Transcript Procedure Code Review

MAC
Coordinators Training
Administrative Claiming Coding Review
Clackamas, OR
August 15, 2006
Presented By:
Oregon Department of Human Services
Medicaid Administrative Claiming
Finance and Policy Analysis Unit
(add trainer information)
Fritz Jenkins
[email protected]
(503) 945-6104
Linda Williams
Lasa Baxter
[email protected]
(503) 945-6730
[email protected]
(541) 975-5614
Administrative Claiming
Coding Review
The following slides contain examples of
activities and supporting documentation
provided by MAC survey participants in the
school setting.
The intent is to provide clarification in coding
of example activities, as well as to assist in
the most effective means of documentation
supporting those activities.
1) Classroom Teacher: A student with
diabetes presented signs of high blood
sugar, tested himself and was found to have
a high blood sugar level. I referred the
student to the RN to assess the blood sugar
level and provide an injection as needed.
The nurse assessed the test results and
gave the student the appropriate injection.
I monitored the student for 15 minutes to
ensure no adverse reactions occurred.
• Is referring the student to the RN a claimable
activity? YES, under code C1.1 as long as the referral
took the predominant portion of a 15-minute period and
the school is registered as a Medicaid provider.
• Is the time the nurse spent giving the injection
claimable? NO, the nurse is providing a direct service.
(Any activity the nurse performs that stems from this
direct service is also not claimable.)
• Is the 15 minutes spent monitoring the student
for adverse reactions by the classroom teacher
claimable? YES, under code C1.3 only if the
monitoring activity is the predominant activity assigned
to the teacher at the time. If the predominant activity
the classroom teacher is performing is teaching during
the 15 minute period in question it is not claimable. In
order for a monitoring activity to be claimable it must be
performed by someone other than the direct service
provider and take the predominant portion of a 15minute period.
2) Delegated Health Care Aide:
A student had an irritated area
around their trach that had to be
cleaned repeatedly throughout the
day. I followed trach protocol and
delegated health care procedures,
which included monitoring the
student to ensure they did not pick
around the irritated area.
• Is the cleaning of the irritated
area around the trach a
claimable activity? NO, the
staff member trained in the
delegated health care procedure is
providing a direct service.
• Is the monitoring a claimable
activity? NO, the monitoring
activity is related to a direct service
activity and therefore is not
claimable.
3) School Counselor: Spoke with dental
office to coordinate services for Spanish
speaking family. Discussed available OHP
covered services and coverage options
with family. Discussed potential use of
Lions club coupon for glasses.
• Is the time by the school counselor
spent :
• Coordinating dental services a
claimable activity? YES, it is claimable
under code C1.2 as long a it took the
predominant portion of a 15-minute period
and the person providing the dental
services is a Medicaid provider.
• Describing OHP covered services and
coverage options with the family a
claimable activity? YES, it is claimable
under code B1.1 as long as it took the
predominant portion of a 15-minute
period.
• Discussing alternative means of
obtaining glasses a claimable
activity? NO, discussing means of
obtaining health care services under nonOHP programs is not claimable.
4) Teacher: Gathered information for
Mental Health referral on a student in
collaboration with the school
counselor to be reviewed by school
psychologist and the student’s private
mental health counselor.
• Is the time the teacher spent
gathering information in advance of a
mental health referral claimable?
YES, under code C1.1 as long as it took
the predominant portion of a 15-minute
increment and the gathering of
information was for an OHP covered
service provided by the private mental
health counselor.
5) Office Secretary: A child came to the
office and requested assistance in testing
her blood sugar because she felt low and
was not able to test herself. I tested the
child’s blood sugar and reported the very
low count to her parents. I then
monitored her for 15 minutes and then
retested her. After being tested for the
second time her blood sugar count was
still extremely low, so I continued to
monitor her for an additional 15 minutes.
I was in contact with the parents to
determine the next appropriate action
throughout. While the direct service took
only a few minutes the monitoring activity
took 45 minutes.
• Is the time the secretary spent
checking the student’s blood sugar
level a claimable activity? NO, the
activity is considered a direct medical
service and is not claimable.
• Is the time the secretary spent
monitoring the child’s blood sugar
level a claimable activity? NO, the
activity is integral to or an extension
of a direct medical service.
