HCS BILLING GUIDELINES

(1)

HCS BILLING GUIDELINES

• You can find the newest version on the DADS

website:

http://www.dads.state.tx.us/handbooks/hcsbg/

(2)

General Information

Department of Aging and Disability Services (DADS) rules at 40 TAC

§9.170 set

forth requirements for Home and Community-based Services (HCS) Program

providers to receive payment for HCS Program services. Specifically, 40 TAC

§9.170(d) requires a program provider to prepare and submit service claims in

accordance with the HCS Program Billing Guidelines. Also, Sections II. H. and II.

T. of the HCS Program Provider Agreement require program providers to

comply with the HCS Program Billing Guidelines. In addition, 40 TAC §9.170(k)

sets forth circumstances under which a program provider will not be paid or

Medicaid payments will be recouped from the program provider.

(3)

General Requirements

Applicable Service Components

• Specialized Therapies

– Audiology; dietary; occupational therapy; physical therapy; behavioral support; social work; and speech and language pathology.

• Day Habilitation

• Nursing

– Registered; Licensed Vocational; Specialized Registered; and Specialized Licensed Vocational.

• Residential Assistance

– Foster/Companion Care; Residential Support; Supervised Living; and Supported Home Living.

• Respite

• Supported Employment

• Adaptive Aids

• Minor Home Modifications

• Dental Treatments

3

(4)

Specific Requirements

(5)

Specialized Therapies

22

(6)

Specific Requirements

Specialized Therapies

• Audiology services

• Dietary services

• Occupational therapy services

• Physical therapy services

• Psychology services

• Social work services

• Speech and language pathology

services

23 http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4200

(7)

Specific Requirements

Specialized Therapies Billable Activity

• The only billable activities for the specialized therapies service component are: • interacting face-to-face or by video conference or speaking by telephone with an

individual, based on the specialized therapies subcomponent provided, to conduct assessments or provide services within the scope of the service provider's practice; • interacting face-to-face or by video conference or speaking by telephone with a person

regarding a specialized therapies subcomponent provided to an individual, but not with:

– a staff person who is not a service provider; or

– a service provider of any nursing service component (registered nursing, licensed vocational nursing, specialized registered nursing or specialized licensed

vocational nursing), or specialized therapies;

• writing an individualized treatment plan for an individual's specialized therapies which, for behavioral support services, is a behavior support plan;

• reviewing documents, except for a written narrative or written summary of a service component as described in Section 3820, to evaluate the quality and effectiveness of an individual's specialized therapies;

(8)

Specific Requirements

Specialized Therapies Billable Activity

• training the following persons on how to provide specialized therapies treatment, including how to document the provision of treatment:

– a service provider of foster/companion care, residential support, supervised living, supported home living, day habilitation, respite, supported employment or employment assistance; or

– a person other than a service provider who is involved in serving an individual; • reviewing documents in preparation for the training described in the bullet above; • participating in a service planning team meeting;

• participating in the development of an implementation plan; • participating in the development of an IPC; and

(9)

Specific Requirements

Specialized Therapies Billable Activity

• for behavioral support services, in addition to the activities listed above: – assessing the targeted behavior so that a behavior support plan may be

developed;

– training of and consulting with an individual, family member or other persons involved in the individual's care regarding the implementation of the behavior support plan;

– monitoring and evaluating the effectiveness of the behavior support plan;

– modifying, as necessary, the behavior support plan based on the monitoring and evaluation of the plan's effectiveness; and

– educating an individual, family members or other persons involved in the

individual's care about the techniques to use in assisting the individual to control maladaptive or socially unacceptable behaviors exhibited by the individual.

(10)

Specific

Requirements

Not Billable as Specialized Therapies

The following are examples of activities that are not billable for the specialized therapies service component:

– providing services outside the scope of the service provider's practice; – providing services that are performed by a service coordinator or were

performed by a former case manager; – scheduling an appointment;

– transporting an individual;

– traveling or waiting to provide a specialized therapies subcomponent;

– training or interacting about general topics unrelated to a specific individual, such as principles of behavior management, or general use and maintenance of an adaptive aid or equipment;

– creating written documentation as described in Section 4260;

– reviewing a written narrative or written summary of a service component as described in Section 3820; and

(11)

Specific

Requirements

Not Billable as Specialized Therapies

The following are examples of activities that are not billable for the specialized therapies service component (continued):

– interacting with:

• a staff person who is not a service provider; or

• a service provider of any nursing service component (registered nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational nursing) or specialized therapies, if not during a service planning team meeting or during the development of an IPC or an

implementation plan.

Activities in Section 3300

– The activities listed in Section 3300, Activity Not Billable, are not billable for the specialized therapies service component.

Activities Not Listed in Section 4220

– Any activity not described in Section 4220, Billable Activity, is not billable for the specialized therapies service component.

