractual services. If no results are found for an individual it is recommended to print the page and retain for your records. This will serve as documentation that the individual was not on the list. It is also suggested to check this list as part of the employment verification process.

5. Required Prior to Billing • Active IEP • Plan of Care (POC) (This is a change of terminology from Service Care Plans (SCP) The terminology has already changed in the IEP program . • Services must be included on the signed POC/SCP prior to billing. • Include all diagnosis codes that apply to Medicaid billable services. • Must be signed by parent, case manager, and direct therapy providers. • If these individuals change, the new staff member is to sign a copy of the SCP. • Obtain Telehealth provider signatures • Parental Consent to disclose information, TCM and billing (Revised August 2019). Consent is only valid for one year from signature date. • Physician Authorization Form for Speech, Occupational Therapy, Physical Therapy, Audiology and Psychological (Revised March 2017). This can be signed by a doctor (MD or DO), Physician Assistant or Nurse Practitioner (APRN). Valid for one year. • Must also send parents annual notice of rights. Distribute with consent form.

6. Molina/DXC Rendering Provider Enrollment • Molina is now DXC. • Individual providers (OT, PT, SLP, Audiology, Psychological, and registered nurses) must be enrolled with DXC and associated with the school district. SSLPA, PTA and COTAs are not enrolled as providers. • Also applicable to contracted services. • Provider applications can be mailed to DXC or entered on the DXC HealthPAS portal. • Need the provider’s licensure/certification and National Provider Identifier (NPI) number to apply. NPI numbers can be searched at https://npiregistry.cms.hhs.gov/. • A new provider can obtain an NPI number. Create a new account at https://nppes.cms.hhs.gov/#/ and complete the application process. • If the provider is already enrolled with DXC just complete Form MPE-2 (two pages).

7. DXC Rendering Provider Enrollment • Provider must be properly licensed. Updated licenses must be submitted to DXC: • Speech – Board of Examiners (WVDE certified only as considered SSLPA and are not enrolled with DXC. BMS considers Provisional licenses as SSLPA.) Valid for two years. Current licenses expire December 31, 2020. • Occupational Therapy – WV Board of OT. (COTAs are not enrolled with DXC). Valid for two years. Current licenses expire on December 31, 2019. Can search and print verification at https://wvbot.org/dharris/licensure/excel_db.php • Physical Therapy – WV Board of PT. (PTAs are not enrolled with DXC). Valid for two years. Current licenses expire December 31, 2019. • Registered Nurse – RN Board of Examiners. Expire October 31st annually. Can search and print license verification at https://wvrn.boardsofnursing.org/licenselookup. • School Psychologist WVDE certification is acceptable as well as the Board of Examiners. WVDE certifications can be looked up and printed at https://wveis.k12.wv.us/certcheck/ For permanent certification submit certification annually. • Audiologist – Board of Examiners. Valid for two years. Current licenses expire December 31, 2020.

8. DXC Provider Enrollment Continued • School nurse and school psychological applications also require a letter from the school system that they are working in the school setting. • Must maintain current certifications to keep provider enrollment active in DXC. • Maintain copies of all enrollment documents mailed, faxed or e-mailed to DXC. • Billing for services provided prior to the date the DXC enrollment is activated and associated with the district will not be processed.

9. DXC Re-validation Process • Every five years the districts provider status has to be revalidated. • The direct provider service account requires updated applications from each rendering provider. • This can be a very time consuming and lengthy process to complete. • Check with Kelley or DXC for the revalidation dates for district ancillary and direct service provider accounts.

10. Diagnosis Codes Required • ICD-10 diagnosis codes are required • For therapies a diagnosis code that is related directly to the therapy is required. A global diagnosis such as Autism would not be appropriate for speech therapy. • Global codes are appropriate for ancillary services such as Targeted Case Management, transportation and personal care services.

11. Updated Psychological Form • The Psychological Billing Form was updated as of January 1, 2019. This form had the replacement codes for CPT 96101 which is no longer valid as of 1.1.19. Testing procedure codes were changed effective that date. Be sure you are using the correct version of the form for services provided from January through July 2019.

12. Random Moment Time Study • Random Moment Time Study Calendar and Roster for the October-December Quarter will open in early August, 2019. The due date for verification will be the first week of September, 2019. • Each staff member on the roster requires a shifts that matches their work day. • As of April 2019, participants do not receive any pre-notification of RMTS assignments. Staff will have two work days to respond. They should complete moments before leaving school the day of a moment. • Responses are codes with results directly impacting the cost settlement calculations.

