Oregon Health Authority (OHA) Health Systems Medicaid School-Based Health Services (SBHS)

1. Oregon Health Authority (OHA) Health Systems MedicaidSchool-Based Health Services (SBHS) Provider Q & A Training2018 Provided by: Linda J Williams, Policy Analyst Oregon Health Authority (OHA) Health Systems Medicaid Policy Unit; And Lasa Baxter, Medicaid Analyst, IMESD by contract with OHA

2. What are School-Based Health Services (SBHS)? • SBHS are special education, related services, or early intervention services provided to Medicaid eligible children with disabilities eligible under the IDEA pursuant to a child’s IEP or IFSP that are also considered a covered service authorized under Oregon’s approved Medicaid State Plan.

3. What are examples of SBHS IDEA Health Related Services? • Nurse Services (including Delegated healthcare) • Occupational Therapy • Physical Therapy • Speech Therapy • Audiology services • Social Worker Services • Psychological Services • Assistive Technology Services • Transportation Services See Handout #1 SBHS, IDEA and Medicaid Intersect And Handout #4 SBHS carved out of MCO CCO

5. What Is the criteria for Related SBHS billed to Medicaid? • SBHS billed to Medicaid are for services provided to a Medicaid eligible student that meet the coverage requirements in OAR 410-133-0080 that : • Addresses physical or mental disabilities of the child or student; • Is identified in a student's Individualized Education Program (IEP), or the Individualized Family Service Plan (IFSP); and • Are services considered a covered service in accordance with the Oregon Medicaid program’s Prioritized List of Health Services;

6. Criteria for SBHS health related Services OAR 410-133-0080 cont. • Are services provided by medically licensed staff within the scope of practice under state law as defined in OAR 410-133-0120 (also see handout #2Recommendation 42CFR440.110); • Is not an excluded service under SBHS OAR 410-133-0200 (Not Covered Services); And • Is recommended by Medically Licensed Staff as a health related service that meets the criteria as “Necessary and Appropriate” for services that are required for prevention, diagnosis or treatment of a health condition which encompasses physical or mental conditions, or injuries.

7. What is the criteria for Medically Licensed staff recommending a service within the scope of practice as a “necessary and Appropriate” health Service?

8. The Criteria for Practitioner written Recommendations: • Must be recommended by a physician or a licensed health care practitioner within the scope of practice under state law for the treatment provided; • must be in compliance with the SBHS Rules and the Code of Federal Regulations for those covered health related services described in a Medicaid-eligible student’s IEP or IFSP used as the prescriptive document; And

9. 3. Must be deemed a Necessary and Appropriate Health Related Service that is: • Consistent with the symptoms of a health condition or treatment of a health condition; • Appropriate with regard to standards of good health practice and generally recognized by the relevant scientific community and professional standards of care as effective; • Not solely for the convenience of the Medicaid-eligible student or provider of the service; and • The most cost-effective of the alternative levels of health services, which can safely be provided to a Medicaid-eligible student. • updated at least annually in alignment with IDEA to determine whether a recommended service continues to be specified on an IEP or IFSP or will terminate.

10. What is meant by Cost Effective Necessary and Appropriate Services? • Cost effective SBHS services billed to Medicaid use a cost methodology in the Medicaid State Plan approved by the Centers for Medicare and Medicaid Services (CMS) . Therefore, Medicaid isn’t charged more than an Education agency’s (EA’s) cost for services they provide based on each EA’s prior year audited costs.

11. I hold a Teacher standards & Practices Commission (TSPC) license, Can I provide the written Licensed Practitioner Recommendation for services I provide?

12. TSPC Licensure alone does not meet medicaid requirements as a physician or practitioner of the healing arts in the code of federal regulations 42 CFR 440.110 ; and therefore cannot recommend health related services billed to Medicaid for SBHS..

13. SBHS Rules 410-133-0160 and TSPC only • If you are a School Psychologists licensed by TSPC only, or • If you are a speech teacher licensed by TSPC only, you Do NOT meet state licensure requirements for providing the required written recommendation for billing Medicaid for services you provide in the school setting.

14. However, there is TSPC EXEMPTION in ors 681.230(4) For a Speech language pathologist (SLP) with ASHA CCC’s and licensed by TSPC before July 1, 2016 as follows: • SLPs previously holding TSPC will be “grandfathered” by continually renewing their TSPC license after July 2016, but in order to bill Medicaid the TSPC holder must also have current ASHA CCC’s as required by 42 CFR 440.110 (see Handout #2) • Also it should be noted that although an Speech Teacher with TSPC only may supervise services provided by an SLPA , the services are not billable to Medicaid under the auspice of an SLP who solely carries a TSPC license.(Also see SBHS Rules 410-133-0160 )

15. When should I provide my practitioner Written Recommendation For Health Services billed to Medicaid?

16. Your written recommendation • May be obtained after the IEP/IFSP Team decision is made, but must be in place prior to billing services and must be for the treatment provided as specified on the IEP or IFSP • Your school district or ESD will provide you with a form for your written recommendation. • Also, the service may NOT be billed if the IEP or IFSP (used as the prescriptive document(s) for services provided has lapsed.

