MAC Coordinators Training

MACCoordinators Training Administrative Claiming Coding Review Updated - August 26, 2009

Presented By: Oregon Department of Human Services Medicaid Administrative Claiming Finance and Policy Analysis Unit (add trainer information) Linda Williams Lasa Baxter Linda.J.Williams@state.or.uslbaxter@ubesd.k12.or.us (503) 945-6730 (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 low blood sugar, tested himself and was found to have a low 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?NO, monitoring of a health condition is not claimable under code C1 regardless of the severity or type of health condition as it is considered integral to or an extension of a direct medical service.

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 medical service and the activity must be coded - F. • Is the monitoring a claimable activity? NO, the monitoring activity is related to a direct medical service activity and therefore is not claimable. This activity must also be coded – F.

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 non-OHP 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 self-medication 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, handing-out medications is not a claimable service under MAC. • Is the time the secretary spent monitoring the students after they self-medicate for adverse reactions claimable?NO, monitoring for adverse reactions to medication is an extension of a direct medical service and must be coded – F.

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 or performs follow-up activities to ensure medical services were received.

8) Teacher: Referred student to an RN at the County Health Department to be treated for head lice.

Is the referral by the teacherfor 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 adirect 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 15-minute 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 assistantfor and coordination of the nursing services a claimable activity? YES, under code C1.1 as long as the school was a Medicaid billing providerand 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.) This example must be coded C1.1 – coordinating medical care.

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 15-minute 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 teacherto 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 counselorspent 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 teacherspent 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 secretaryspent 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 SupportClaimable 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. • GOOD EXAMPLE • C1.1 – I referred a student to the RN to receive an insulin injection as needed.

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

MAC Coordinators Training