(12)

Specific Requirements

Examples of Activity Not Billable

– providing services outside the scope of the service provider's practice;

– providing services that are performed by a service coordinator or were performed by a former case manager;

– scheduling an appointment; – transporting an individual;

– traveling or waiting to provide a specialized therapies subcomponent;

– training or interacting about general topics unrelated to a specific individual, such as principles of behavior management, or general use and maintenance of an

adaptive aid or equipment;

– creating written documentation as described in Section 4260;

– reviewing a written narrative or written summary of a service component as described in Section 3820; and

– interacting with:

• a service provider of any nursing service component (registered nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational nursing) or specialized therapies, if not during a service planning team meeting or

during the development of an IPC or an implementation plan. 29

(13)

Specific Requirements

Specialized Therapies Written Documentation

• Except as provided in

Section 4270

, Insurance Co-payment and Deductible

(see No. 1, Item c and No. 2, Item c), a program provider must have written

documentation to support a service claim for specialized therapies that:

• meets the requirements set forth in

Section 3800

, Written Documentation;

• includes the exact time the service event began and the exact time the service

event ended documented by the service provider making the written service

log; and

• for any activity performed by multiple service providers at the same time for

the same individual, includes a written justification in the individual's

implementation plan for the use of multiple service providers.

(14)

Common Errors

• No begin and/or end times

• No location of service provided

• Reviewing or creating service delivery records

• Family paying for rate differential

• No Progress Note

(15)

Day Habilitation

32

(16)

Specific Requirements

Day Habilitation Billable Activity

• The only billable activities for the day habilitation service component are:

• interacting face-to-face with an individual to assist the individual in

achieving objectives to:

– acquire, retain or improve self-help skills, socialization skills or adaptive skills that are necessary to for the individual to successfully reside, integrate and participate in the community;

– reinforce a skill taught in school, specialized therapies; and

– develop opportunities for employment in the community (for example, completing a job application, assessing employment skills and training on employment-related issues);

• transporting an individual between settings at which day habilitation is

provided to the individual;

• assisting an individual with his or her personal care activities if the

individual cannot perform such activities without assistance;

• participating in a service planning team meeting;

• participating in the development of an implementation plan; and

• participating in the development of an IPC.

(17)

Specific Requirements

Not Billable as Day Habilitation

• Travel time (except from one Day

Habilitation site to another)

• Written documentation

• Reviewing records

• Drafting Implementation Plans

• Staff Training/Conferences

• Processing service claims

• Assisting an individual for the sole

purpose of meeting vocational goals

(18)

Specific Requirements

May not submit DH service claim for:

• An individual who refuses to participate

• An individual who is sleeping

• Assisting an individual in achieving goals

not documented in their IP

• More than five units of service in a calendar

week

• More than 260 units of service per IPC year

• Day habilitation that is funded by another

source other than HCS

(19)

Specific Requirements

Day Habilitation Unit of Service

A unit of service for Day Habilitation is one day

• One-quarter unit of service if service is provided at

least one and one-quarter hours of consecutive day

habilitation on a calendar day

• One-half unit of service may be billed if service is

provided for at least two and one-half hours on a

calendar day. Two of the two and one-half hours

must be consecutive.

• Three-quarters unit of service may be billed if service

is provided for at least three and three-quarter hours

on a calendar day. Two of the three and

three-quarter hours must be consecutive.

• One unit may be billed if service is provided for at

least five hours on a calendar day. Two of the five

hours must be consecutive.

(20)

Common Errors

• Individual sleeping

• Not signing individual out of Day Habilitation for other services

provided (NU, SHL, etc.)

• No description of service provided (details about interactions,

activities, behaviors, successes, refusals, etc.)

• Vocational Goals – Sheltered Workshops

• No Progress Note

(21)

Supported Employment

40

(22)

Specific

Requirements

Supported Employment

• Supported employment is a service that

assists an individual to sustain

competitive, integrated employment.

(23)

Specific

Requirements

Supported Employment Billable Activity

• The only billable activities for the supported employment service component are:

• interacting face-to-face with an individual at the individual's work site to provide training, support and intervention necessary to sustain the individual's employment;

• interacting face-to-face or by telephone with an individual's employment supervisor as necessary to sustain the individual's employment;

• transporting an individual to and from the individual’s work site; • participating in a service planning team meeting;

• participating in the development of an implementation plan; and • participating in the development of an IPC.

(24)

Specific

Requirements

Examples of Activities Not Billable under SE

• The following are examples of activities that are not billable for the supported employment service component:

– interacting with an individual prior to the individual's employment; – conducting employment interest assessments, assisting with or

arranging interviews, and completing job applications;

– interacting with an individual when the individual is not on duty; and – transporting an individual to a job interview.