6) Office Secretary: I
handed-out medications
to students for them to
complete selfmedication then
monitored the students
for a 15 minute period
to ensure no adverse
reactions to the
medications occurred.
• Is the time the secretary spent handing-
out medications claimable? NO, although
handing-out medications is not considered
a direct service, it is not a claimable
service under MAC.
• Is the time the secretary spent monitoring
the students after they self-medicate for
adverse reactions claimable? YES, under
code C1.3, if it occurs directly following
the hand-out of medication and as long as
the monitoring activity is the primary
focus of the activity being performed and
took the predominant portion of a 15minute period.
7) Teacher: Participated in an IEP
meeting to discuss and evaluate the
medical service components of the
IEP.
• Is the time spent evaluating the medical
service components of the IEP during the
IEP meeting a claimable activity?
NO, none of the activities performed during an
IEP meeting(s) are claimable under MAC, even if
an activity (such as evaluating the medical
service component of the IEP, Code C.1) occurs.
• NOTE: Any activity involved in the initial
development of the IEP and/or formal IEP
meetings (i.e. annual, 3-yr.) is not claimable
under MAC.
Monitoring and Evaluating the
Medical Service Component of the
IEP
What are some examples of claimable activities
that fit the above description?
– Appropriate staff participate in evaluating the medical
component(s) of an IEP in a team conference or
individually with a therapist.
– Appropriate staff observes the delivery of medical
services on a child’s IEP to ensure they are receiving
prescribed Medical services.
8) Teacher: Referred student to
an RN at the County Health
Department to be treated for
head lice.
• Is the referral by the teacher for treatment
of head lice to medically qualified staff a
claimable activity?
– YES, the referral for treatment of head lice is
claimable under code C1.1 as long as the treatment is
provided by a Medicaid provider. Gathering
information in advance of the referral to a Medicaid
provider for treatment by checking a student for head
lice is also a claimable activity under code C1.1.
– NOTE: Referral for treatment of head lice is not claimable if it is not
provided by a Medicaid provider, such as when a student is treated
solely at home by parents.
– Checking head lice as part of regular school policy or procedures for all
students is not a claimable activity under MAC. In order to be
claimable, the gathering of information in advance of a referral by
checking for head lice, must be completed based on individual need.
9) Nurse: Received requested
information from a student’s
physician regarding a medical
protocol procedure on
catheterization. Discussed next
years needs with doctor.
• Is the time the nurse spent
gathering patient history and
procedures for medical protocol
a claimable service?
NO, the activity provided is integral
to or an extension of a direct service
provided by the nurse.
10) School Counselor: Met with a
student with special needs who had become
volatile. Gathered information, encouraged
him to be willing to seek professional help
for anger. Contacted and met with parents
to discuss behavior patterns.
Recommended the family seek professional
support for student and provided referral
connections to county mental health and a
private practitioner.
• Is the time the school counselor spent
gathering information about the student
from both the student and the family a
claimable activity? YES, under code C1.1 as
long as it took the predominant portion of a 15minute period and was not provided as part of
existing direct therapy services.
• Is the time the school counselor spent
completing the referral a claimable
activity? YES, under code C1.1 as long as it
took the predominant portion of a 15-minute
period and was not provided as part of existing
direct therapy services.
11) Classroom Assistant: Made a
referral to and scheduled an
appointment with the school RN to
evaluate a student’s skin issue.
Escorted student with behavior
issues to appointment with nurse,
shared concerns, stayed with the
student while the nurse completed
the exam and escorted student back
to class.
• Is the referral by the classroom assistant for and
coordination of the nursing services a claimable
activity? YES, under code C1.1 as long as the school
was a Medicaid billing provider and the referral took the
predominant portion of a 15-minute period.
• Is escorting the student with behavior issues to
and from the RN appt. to ensure the student
receives the health service they were referred for a
claimable activity? It depends on the following:
– If escorting or supervising a child with behavior issues is
performed as part of standard school policy or procedures the
activity is not claimable.
– If an escort or supervision is required for a child based on a
Medical need and is performed to ensure the child receives a
Medicaid covered service the activity may be claimable. (For
example: I escorted a diabetic child who had extremely low blood
sugar to the RN to receive a necessary insulin injection.)
12) Special Education Teacher:
Met with OT/SLP/Special Education
Director to develop and discuss
strategies to improve the delivery of
OT and Speech services throughout
the district.