17. A Written Recommendation For Health Services May Include the Following Information: • -- Beginning & Ending Dates of • Service • Amount, Frequency and Duration • Location of Service • Practitioner Contact Information • Practitioner Signature and Credentials • Recommendation may be put into place after the IEP Teams decision but should be in place prior to billing for services provided as specified on the IEP or IFSP • Recommendation criteria language • Student Name • Student DOB • Student ID Number • Treating Diagnosis • ICD10 Code • Reason for Service (medical) • Service/Treatment To Be Provided

18. What are Supervision Requirements for IDEA covered services provided by or under the direction of Medically Qualified Staff? Medically Qualified staff must meet the respective medical provider's Oregon licensing board governing definitions, scope of practice, documentation requirements, and licensure or certification for the health services provided within the scope of practice; and must be in compliance with SBHS rules

19. Am I required to initial each entry for staff under my supervision for services provided under my license? SBHS provided by and under the direction of a licensed therapist/practitioner supervising Aides/ and/or unlicensed staff may only be billed to Medicaid by and under the auspice of the supervising therapist/practitioner’s license.

20. Best Practice for meeting supervision requirements for services provided and billed to Medicaid under SBHS would be: To initial each entry as the supervising therapist/practitioner over the services provided under your direction, If you simply sign off at the bottom of unlicensed staff service logs describing activities performed/delegated under your direction as the supervising practitioner/therapist, you are essentially approving all activities provided and recorded on the log above your signature.

21. Reviewing and initialing services performed under your direction and supervision mitigates risk and allows you to only authorize services billed to Medicaid as authenticated by you under your license and scope of practice.

22. Please describe and provide some examples of SBHS Health Services that may be billed to Medicaid, The following slides will describe and provide examples of health services listed in the Oregon’s current Medicaid State Plan for SBHS provided in school settings:

23. SBHS Health Services-410-133-0060 • (A) Neuromotor or neurodevelopmental assessment; • (B) Assessing and treating problems related to musculo-skeletal status; • (C) Gait, balance, and coordination skills; • (D) Oral motor assessment; • (E) Adaptive equipment assessment; • (F) Gross and fine motor development; • (G) Observation of orthotic devices; and • (H) Prosthetic training. • (a)Physical Therapy Evaluations and Treatments that include assessing, preventing, or alleviating movement dysfunction and related functional problems, obtaining and interpreting information, and coordinating care and integrating services relative to the student receiving treatments such as:

24. SBHS Health Services-410-133-0060 • (A) Neuromuscular and musculo-skeletal status (muscle strength and tone, reflex, joint range of motion, postural control, endurance); • (B) Gross and fine motor development; • (C) Feeding & oral motor function; • (D) Adaptive equipment assessment; • (E) Prosthetic or orthotic training; • (F) Neuromotor or neurodevelopmental assessment; • (G) Gait, balance, and coordination skills. • (b) Occupational Therapy Evaluations and Treatments that include assessing, improving, developing, or restoring functions impaired or lost through illness, injury, or deprivation; improving ability to perform tasks for independent functioning when functions are lost or impaired; preventing through early intervention initial or further impairment or loss of function; obtaining and interpreting information; coordinating care; and integrating services relative to the student receiving services such as:

25. SBHS Health Services-410-133-0060 • (A) Expressive language; • (B) Receptive language; • (C) Auditory processing, discrimination, perception and memory; • (D) Vocal quality; • (E) Resonance patterns; • (F) Phonological; • (G) Pragmatic language; • (H) Rhythm or fluency; and • (I) Feeding and swallowing assessment. • (c) Speech Evaluation and Therapy Treatments that include assessment of children with speech and language disorders, diagnosis and appraisal of specific speech or language disorders, referral for medical and other professional attention necessary for the rehabilitation of speech-language disorders, provision of speech-language services for the prevention of communicative disorders, obtaining and interpreting information, coordinating care and integrating services relative to the student receiving services.