(25)

Specific

Requirements

Restrictions (SE):

A program provider may not submit a service claim for

supported employment provided to an individual:

• while the individual is employed by the program provider; • in excess of 600 units of service (150 hours) per IPC year; or • if supported employment is available to the individual through

the public school system or the Department of Assistive and Rehabilitative Services.

(26)

Common Errors

• Training not occurring at the job site

• Pre-vocational training

• No Progress Note

(27)

Nursing

47

(28)

Specific Requirements

Registered Nursing Billable Activity

• The only billable activities for the registered nursing service component are:

• interacting face-to-face with an individual who has a medical need for registered nursing, including:

– preparing and administering medication or treatment ordered by a physician, podiatrist or dentist;

– assisting or observing administration of medication; and

– assessing the individual's health status, including conducting a focused assessment or a comprehensive assessment;

• speaking by telephone with an individual who has a medical need for registered nursing, including assessing the individual's health status; • interacting by video conference with an individual who has a medical

need for registered nursing, including:

– observing administration of medication; and

– assessing the individual's health status, including conducting a

focused assessment or a comprehensive assessment; ₄₈

(29)

Specific Requirements

Registered Nursing Billable Activity

(cont.)

• at the time an individual receives medication from a pharmacy, ensuring the accuracy of:

– the type and amount of medication; and – the dosage instructions;

• researching medical information for an individual who has a medical need for registered nursing, including:

– reviewing documents, except for a written service log or written summary log of a service component as described in Section 3820, to evaluate the quality and effectiveness of the medical treatment the individual is receiving; and

– completing a comprehensive assessment;

(30)

Specific Requirements

Registered Nursing Billable Activity

(cont.)

• training the following persons how to perform nursing tasks:

– a service provider of foster/companion care, residential support, supervised living, supported home living, day habilitation,

respite, supported employment or employment assistance; or – a person other than a service provider who is involved in serving

an individual;

– reviewing documents in preparation for the training described in the bullet above;

(31)

Specific Requirements

Registered Nursing Billable Activity

(cont.)

• interacting face-to-face or by video conference or speaking by

telephone with a person regarding the health status of an individual, but not with:

– a staff person who is not a service provider; or – a service provider of:

• registered nursing;

• licensed vocational nursing unless supervised by the registered nurse;

• specialized registered nursing;

• specialized licensed vocational nursing unless supervised by the registered nurse; or

• specialized therapies;

(32)

Specific Requirements

Registered Nursing Billable Activity

(cont.)

• interacting face-to-face or speaking by telephone with a pharmacist or representative of a health insurance provider, including the Social Security Administration, about an individual's insurance benefits for medication if the registered nurse justifies, in writing, the need for the registered nurse to perform the activity;

• instructing a service provider, except a service provider of registered nursing or specialized registered nursing, on a topic that is specific to an individual such as choking risks for an individual who has

cerebral palsy;

• supervising a licensed vocational nurse regarding an individual's nursing services or health status;

• instructing, supervising or verifying the competency of an unlicensed person in the performance of a task delegated in accordance with rules of the Texas Board of Nursing at 22 TAC, Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions) or the Human Resources Code,

§§161.091-.093, as applicable; 52

(33)

Specific Requirements

Registered Nursing Billable Activity

(cont.)

• participating in a service planning team meeting;

• participating in the development of an implementation plan; and • participating in the development of an IPC.

(34)

Specific Requirements

Licensed Vocational Nursing Billable

Activity

• interacting face-to-face with an individual who has a medical need for licensed vocational nursing, including:

– preparing and administering medication or treatment ordered by a physician, podiatrist or dentist;

– assisting or observing administration of medication; and – conducting a focused assessment of the individual's health

status;

• speaking by telephone with an individual who has a medical need for licensed vocational nursing, which may include conducting an assessment of an individual if:

– the assessment is conducted using protocol approved by DADS; and

– the licensed vocational nurse has been trained by a registered nurse on using the protocol;

54 http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4471.2

(35)

Specific Requirements

Licensed Vocational Nursing Billable

Activity

(cont.)

• interacting by video conference with an individual who has a medical need for licensed vocational nursing, including:

– observing administration of medication; and

– conducting a focused assessment of the individual's health status;

• at the time an individual receives medication from a pharmacy, ensuring the accuracy of:

– the type and amount of medication; and – the dosage instructions;

(36)

Specific Requirements

Licensed Vocational Nursing Billable

Activity

(cont.)

• researching medical information for an individual who has a medical need for licensed vocational nursing, including:

– completing a focused assessment;

• training a service provider of residential assistance, day habilitation, respite or supported employment, or a person other than a service provider who is involved in serving an individual, regarding how to perform nursing tasks;

• reviewing documents in preparation for the training described in the bullet above;

(37)

Specific Requirements

Licensed Vocational Nursing Billable

Activity

(cont.)

