Chapter 538 School-Based Health Services

1. Chapter 538 School-Based Health Services Targeted Case Management (TCM) Billing

2. Effective August 1, 2019 • Targeted Case Management (TCM) can only be billed for students getting billable services based upon medical necessity. • An SLD student who doesn’t have Speech, OT, PT, Nursing, Audiological, Personal Care, Psychotherapy, or Behavior intervention would not be eligible for TCM • Can be billed by multiple providers, but should be coordinated by one person. Billing is for the county not the individuals. Combine all for the daily billable total.

3. Targeted Case Management • Procedure code T1017 SE is billable in fifteen-minute units. • TCM is capped at five units per instructional day. • TCM can be billed on days the student is absent. • Minutes can be combined from multiple days in one month to create a unit. In that scenario bill the unit the day the 15th minute occurs.

4. Demographics • Enter the date of the Plan of Care at the top right of the page. • Complete the sections with attention to the following: • The diagnosis code should not be based on an education disability such as Learning Disability. Ex. An LD student with speech as a related services, use a speech diagnosis code.

5. Complete the demographics:

6. Approved Activity List • Has been organized into four major categories • A – Needs Assessment and Reassessment • B- Development/Revision of the Services Plan • C- Referral and Related Services • D- Monitoring and Follow up

7. A – Needs Assessment and Reassessment • Review of the individuals current and potential strengths, resources, deficits, medical services or other services • Gather information from sources such as family medical providers, social worker, educators to form a complete assessment. • Review the results of the assessments and evaluations with the individual and or their parents and/or guardian to determine services are needed. • Face to face reassessments shall be completed annually, at a minimum, to determine if the clients needs or preferences have changed.

8. Billable example of TCM for activity A • Activity: A. Assessed current progress notes/therapy logs. • Purpose: Coordinate and provide a continuity of services. • Individualized Services Note: Reviewed current therapy notes to prepare for continuation of therapy, and assess present level of performance. • ** This is billable because the individualized service note explains the activity and purpose. The entire claim can be read as a paragraph and it makes sense.

9. Non-billable example of TCM for activity A • Activity: Consulted/met with teacher (General or Special Ed) teachers • Purpose: Assess/reassess progress and generalization of Medicaid related services. • Individualized service Note: Discussed with general education. • ** This is not billable because the individualized service not does not provide any information that explains the activity and purpose, it only repeats the activity.

10. B- Development/Revision of Service Plan • Develop a written plan bases on the assessment of strengths and needs, which identifies the activities of assistance needed to accomplish the goals that were collaboratively developed by the individual, their parents, and/or guardian. • Development and periodic revision of the TCM service plan will specify the goals and actions to address the medical, social, educational, and other services needed by the individual. • The IEP is not the TCM Services Plan.

11. Billable example of TCM for activity B • Activity: Conducted a revision of a plan. • Purpose: Coordinate a continuity of services • Individualized Services Note: We updated the plan to reflect the newly added speech therapist that will be providing therapy. Sent parent/guardian updated plan. • **This TCM is billable. The individualized service note explains the activity and the purpose.

12. Non-billable example of TCM for activity B • Activity : C. Consulted/met with teacher (General or Special Ed) teachers • Purpose: Assure student receives appropriate actions as medically necessary. • Individualized Service Note: Attended IEP meeting. • ** This is non-billable because we cannot get reimbursement for attending the IEP meeting, however you can bill for drafting a service care plan. TCM is a function of the service care plan, health care plan or BIP!

13. C- Referral and Related Activities • Facilitating the individual’s access to the care, services, and resources through linkage, coordination, referral, consultation, and monitoring. • Conducting in-person and telephone contacts with the individual, their parents and/or guardian as necessary but at least annually. • Facilitating the individuals physical accessibility to services. • Arranging transportation to medical, social, educational, or other services. • Advocating for the individual. • Linking the individual and their family to resources in the community and providing information for obtaining these services through community programs.

14. Billable example of TCM for activity C • Activity:  Consulted with parent/guardian. • Purpose: Determine an appropriate Behavior Intervention Plan as it relates to medically necessary services • Individualized Service Note: Advised parent of a behavioral issue that has recently developed while student is in speech class.  Invited parent and speech therapist to meet with me on Friday to address the current activity and develop a plan to address the area. • ** This TCM is billable because the author is creating a BIP and the individualized service note is very clear and explains the activity.

15. Non-billable example of TCM for activity C • Activity: Advocated for Student with administration. • Purpose: Coordinate a county of services. • Individualized Services Note: Talked with principal about the possibility of testing for gifted program for this student. *** Gifted services, are not billable.

16. D-Monitoring and Follow- Up Activities • Conduct monitoring and follow- up activities with other service providers, the individual, their family or guardian to ensure services are being furnished in accordance with the TCM serviceplan. • Periodic review of the individual’s progress and effectiveness of the services be provided, which may result in a revision of the plan, continuing the plan, or termination of the TCM services if they are no longer appropriate. • These reviews may be completed through personal and telephone contacts with the individual and other involved parties. • These reviews must be conducted at least annually.

17. Billable example of TCM for activity D • Activity: A. assess/reassess student • Purpose: Assure student receives appropriate action as medically necessary. • Individualized Services Note: Monitor compliance with special diet and check for any problems she may be having. No evidence of allergic reaction pertaining to her special diet at this time. • ** This is billable because the individualized service note explains the activity and purpose. The claim can be read as a paragraph and makes sense.

18. Non-billable examples of TCM for activity D • Activity: C. Consulted/met with teacher (General or Special Ed) teacher. • Purpose: Assess if target communication skills are being generalized in the school environment. • Individualized Services Note: Consulted with teachers about Bob’s grades to prepare his progress report. • ** This is not billable because we cannot ask for reimbursement for academic purposes.

19. Key Words • When thinking about TCM activities think of these words or words like these: • Coordination • Linking • Referring • Advocating • You are doing these activities everyday anyway in your jobs, so give yourself the credit you deserve!

20. Words to avoid in the Individualized Note • Academic related – Discussing math, writing, reading, science or any other academic area is not considered TCM. • Teaching – Teaching is not TCM. Teaching social skills is not TCM billable. Providing interventions from a BIP is TCM billable. • IEP – If billing for drafting or revising a plan, use the appropriate terms such as Plan of Care, BIP, Nursing Care Plan, etc. You are drafting a Plan of Care in conjunction with drafting an IEP for medically appropriate portions of the IEP (not academic sections).

21. Compete the activity documentation section • Enter the date of service by typing or using the calendar link • Enter the number corresponding to the type of contact • Enter A-D for the type of TCM activity • Enter the state and end times • Enter the total minutes • Under Progress Note select an approved activity from the menu. • Select an approved purpose from the menu that is appropriate for the activity. • Individualized Service Note – Write one personalized sentence to explain what you did. • Sign, enter credentials and Date.

22. Compete the activity documentation section

23. Contact Information Kelley Johnson – CoordinatorOffice of Special Educationkelley.johnson@k12.wv.us304-558-2696 ext 53539WVDE Medicaid Website:https://wvde.us/special-education/Medicaid/