26. SBHS Health Services-410-133-0060 • (A) Auditory acuity (including pure tone air and bone conduction), speech detection, and speech reception threshold; • (B) Auditory discrimination in quiet and noise; • (C) Impedance audiometry, including tympanometry and acoustic reflex; • (D) Central auditory function; • (E) Testing to determine the child’s need for individual amplification; • (F) Auditory training; and • (G) Training for the use of augmentative communication devices. • (d) Audiological Evaluation and Services that include assessment of children with hearing loss; determination of the range, nature, and degree of hearing loss, including the referral for medical or other professional attention for restoration or rehabilitation due to hearing disorders; provision of rehabilitative activities such as language restoration or rehabilitation, auditory training, hearing evaluation and speech conversation; and determination of the child’s need for individual amplification; obtaining and interpreting information; coordinating care and integrating services relative to the student receiving services such as:

27. SBHS Health Services-410-133-0060 • The RN is responsible for periodic supervision for services provided to coordinating care and integrating nursing tasks and services that can be performed in the educational setting such as: • (e) Nurse Evaluation and Treatment Services that include assessments, treatment services, and supervision of delegated health care services provided to prevent disease, disability, other health conditions or their progression, prolong life, and promote physical and mental health and efficiency. • This includes any medical or remedial services recommended by a physician or other licensed health care practitioner within the scope of practice under state law for maximum reduction of physical or mental disability and restoration of a recipient to his or her best possible functional level.

28. SBHS Health Services-410-133-0060 • (D) Tracheotomy care, changing dressings, emergency trach replacement, suctioning, changing “nose”, and providing humidification as necessary; • (E) Catheterization, assisting with or performing procedure for catheterization, monitor urinary tract infections, and performing skin integrity checks; • Examples of Nurse Services cont. • (A) Monitoring patient’s seizure activity for breathing patterns, onset/duration of seizure, triggers/auras, level of consciousness, support after seizure, administering medication as ordered; • (B) Monitoring and providing treatment for high and low blood sugar, checking urine keytones, blood glucose testing, carbohydrate calculations, assisting with insulin administration; • (C) Ventilator Care, suctioning, and equipment management;

29. SBHS Health Services-410-133-0060 • (H) Medication management, e.g., monitoring signs and symptoms for medication administration, administering medications, observing for side effects. • Examples of Nurse Services cont. • (F) Gastrostomy tube feeding, administering tube feedings per physician order, monitoring skin status around the tube, and emergency treatment for button dislodgement; • (G) Medication pumps, e.g., insulin pump, calculate carbohydrate amounts in food/snacks, provide insulin bolus per physician order, emergency disconnect procedure and monitoring blood sugar; and

30. SBHS Health Services-410-133-0060. • (f) Mental Health Evaluation and Treatment Services that include assessment and treatment services provided by or under the supervision and direction of a psychiatrist, psychologist, a mental health nurse practitioner, or by a social worker qualified and licensed to deliver the service and who may provide care coordination and integration for services relative to the student for outpatient mental health services received in the educational setting to prevent disease, disability, other health conditions or their progression, to prolong life and promote physical and mental health and efficiency. or remedial services for maximum reduction of physical or mental disability and restoration of a recipient to his or her best possible functional level, such as:

31. Sbhs Health Services-410-133-0060. Mental health evaluations & treatment Cont. • (A) Mental health assessment; • (B) Psychological testing (non-educational cognitive and adaptive testing); • (C) Assessment of motor language, social, adaptive, and cognitive functioning by standardized developmental instruments; • (D) Behavioral health counseling and therapy; and • (E) Psychotherapy (group/individual).

32. Are there SBHS that are considered Not Covered Services? • Medical care not documented in the IEP/IFSP • Review of records (exception: as part of an evaluation) • Meeting Preparation • Report Writing (exception: as part of the initial evaluation) • Correspondence • Medication management not specific to Health Services on the IEP/IFSP • Assistive Technology Devices • 504 Plan svcs; and ISP svcs for children in private school settings • Yes, please see Handout # 9

33. Also see SBHS Rules Not Covered Services 410-133-0200 • Services not on the IEP/IFSP • Health Services that have no current licensed practitioner recommendation • Medically necessary Transportation billed on a day a child did not also receive a paid Medicaid covered service on the same day and both services are specified on the IEP/IFSP • See SBHS Rules 410-133-0080 (12) Transportation

34. Coding & Documenting Therapy Services • Provide SBHS Procedure code that best describes the therapy provided (see SBHS Coding and Billing Instructions http://www.oregon.gov/oha/healthplan/Pages/sbhs.aspx ) • Provide a physician’s primary diagnosis code if it fits the reason for your therapy/services • Fragile children and orthopedically impaired children Likely have a diagnosis provided by a physician NOTE: Signs and symptoms codes may NOT be used for billing services provided to a child that has acquired a physician’s diagnosis which appropriately fits the reason the child is receiving treatment.

35. Coding a Diagnosis • If the child doesn’t have a physician diagnosis/primary diagnosis that fits the therapy/treatment you are providing, you may use the diagnosis for signs and symptoms within the scope of your practice that best fits the treatment you are providing • Example: A speech therapist is providing individual language therapy to a child who does not have a primary diagnosis, but is treating the child's expressive language disorder (F80.1), the speech therapist should report the ICD-10 code that best fits the reason (expressive language disorder) he/she is treating the child.