• researching medical information for an individual who has a medical need for licensed vocational nursing, including:

– completing a focused assessment;

• training a service provider of residential assistance, day habilitation, respite or supported employment, or a person other than a service provider who is involved in serving an individual, regarding how to perform nursing tasks;

• reviewing documents in preparation for the training described in the bullet above;

(38)

Specific Requirements

Licensed Vocational Nursing Billable

Activity

(cont.)

• interacting face-to-face or by video conference or speaking by telephone with a person regarding the health status of an

individual, but not with:

– a staff person who is not a service provider; or

– a service provider of any nursing service component

(registered nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational

nursing) or specialized therapies;

• interacting face-to-face or speaking by telephone with a pharmacist or representative of a health insurance provider, including the Social Security Administration, about an

individual's insurance benefits for medication if the licensed vocational nurse justifies, in writing, the need for the licensed vocational nurse to perform the activity;

(39)

Specific Requirements

Licensed Vocational Nursing Billable

Activity

(cont.)

• instructing a service provider, except a service provider of registered nursing or specialized registered nursing, on a topic specific to an individual such as choking risks for an individual who has cerebral palsy;

• participating in a service planning team meeting;

• participating in the development of an implementation plan; and

• participating in the development of an IPC.

(40)

Specific Requirements

Specialized Registered and Licensed

Vocational Nursing

• Follow respective sections

only

for an individual who has

a tracheostomy or is dependent on a ventilator.

60 http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4472.2 &

(41)

Specific Requirements

Examples of Non-Billable Activities:

• performing or supervising an activity that does not constitute the practice of licensed vocational nursing, including:

• performing an activity that constitutes the practice of

professional nursing and must be performed by a registered nurse;

• transporting an individual;

• waiting to perform a billable activity; and

• waiting with an individual at a medical appointment; • making a medical appointment;

• instructing on general topics unrelated to a specific individual, such as cardiopulmonary resuscitation, or infection control; • preparing a treatment or medication for administration and not

interacting face-to-face with an individual;

• storing, counting, reordering, refilling or delivering medication except as allowed in the fourth bullet of Section 4471.2;

• creating written documentation as described in Section 4471.7;

(42)

Specific Requirements

Examples of Non-Billable Activities:

• reviewing a written service log or written summary log of a service component as described in Section 3820;

• interacting with:

• a service provider of any nursing service component (registered nursing, licensed vocational nursing, specialized registered

nursing or specialized licensed vocational nursing), or

specialized therapies, if not during a service planning team meeting or during the development of an IPC or an

implementation plan; and

• performing an activity for which there is no medical need.

(43)

Specific Requirements

Nursing Rule of Thumb:

If it does not require a nursing license

to perform a task, it is not billable.

(44)

Specific Requirements

Nursing Unit of Service

• 15 Minute of Service

A service claim cannot be made for

a fraction of a unit of service

• Accumulation of Service Times

Can be accumulated for nursing

provided to one individual on a

single calendar day

(45)

Common Errors

• Billing for creating and reviewing service records.

• No medical necessity shown when residential staff calls nurse to

administer over the counter medication to individual

• No medical necessity for follow-up phone call

• Billing for services without Face-to-Face, Telephone or Video

conferencing contact

• Providing any activity not requiring a nursing license

• One note used for multiple service events

• No Progress Note

(46)

Residential Assistance

69

(47)

Specific Requirements

Residential Assistance Residential Location

• Own Home/Family Home

– if no foster/companion

care, residential support or supervised living is

provided to the individual

• Foster/Companion Care

– is not owned or leased by

the program provider, a service provider provides care

to the individual; and the care provider and the

individual have the same address

(48)

Specific Requirements

Residential Assistance Residential Location

• 3-Person Home

– the individual’s

residence is a 3-person residence and a

service provider provides residential

support or supervised living to the

individual

• 4-person Home –

the individual’s

residence is a 4-person residence and a

service provider provides residential

support or supervised living to the

individual (one must be RSS)

71

(49)

Supported Home

Living

72

(50)

Specific Requirements

Supported Home Living Billable Activity

Interacting face-to-face with the individual:

• to assist with activities of daily living

• to assist with ambulation and mobility

• to reinforce counseling and therapy subcomponents

• to assist with administration of medication or tasks delegated by an RN

• to conduct habilitation activities

• to secure transportation for the individual

• to supervise the individual’s safety and security

• interactions regarding an incident directly affecting the individual's health

or safety;

• performing allowable non-face-to-face activities

• participating in a service planning team meeting;

• participating in the development of an implementation plan; and

• participating in the development of an IPC.

(51)

Specific Requirements

Supported Home Living claims may not be

submitted for:

• An individual whose IPC does not have a residential location of “own home/family home”

• the sole activity of supervising the individual's safety and security • Transporting an individual from one DH or SE site to another

– supporting home living provided to an individual:

• in a residence in which residential support or supervised living is provided to another individual;

• by a service provider who is simultaneously providing residential support, supervised living or foster/companion care to another individual;

• if the day habilitation service component is simultaneously provided to the individual by another service provider; or

• if the respite service component is simultaneously provided to the individual by another service provider.

