Chapter 538 SchoolBased Health Services Occupational Therapy Billing

Chapter 538 School-Based Health Services Occupational Therapy Billing Form Effective August 1, 2019

Consent to Bill Medicaid • Prior to billing parents must provide written consent to release information and to bill for Medicaid reimbursement. • Consent is valid for one calendar year from the signature date. • Parents are to be provided an annual notice. 2

Plan of Care • Services must be documented on the Plan of Care signed by the parent and therapist. • Effective August 1, 2019 Service Care Plan is now called a Plan of Care. This provides more consistency and avoids a terminology conflict with private school service plans. There is not a need to have a new one signed if it says Service Care Plan • The IEP Program has been adjusted to reflect the change in terminology. • Specific ICD-10 diagnosis codes are required. ICD-10 codes must relate to the specific type of therapy being provided. Think of these more as treatment diagnosis codes. All appropriate diagnosis codes need to be listed on the Plan of Care. • A global code such as Cerebral Palsy would not be appropriate. 3

Physician Authorization Form • Physician Authorization is required annually to bill for occupational therapy. • The Occupational Therapist is to document suggested ICD-10 diagnosis codes that specifically relate to therapy being provided. • When the physician signs the authorization form they are confirming therapist’s code(s). • Authorizations can be signed by a Physician (MD or DO), Physician’s Assistant (PA) or by an Advanced Practice Registered Nurse (APRN). 4

Student Demographics • Use the student’s real name as listed in WVEIS • The diagnosis code is to be an ICD-10 code that matches the need for occupational therapy. • County and school names can be written out or use the county and school WVEIS codes. • For provider name print the name of the person providing the service. 5

Service Record – School Based Occupational Therapy Billing Form Medicaid Number Last Name First Name WVEIS Number Date of Birth Provider Name County School Month/Year 6

Service Record – School Based Occupational Therapy Billing Form Medicaid Number Last Name First Name 03900000001 Doe Brody WVEIS Number Date of Birth Provider Name 99999 9 -11 -2001 William Dunton Jr County School Month/Year Vandalia 501 Sept/2019 7

Diagnosis Codes • Enter the OT specific ICD 10 Diagnosis Codes on the form starting with box number one. • Enter the codes that are directly associated with therapy sessions and/or assessments. 8

ICD 10 Diagnosis Codes LIST ALL DIAGNOSIS CODES RELATED TO OCCUPATIONAL THERAPY 1. 2. 3. 4. 5. 6. 9

ICD 10 Diagnosis Codes LIST ALL DIAGNOSIS CODES RELATED TO OCCUPATIONAL THERAPY 1. R 26. 9 2. M 62. 81 3. R 27. 8 4. 5. 6. 10

Occupational Therapy Procedure Codes Code 97165 97166 97167 97168 97032 GO 97110 GO 97112 GO 97113 GO 97116 GO 97150 GO 97140 GO 97533 GO Procedure Occupational Therapy Evaluation Low Complexity Occupational Therapy Evaluation Moderate Complexity Occupational Therapy Evaluation High Complexity Occupational Therapy Re-evaluation Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility each 15 minutes Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception for sitting and/or standing activities, each 15 minutes Aquatic Therapy with therapeutic exercises, each 15 minutes Gait training (includes stair climbing) each 15 minutes Therapeutic procedure(s), group (2 or more individuals), each 15 minutes. Manual therapy techniques (mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions each 15 minutes Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance) each 15 minutes Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes Service Unit 1 event per calendar year 2 events per calendar year 20 units per month 20 units per month 20 units per month 11

Procedure Code Changes • Procedure Code 97532 GO is no longer a valid CPT code. 12

Enter Claim Documentation • Use the CPT codes and caps from slide nine to complete the claim documentation section of the billing form. • In the first column list the service date. (If combining minutes from different days for a unit use the date the 15 th minute occurred to complete the unit. No span dates are allowed. ) • Column two - enter one or more of the diagnosis code numbers that directly relates to the services. (examples 1, 1 & 3, 2) • Column three - enter the CPT code including the GO modifier if appropriate. • Columns four and five - enter the start and end time. • In the last column enter the total number of units or event(s). 13

Claim Documentation Service Date List Diagnosis Code Number(s) Procedure code Start Time End Time Units/Event 14

Claim Documentation Service Date List Diagnosis Code Number(s) 9 -3 -2019 9 -6 -2019 9 -10 -2019 9 -13 -2019 9 -17 -2019 9 -20 -2019 9 -24 -2019 9 -27 -2019 1 2, 3 1 1, 2, 3 Procedure code 97116 GO 97110 GO 97116 GO 97168 GO Start Time End Time Units/Event 9: 12 1: 30 9: 12 10: 00 9: 37 1: 45 9: 37 2: 00 9: 37 11: 14 1 1 1 2 1 1 15

Third Party Billing • At times a student may be eligible for Medicaid as the secondary insurance. • Medicaid is the payer of last resort for direct services (OT, PT, Speech, Audiology, Psychological, and Nursing). • If the student has special transportation services, the direct billing should be submitted. The claim will be denied but will justify claiming transportation billing for that instructional day. • Medicaid will pay ancillary services (TCM, personal care aide and special transportation) as the secondary insurance. • Occasionally a student may be eligible for Medicaid under two numbers. In this case district’s should always use the primary Medicaid number. 16

Certified Occupational Therapy Assistant (COTA) • COTAs can only bill for therapy when an Occupational Therapist (OT) certified by the WV Board of Examiners is directly supervising. • Directly supervising requires the Board Certified OT to be on site when therapy is being provided. • COTA progress/therapy logs are to be co-signed by the supervising OT for therapy dates that are billed for Medicaid. This only applies to dates when the OT was directly supervising the COTA. To make this clear to the person entering billing, the OT should initial the days that they provided direct supervision. • COTAs can not bill for evaluations.

Signature and Credentials • Staff who provided or directly supervised the service will sign the form and list credentials. • For COTAs, the supervising OT must co-sign the billing form and initial specific claims directly supervised. • An OT is considered to be directly supervising when in the building at the time of the service. • Claims initialed by the OT can be submitted for billing.

Signature and Credentials __________ Signature/Credentials ________ Date Co-Signature/Credential (Initial dates directly supervised) Date 19

Signature and Credentials __William Denton Jr. ____ Signature/Credentials OT___ October 1, 2019 Date Co-Signature/Credential (Initial dates directly supervised) Date 20

Additional Documentation • Progress/therapy logs will also be required. • Original copies of progress/therapy logs must be on file in the special education central office. • There is not a required form for documentation of progress/therapy logs.

Kelley Johnson – Coordinator Office of Special Education kelley. johnson@k 12. wv. us 304 -558 -2696 ext 53539 WVDE Medicaid Website: https: //wvde. us/special-education/Medicaid/