• Is the time the special education teacher
spent developing and discussing strategies
to improve the delivery of Medicaid
covered health services in a school district
claimable?
YES, it is a claimable activity under code E1.1 as
long as it took the predominant portion of a 15minute period.
Note: Generally, strategy meetings of this nature
are regularly scheduled and take at least 30+
minutes.
13) Classroom Teacher at
Therapeutic School: Visited a
child/family on OHP at home as
follow-up to ensure the child was
receiving prescribed medical health
services. The child was recently
injured in an accident and received
surgery at OHSU.
• Is following-up by the teacher to
ensure that prescribed Medicaid
covered health services are being
provided a claimable activity?
YES, under code C1.3 as long as it took
the predominant portion of a 15-minute
period and because the service was
provided by a Medicaid provider.
14) School Counselor: Discussed
with teacher general health issues
impairing a student’s education.
• Is the time the school counselor
spent discussing general health
issues impairing a student’s
education a claimable activity?
NO, discussion of general health
issues is not a claimable activity.
15) Teacher: Discussed with
high school students in Life
Skills/Health class how to access
and use OHP. Also discussed
what services are covered under
OHP.
• Is time the teacher spent informing
HS students of how to access and use
OHP a claimable service?
YES, informing potential clients according
to their individual needs of how to access
and use OHP is considered outreach and
may be claimed under code B1.1.
CAUTION: Providing information on OHP
as part of regular classroom curriculum is
not a claimable activity.
16) Office Secretary: Contacted
parents to discuss their child’s
immunization status. I provided
information about a free clinic to
meet the student’s immunization
needs.
• Is time office secretary spent
informing parents of
immunizations available at a free
clinic a claimable activity?
NO, informing people of free health
care options is not a claimable
activity.
Documentation to Support
Claimable Activities
• When completing documentation to support
claimable Medicaid Administrative Claiming
(MAC) activities, it should be:
– Brief;
– Concise;
– Use descriptive words (For example, use the code
descriptions in the MAC provider manual as your
guide such as referred, coordinated, monitored,
etc.); and
– Only provide information pertinent to the claimable
activity that was performed.
Documentation Examples
• POOR EXAMPLE
A student with diabetes presented signs of low blood sugar, tested
himself and was found to have a low blood sugar level. I referred
student to the RN to assess the blood sugar level and provide an
injection as needed. The nurse assessed the test results and gave
the student the appropriate injection. I monitored the student for
15 minutes to ensure no adverse reactions occurred.
• GOOD EXAMPLE
– C1.1 – I referred a student to the RN to receive an insulin
injection as needed.
– C1.3 – I monitored the student for 15 minutes afterward to
ensure no adverse reactions occurred.
Are Trainings Claimable?
• Participation in some trainings is claimable
•
under code C1. The premise for claiming
trainings is that they fit within the
following description:
This code may also be used when
coordinating and participating in training
events and seminars for outreach
regarding the benefits of the
Medicaid/OHP program, how to assist
families to access Medicaid/OHP services,
and how to more effectively refer students
for services.
Examples of Claimable
Trainings
• Participating in a MAC training (Note: This does not include
•
•
•
instructions on how to complete a survey form or the web-based
survey.)
Attending a seminar on how to effectively provide OHP outreach to
pregnant and parenting teens
Participating in a training to learn how to assist potential OHP
clients in completing an OHP/CHIP application
Participation in the portion of a training that focuses on
recognition of signs & symptoms of specific medical conditions.
Examples of the portion of trainings that may be allowable:
– Training to recognize signs and symptoms of potential suicide
risk
– Training to recognize the signs and symptoms of Autism
– NOTE: Most trainings to identify signs and symptoms are not
claimable in their entirety, such as the portion dealing with the
district policies and protocols.
Examples of
Non-Claimable Trainings
• Participating in a First Aid Training
• Participating in an EPI Training
• Attending a lecture on IDEA Reauthorization:
•
•
•
How the changes will affect district and health
agencies in disciplining students with disabilities
Participating in a seminar on “Strategies to keep
kids in school and lower problem behaviors for
students on IEP’s”
Bloodbourne Pathogens Training
NOTE: Trainings whose sole purpose are to assist
in the improvement of professional skills or
development are not claimable.
QUESTIONS