(52)

Specific Requirements

Supported Home Living Unit of Service

• 15 Minute of Service – may not include

fraction of service

• Calculating transportation – use Method A

or Method B (can only use one method on

a single calendar day)

(53)

Transportation

Method

A

Individual Departure Time Arrival Time

A. Dorothy N. Kansas 7:00am 9:00am

B. Dorothy N. Kansas 3:00pm 4:30pm

a. Transportation time of 120 minutes (7:00am-9:00am) with 6 passengers (Dorothy + 5 others) and 1 service provider for Trip A

SERVICE TIME = (1 X 120) ÷ 6 = 20 minutes

b. Transportation time of 90 minutes (3:00pm-4:30pm) with 5 passengers (Dorothy + 4 others) and 1 service provider

SERVICE TIME = (1 X 90) ÷ 5 = 18 minutes 20 min + 18 min = 38 minutes (accumulation)

According to Attachment C:

38 minutes = 3 Units Billed (accumulation)

1 Unit (20 min) + 1 Unit (18 min)= 2 Units Billed (no accumulation)

79

(54)

Transportation Method B

Individual Departure Time Arrival Time

Dorothy N. Kansas 7:00am 9:00am

Little B. Blue 7:15am 9:00am

Mary Q. Contrary 7:30am 9:00am

Transportation time for Dorothy N. Kansas:

a. Transportation time of 15 minutes (7:00am-7:15am) with one passenger (Dorothy only) and 1 service provider

b. Transportation time of 15 minutes (7:15am-7:30am) with two passengers (Dorothy and Little) and 1 service provider

SERVICE TIME = (1 X 15) ÷ 2 = 7.5 minutes

c. Transportation time of 15 minutes (7:30am-9:00am) with three passengers (Dorothy, Little and Mary) and 1 service provider

15 min + 7.5 min + 30 min = 52.5 minutes

According to Attachment C: 52.5 minutes = 3 Units 80

(55)

Common Errors

• Overlapping times with other services

• Transportation method completed incorrectly

• Time not divided evenly between two or more individuals

receiving services at the same time

• Non-qualified Service Provider (Proof of residence, etc.)

• No justification for receiving SHL in DH facility

• No begin and/or end times on documentation

• No location of services provided on documentation

• No Progress Note

(56)

Foster Care

82

(57)

Specific Requirements

Foster Care Requirements of Setting

• The program provider may not lease or own the

residence

• The individual receiving care must have a

residence in which no more than three persons

receive: foster/companion care, a non-HCS

Program service similar to foster/companion

care; and

• If the individual is a minor, the parent or

step-parent may not provide this service

(58)

Specific Requirements

Foster Care Requirements of Setting

• The service provider must have the

same residence as the individual; and

• Ensure that foster/companion care is

provided to an individual when

necessary

(59)

Specific Requirements

Foster Care Unit of Service

• Unit of service is one day

• May not be for more than one day

• May not have a fraction of a unit of

service

(60)

Specific

Requirements

Foster Care Billable Activity

• Assisting the individual with activities of

daily living (bathing, dressing, personal

hygiene, eating, meal planning and

preparation and housekeeping)

• Assisting the individual with ambulation and

mobility

• Reinforcing any counseling and therapy

subcomponent provided to the individual

• Assisting with the administration of the

individual’s medication or to perform a task

delegated by an RN

(61)

Specific Requirements

Foster Care Billable Activity

• Conducting habilitation activities that

train the individual to:

– Develop or improve skills that allow

the individual to live more

independently

– Develop socially valued behaviors

– Integrate into community activities

– Use natural supports and typical

community services available to the

public

– Participate in leisure activities

(62)

Specific Requirements

Foster Care Service Claim for an

Individual on a Visit with Family or

Friend

A program provider may submit a service

claim for an individual who is on a visit with

a family member or friend away from their

residence if the visit is for at least a calendar

day. If the visit is for more than

14 consecutive calendar days

, the program

provider may submit a service claim for only

14 calendar days of the visit.

(63)

Specific Requirements

Foster Care Service Claim for an Individual on a

Visit with Family or Friend Written

Documentation

Written documentation must include the

individual’s name, the dates the

individual was visiting the family

member or friend, the location of the

visit and the date and signature of the

service provider.