36. Coding a Procedure code Most Commonly Used • T1024 – Evaluation • T1018 – Direct Therapy • 92508 – Group - Speech Therapy Group • 97150 – Group - OT/PT Therapy Coordinated Care G9005, G9007, & G9012 • Services directly related to SBHS covered Health Services specified in the IEP or IFSP, performed by Medically Qualified Staff, and allowed under 410-133-0080, Coverage to manage integration of those Health Services in an education setting.

37. Coding a Procedure code • Consultation G9005 – Performed by Medically Qualified Staff within the scope of practice providing technical assistance to or conferring with, special education providers, physicians, and families to assist the Medically Qualified Staff in providing a covered Health Service for Medicaid-eligible students related to a specific Health Service in support of goals and objectives in the IEP or IFSP. • Conference G9007– The portion of a conference in a scheduled meeting, between Medically Qualified Staff and interested parties, to develop, review, or revise components of School-Based Health Services provided to a Medicaid-eligible studentfor the purpose to establish, re-establish or terminate a Medicaid covered Health Service on a Medicaid-eligible student’s IEP or IFSP) or To develop, review, or revise components of a covered Health Service currently provided to a Medicaid-eligible student to determine whether or not those covered Health Services will continue to be specified on an IEP or IFSP. • Please note: Medically licensed staff should NOT bill for the entire IEP/IFSP meeting time

38. Coding a Procedure code • G9012 - Coordinated care for other specified care management for a new chronic medical condition that is not addressed on the current IEP or IFSPthat will result in amending services specified in the IEP or IFSP and requires an updated plan of care. • This may result in an increase in supervision, monitoring and training of staff to provide new tasks related to the change in medical condition. • If the condition is due to an exacerbation of a current condition requiring more services or service time provided by or under the supervision of Medically Licensed Staff, the IEP/IFSP can be amended without a meeting if all parties agree that would allow increased amount frequency and duration to accommodate the child’s condition for services and/or service time that may be billed to Medicaid’ And can be amended again to lower/change services again accordingly based on the child’s medical condition.

39. IMPORTANT things to remember for Documentation of Therapy Services • Documentation must be: • Accurate- describes the care provided • Code-able – supports the procedure code and Diagnosis code • Understandable- clear to the reader (and not just to another medically licensed therapist/practitioner) • Timely – entered when the service is provided • Error free- stands alone as a legal document

40. Services that are not documented were not done • Every treatment/therapy visit provided must be documented for all individuals served • Documentation must be timely – when the service was provided. • All documentation must be dated and signed accordingly with your licensing board requirements and SBHS rules

41. Use professional language that demonstrates your clinical skill: • Report objective data to support goals • Explain your decision making/rationale for treatment and recommendations

42. Services must always be documented by the person who provided the service. • You are responsible for documenting services you provide whether direct treatment/therapy or supervision of treatment/therapy provided • Documentation must identify assistants and/or individuals providing services to clients under your supervision and authorized accordingly with your licensing board requirements and the SBHS rules.

43. Services must always be documented by the person who provided the service. • Please remember supervising practitioners/therapists should initial each service provided under your license as the supervising practitioner/therapist indicating services were reviewed and accepted for approving those services before signing off on the documented tasks performed billed to Medicaid

44. Services must always be documented by the person who provided the service. • Documentation must support the scope and level of services (complexity or time) • Services must be appropriate by provider type scope of practice for area of service provided • Services you provide must be signed and include credentials

45. Documenting Services in Schools • School based paperwork for IEP/IFSP under IDEA is very different from health care based documentation. • However, medically licensed therapists providing services must document services accordingly with your licensing board requirements regardless of the setting you are in.

46. IMPORTANT things to remember for Documentation of Therapy Services • Describe therapy and child’s measurable response to the therapy provided in correlation with the treatment plan and goals in the IEP/IFSP • Bill the amount of time per session as specified in the IEP/IFSP (can provide more time but can’t bill for more time than IEP/IFSP prescribes) • Billing date is the date the service was provided • Documentation should be past tense • Identify assistants when documenting care coordination for services supervised

47. Do not over abbreviate or use jargon • A list of approved abbreviations may be used fortreatment/therapy notes to assist you with the written permanent record in the required format in compliance with documentation requirements for your licensing board • A list of approved abbreviations also is needed for documentation to be understood by classroom teacher, parent of client, or non-practitioner/therapists when coordinating care

48. Do not over abbreviate or use jargon • Don’t copy or paste treatment/therapy notes as they must be for individualized treatment/therapy • Only include factual information pertaining to the visit • Templates can be filled in for identification info, and clients numbered goals written out can be used to increase efficiency but you then fill in the client’s specific response to goals for therapy provided.

49. Questions?