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Chapter 538 School-Based Health Services

This chapter provides information on school-based audiology billing, including obtaining consent, documenting services on the Plan of Care, using specific ICD-10 diagnosis codes, obtaining physician authorization, recording student demographics, and completing the billing form. It also discusses Medicaid billing as a secondary insurance and provides contact information for assistance.

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Chapter 538 School-Based Health Services

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  1. Chapter 538 School-Based Health Services Audiology Billing Form

  2. 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.

  3. 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 Autism would not be appropriate.

  4. Physician Authorization Form • Physician Authorization (PAF) is required annually to bill for occupational therapy. • The Audiologist is to document suggested ICD-10 diagnosis codes that specifically relate to the therapy being provided. • When the physician signs the authorization form they are confirming the 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). • Should still obtain PAF even if the student will be working with an SSLPA.

  5. 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 audiology. • 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.

  6. Service Record – School Based Audiological Billing Form

  7. Service Record – School Based Audiological Billing Form

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

  9. ICD 10 Diagnosis Codes

  10. ICD 10 Diagnosis Codes

  11. Procedure Code Changes • The following is no longer a valid CPT code for billing audiological services in West Virginia. • 92561 – Bekesy Diagnostic

  12. Audiological Services: Physician’s authorization on file. Must be on Plan of Care. Part One

  13. Audiological Services: Physician’s authorization on file. Must be on Plan of Care. Part Two * Procedures performed during Audiology Hearing Evaluations **Unit is one encounter/visit (with no time limit) unless otherwise specified

  14. Enter Claim Documentation • Use the CPT codes and caps from slides 12-13 to complete the claim documentation section of the billing form. • In the first column list the service date. • Column two - enter one or more of the diagnosis code numbers that directly relates to the service. (examples 1, 1 & 3, 2) • Column three - enter the CPT code. • Columns four and five - enter the start and end time. • In the last column enter the total number of event(s).

  15. Claim Documentation

  16. Claim Documentation

  17. 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.

  18. Signature and Credentials _____________________ ______________ Signature/Credentials Date

  19. Signature and Credentials __Marion Downs___ AUD___October 1, 2019 Signature/Credentials Date

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

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