(64)

Common Errors

• Failure to discharge individual while in the

hospital

• Weekly summary exceeds seven days

• Not documenting location information

• No Progress Note

(65)

Residential Support

Services

92

(66)

Specific Requirements

Residential Support Requirements of Setting

• The residence must be a Three or Four person

residence

• The program provider may not have the same

residence as the individual

• The service provider must be available to provide

residential support to an individual as needed; and

• The service provider must be present and awake in the

residence when the individual is present in the

residence

(67)

Specific Requirements

Residential Support Billable Activity

– assisting the individual with activities of daily living; – assisting the individual with ambulation and mobility;

– reinforcing any specialized therapies subcomponent provided to the individual;

– assisting with the administration of the individual's medication or to perform a task delegated by a registered nurse in accordance with rules of the Texas Board of Nursing at 22 TAC, Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions) or the Human Resources Code, §161.091-.093, as applicable;

– conducting habilitation activities that train the individual;

– securing transportation for or transporting the individual; and – supervising the individual's safety and security.

(68)

Specific Requirements

Residential Support Unit of Service

• Unit of service is one day

• A service claim may not be for more

than one day

• A service claim may not include a

fraction of a unit of service

(69)

Specific Requirements

Residential Support Service Claim for an

Individual on a Visit with Family or Friend

A program provider may submit a service claim for

an individual who is on a visit with a family

member or friend away from their residence if

the visit is for at least a calendar day. If the visit

is for more than

14 consecutive calendar days

,

the program provider may submit a service

claim for only 14 calendar days of the visit.

(70)

Specific

Requirements

Service Claim for an Individual on a Visit

with Family or Friend Written

Documentation

Written documentation must include

the individual’s name, the dates the

individual was visiting the family

member or friend, the location of the

visit and the date and signature of the

service provider.

(71)

Common Errors

• Failure to discharge individual while in the hospital

• Not providing location codes

• Not providing staff signatures

• Not showing night shift coverage activities

(72)

Supervised Living

100

(73)

Specific

Requirements

Supervised Living Requirements of Setting

• The residence must be a 3 or 4-person

residence

• The service provider must be available to

provide residential support to an

individual as needed; and

• The service provider must be present in

the residence when the individual is

present in the residence

(74)

Specific

Requirements

Supervised Living Billable Activity

– assisting the individual with activities of daily living; – assisting the individual with ambulation and mobility;

– reinforcing any specialized therapies subcomponent provided to the individual;

– assisting with the administration of the individual's medication or to perform a task delegated by a registered nurse in accordance with rules of the Texas Board of Nursing at 22 TAC, Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions) or the Human Resources Code, §161.091-.093, as applicable;

– conducting habilitation activities that train the individual;

– securing transportation for or transporting the individual; and – supervising the individual's safety and security.

(75)

Specific

Requirements

Supervised Living Unit of Service

• Unit of service is one day

• A service claim may not be for more

than one day

• A service claim may not include a

fraction of a unit of service

(76)

Specific

Requirements

Supervised Living Service Claim for an

Individual on a Visit with Family or

Friend

A program provider may submit a service claim

for an individual who is on a visit with a family

member or friend away from their residence if

the visit is for at least a calendar day. If the visit

is for more than

14 consecutive calendar days

,

the program provider may submit a service

claim for only 14 calendar days of the visit.

(77)

Specific

Requirements

Service Claim for an Individual on a

Visit with Family or Friend Written

Documentation

Written documentation must include

the individual’s name, the dates the

individual was visiting the family

member or friend, the location of the

visit and the date and signature of the

service provider.

(78)

Common Errors

• Failure to discharge consumer while in the

hospital

• Not providing location

• No Progress Note

(79)

Respite

108

(80)

Specific

Requirements

Respite

– is the temporary provision of assistance and support necessary for an individual to perform personal care, health maintenance and independent living tasks, participate in community activities, and develop, retain and improve community living skills; and – provides relief for a caregiver of the individual who:

• has the same residence as the individual;

• routinely provides assistance and support necessary for an individual to perform personal care, health maintenance and independent living tasks, participate in community activities, and develop, retain and improve community living skills; • is temporarily unavailable to provide such assistance and

support; and

• is not a service provider of foster/companion care,

residential support or supervised living to the individual.

4.06-1 109 http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4610

(81)

Specific

Requirements

Respite

Room and Board-

If respite is provided in a setting other

than the individual's residence, the

program provider must provide room

and board to the individual free of

charge.

4.06-1 110 http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4600

(82)

Specific

Requirements

Respite Billable Activity

• interacting face-to-face with an individual to:

– assist the individual with activities of daily living; – assist the individual with ambulation and mobility;

– reinforce any specialized therapies subcomponent provided to the individual;

– assist with the administration of the individual's medication or to perform a task delegated by a registered nurse in accordance with rules of the Texas Board of Nursing at 22 TAC, Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions) or the Human Resources Code, §161.091-.093, as applicable;

– conduct habilitation activities that teach the individual; – secure transportation for the individual;

– supervise the individual's safety and security; and

– transport the individual, except from one day habilitation site to another;

(83)

Specific

Requirements

Respite Billable Activity

• interacting face-to-face or by telephone with an individual or an involved person regarding an incident that directly affects the individual's health or safety; and

• performing activities that does not involve interacting face-to-face with an individual described in Section 4620.