13. Maintain Student Eligibility in WVEIS • Medicaid numbers for members (students) must be kept current in WVEIS. • Medicaid numbers can be verified through the CFM.MMI application on WVEIS WOW. This is uploaded periodically so can be dated information. • Current eligibility data is available through the DXC Portal. • Periodically check students for eligibility or termination of eligibility. • Update information in WVEIS as needed. • This information is still needed to generate the Medicaid Eligibility Report. This will be based on December 1, 2019 Child Count, determining the ratios used in the cost settlement process. • Crucial to maintain accurate special education service codes as well as TCM, transportation and PC status.

14. Student Eligibility Third Party Insurance • Students that also are covered by third party insurance are considered secondary for Medicaid. In this case billing for direct services will be denied. Ancillary services are payable by Medicaid. • To justify billing for transportation of these students submit direct billing. Although it will be denied it does establish a claim that justifies billing for specialized transportation for that date. • Third party insurance is often indicated in WVEIS with a fictional closing date of 2-22-2222 (or similar dates). This is not required but is helpful information for transfer students.

15. Member Verification Through DXC Portal • At portal main screen select Verify Member Eligibility button. • Under Find Member enter the student’s last name, first name and date of birth. • If you know the Medicaid number you can use it to look up as well. Must have two rows of information. Hit submit • Student Member name will appear with date of birth, member ID and Gender. Hit submit • Effective and termination dates will be visible if applicable. Student numbers starting with 039 will have a rolling termination date that changes monthly. • Occasionally a student will have more than one Medicaid number. In this case use the primary Medicaid number.

16. Changes Effective August 1, 2019 • Speech/Audiological: • CPT codes 92540 Basic Vestibular Evaluation and 92561 Bekesy: Diagnostic have been eliminated • Maximum units of speech therapy for a student has increased to 24 units per month • Can assign multiple diagnosis codes for a therapy session.

17. Psychological Changes • Psychotherapy service limits for sessions increased to twenty (20) units per calendar year. • Crisis psychotherapy service limits increased to four per calendar year. • CPT code 96101 replaced by four codes: • 96130 Initial hour of testing. 60 minute unit. Two allowed per calendar year. • 96131 Additional hour of testing. 60 minute unit. Four per calendar year. • 96136 Test Admin and Scoring initial 30 minutes. One per calendar year. • 96137 Test Admin and Scoring additional 30 minutes. Three per calendar year.

18. Nursing • Additional procedures are now available for billing: • T1001 SE: Diabetic Management • T1000 SE: Catheterization Self-Management

19. Nursing • 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.

20. Nursing • 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.

21. Transportation • Both CPT codes have units indicating one-way trips. Previously T2002 SE indicated per diem. • If there is an additional trip during the day for a Medicaid billable procedure code, two additional trips can be billed with a maximum service limit of 4 trips daily.

22. Form Changes • Must use new forms as of August 1, 2019. • Fillable forms are being developed and will be available on the department website. • Revised billing form modules are available on the WVDE Medicaid website. • New forms except for ancillary are set up in a similar manner. • Direct services the provider lists all diagnosis codes that are applicable for the student’s services at the top of the form starting with box 1. • Each claim is entered including the date of service, corresponding numbers for the diagnosis code(s) that relate to the claim, procedure code, start time, end time and the number of units or events. • OT and PT forms now have a line for directly supervising OT and PT to co-sign. The supervising OT or PT initials dates they were directly supervising. Directly supervising means they are in the building at the time of the service.

23. Ancillary Form Changes • TCM – Service Care Plan has been changed to Plan of Care at the top of the form. • Personal Care – The form is still used for a single date. The form still has the 25 activities which have been assigned a number. Staff providing personal care activities enter the corresponding number and document the start and stop times. There are spaces for total minutes per column. • Transportation – The mileage column has been removed. Also the column to list services has been eliminated. Staff can enter DS for designated stop. The total number of one way trips is calculated and the form is signed by the driver and aide. District staff working with Medicaid billing will determine the which trips are billable

24. Claim Submission in DXC Portal • Effective with services provided after August 1, 2019 claim submission will no longer be processed through WVEIS. • The DXC Portal allows free claim submission. • See the West Virginia Trading Partner Account Claim Submission User Guide for step-by-step directions including screen shots. A modified version will be provided during the training session.

25. QUESTIONS? • Kelley Johnson • kelley.Johnson@k12.wv.us • 304-558-2696 x53539