(84)

Specific

Requirements

Respite must be provided:

Residence

• If an individual receives respite in a residence, the residence must be: – the individual's residence;

– a three-person residence; – a four-person residence; or

– the residence of another person (other than a three-person residence or a four-person residence) in which no more than three persons are receiving HCS Program services or a non-HCS program service similar to HCS Program services.

Non-residence

• If an individual is receiving respite during an overnight stay in a setting that is not the residence of any person, no more than six persons receiving HCS Program services or a non-HCS Program service similar to HCS Program services may be in the setting.

(85)

Specific

Requirements

Submitting a Service Claim for Respite

Respite Provided in an Individual's Residence

• If a program provider provides respite in an individual's

residence, the program provider may submit a service

claim for no more than 96 units of service (24 hours) in

one calendar day.

Respite Provided in Location Other Than the Individual's

Residence

• If a program provider provides 10 hours or more of

respite to an individual in one calendar day in a location

other than the individual's residence, the program

provider may submit a service claim for no more than 40

units of service.

(86)

Common Errors

• Location of service not on documentation

• Billing more than 10 hours for respite occurring out of the

individuals home

• Individual lives alone without a live-in caregiver

• No begin and/or end times

• Non Qualified Service Provider (Proof of residence, etc.)

• Not providing location information

• No Progress Note

(87)

Billing & Payment

Review Protocol

(88)

Billing and Payment Review

• Conducted by DADS Billing and

Payment staff

• Review of authorization and written

documentation of service delivery

maintained by program provider

(89)

Purpose:

To determine whether the program provider is in

compliance with the HCS Program Billing Guidelines

Outcome:

DADS will recoup non-verified claims that were not

supported by authorization and/or written

documentation and may require a corrective action

plan (CAP) by the program provider.

(90)

Types of Reviews:

• Routine

Once every 2 years, all services are reviewed with the

number of individuals reviewed and review period

determined by previous error rates or number of individuals

served

• Special

As determined by DADS, result of a complaint, referral or

billing anomalies

(91)

Routine or special review can be either:

• On-site

– conducted at provider’s place

of business

• Desk

– conducted at DADS Headquarters

(documentation submitted by mail )

(92)

Samples are chosen based upon documentation error rate:

Error Rate = non-verified dollars divided by

the total amount billed during the review

period

(93)

Example of Error Rate:

Non-Verified Claims Total...$15,400.00

Total Claims Billed...$125,600.00

$15,400.00

$125,600.00 = .1226

Error Rate: 12.26%

(94)

BPR sample size:

Error Rate

Less

Than Ten Percent (10%):

• Provider serves more than 10 individuals – 5 + 5% reviewed

• Provider serves less than 10 individuals – All reviewed

(95)

BPR sample size--

Error Rate

More

Than Ten Percent (10%):

• Provider serves more than 10 individuals – 10 + 10%

reviewed

• Provider serves less than 10 individuals – All reviewed

(96)

BPR sample size

Never Reviewed:

• Provider serves more than 10 individuals-

5 + 10%

• Provider serves less than 10 individuals-

up to 5

(97)

On-site Reviews:

Notification:

• Routine:

• At least fourteen(14) days notice by phone and followed by a

faxed letter.

• Individual sample list from outside of Waiver Contract Area

(WCA) of review location provided two business days prior to

Entrance Conference.

• Special:

• Will be conducted without notice.

(98)

On-site Reviews:

List of individuals within the review location’s WCA are

identified at Entrance Conference.

PROVIDERS ARE NOT PERMITTED TO CREATE ANY

DOCUMENTATION AT ANY TIME WHILE REVIEW IS IN

PROGRESS

(99)

Error Sheet Forms

(100)

Refuting – On-site Reviews

• Refuting is conducted while on-site.

• DADS will not accept additional

documentation or refute any unverified

claims after the Exit Conference.

(101)

Demand for Payment-on-site review:

Following the Exit Conference, generally within

30 days, DADS will send a certified letter

(Demand for Payment) to the provider

detailing any unverified claims. The letter

includes the amount to be recouped, any

required corrective action and notice of the

right to request an Administrative Hearing.

(102)

On-Site Review:

Request for Administrative Hearing (appeal)

Must be made within 15 calendar days from

receipt of certified green card from

Demand for Payment letter

(103)

Payment of unverified claims:

Recoupment is done electronically through the automated

billing system (CARE)

Please do not send checks.

(104)

Desk reviews:

Notification:

•Telephone and Certified Mail

(105)

Timeframe to Provide Documentation-desk review

14 calendar days from receipt of certified

green card from notification letter.

Documentation received after 14 days has

elapsed will not be accepted and all

services requested will be subject to

recoupment.

(106)

Results-desk review:

Provider notified of results in certified letter

Refuting-desk review:

Additional documentation must be submitted within 14

calendar days of receipt of certified green card from

results letter

Late submissions are not accepted

(107)

Demand for Payment-desk review:

Certified letter notifies provider of final account of unverified

claims after considering refuting documentation (if any

submitted)

(108)

Desk Reviews:

Request for Administrative Hearing

(appeal):

Must be made within 15 calendar days

from receipt of certified green card

from Demand for Payment letter

(109)

Payment of unverified claims:

Recoupment is done electronically through the automated

billing system.

Please do not send checks.

(110)

(111)

2011 Billing Guidelines

Guidelines:



http://www.dads.state.tx.us/handbooks/h

csbg/index.htm

Guideline Changes:



http://www.dads.state.tx.us/handbooks/h

csbg/rmemo/11-1.htm

(112)

Section Title Change

2000 Definitions Adds definitions for competitive employment, comprehensive assessment, focused assessment, integrated employment, service coordination and service coordinator.

3210 General Requirements Updated references. 3230 Service Claim for Day Habilitation for

Individual Receiving Supported Employment

Deleted.

3230 Service Claim for Foster/Companion Care, Residential Support or Supervised Living for Individual on a Visit with Family or Friend

Section 3240 is renumbered to 3230.

3430 Relative, Guardian or Managing Conservator Qualified as Service Provider

Updates information in the first paragraph and deletes outdated information.

3610 15-Minute Unit of Service Defines “person” under No. 2, Service Time.

3620 Daily Unit of Service Updates billable units of service.

3700 Billing Service Components Provided at the Same Time and Billing Day

Habilitation Provided at the Same Time as Service Coordination

Revises section heading.

3730 Service Coordination and Day

Habilitation Provided at the Same Time Adds new section.

3810 General Requirements Adds new information and deletes outdated material.

3820 Written Service Log and Written

Summary Updates section title; adds new information; deletes outdated material.

3850 Example Forms Updates title and adds new information.

4210 General Description of Service

Component Defines specialized therapies subcomponents.

4220 Billable Activity Updates billable activities for the specialized therapies.

4230 Activity Not Billable Updates examples of non-billable activities.

4250 Unit of Service Adds service time information.

4260 Written Documentation Updates documentation required to support a service claim for specialized therapies.

4320 Requirements of Setting Adds retirement age as justification for providing day habilitation at the individual’s residence.

4370 Unit of Service Updates billable units of service.

4380 Written Documentation Deletes outdated information and clarifies required documentation to support a service claim for day habilitation.

(113)

4390 Submitting a Service Claim for Individuals Receiving Supported Employment

Deleted.

4420 Billable Activity Updates billable activities for the licensed registered nursing service component.

4430 Activity Not Billable Updates text.

4450 Unit of Service Adds No. 3, Service Time.

4470 Written Documentation Deletes outdated information.

4471.2 Billable Activity Updates billable activities for the licensed vocational nursing service component.

4471.3 Activity Not Billable Updates examples of non-billable activities.

4471.5 Unit of Service Adds No. 3, Service Time.

4471.7 Written Documentation Deletes outdated information.

4472.2 Billable Activity Updates billable activities for the specialized registered nursing service component.

4472.3 Activity Not Billable Updates text.

4473.2 Billable Activity Updates bill activities for the specialized licensed vocational nursing service component.

4473.3 Activity Not Billable Updates text.

4540 Supported Home Living Subcomponent Updates rule citations; adds new requirements; deletes outdated information.

4550 Foster/Companion Care Subcomponent Updates rule citations; clarifies requirements for service provider; updates text in No. 5, Restrictions Regarding Submission of Claims for Foster/Companion Care; and clarifies required documentation in No. 8, Written Documentation.

4560 Residential Support Subcomponent Deletes text under No. 1(d), Service Provider Shifts; updates rule citations under No. 2, Billable Activity; updates information in No. 5, Restrictions Regarding Submission of Claims for Residential Support; adds new bullet under No. 8, Written Documentation; and makes minor wording changes to No. 9, Submitting a Service Claim for an Individual on a Visit with Family or Friend.

4570 Supervised Living Subcomponent Updates rule citations under No. 2, Billable Activity; updates information in No. 5, Restrictions Regarding Submission of Claims for Supervised Living; adds new bullet under No. 8, Written Documentation; and makes minor wording changes to No. 9, Submitting a Service Claim for an Individual on a Visit with Family or Friend.

Component Updates information in No. 1, Temporary Provision of Assistance, and No. 2, Room and Board.

4620 Billable Activity Updates rule citations.

4651 Restrictions Regarding Submission of

Claims for Respite Adds reasons for which a program provider may not submit a service claim.

4690 Written Documentation Deletes a bulleted item and makes minor wording changes.

Component Updates definition of supported employment.

4730 Billable Activity Adds transporting individual to and from the individual’s work site as a billable activity for the supported employment service component.