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Missing Medicaid Billing Codes for LEA

Posted on 11/20/2015 at 12:00 AM by MaryAnn Strawhacker

Dear School Nurses:

I went to the Local Education Agency (LEA) Medicaid manual late summer to determine what had changed, only to discover the billing codes school nurses use were gone! It wasn't until yesterday that I was actually able to call Jim Donoghue at the Iowa Department of Education to investigate. Promised I would pass along his insights to all of you. Yes indeed ,the billing codes are no longer found in the manual. To make all the Medicaid manuals uniform, DHS removed codes from the LEA manual. To match labels with billing codes now requires multiple steps.

1. On page 73 of the LEA manual there are two links labeled click "here". One provides you with the label for the code and its maximum rate, regardless of actual cost, that a district may bill for a particular code. The second list is your actual district rate, determined for you based on your costs submitted to the Department of Education.

2. You must use these two lists together to match codes with labels.

Below I have listed the most common Medicaid health billing codes with the maximum LEA rate. Transportation has no maximum listed but is strictly figured by district. This example is to show you that the code numbers themselves have not changed.

  • T1001 Nursing Assessment/Evaluation (can only bill once per day)  $189.00
  • T1002 RN Services *up to 15 minutes   $21.00
  • T1003 LPN Services *up to 15 minutes $18.90
  • T1019 Personal Care Service per 15 minutes   $10.50
  • ^   T1020 Personal Care Service per diem     $294.00
  • 96152 Health and Behavior Intervention/15 minutes $10.20
  • 96153 Health and Behavior Interventions, group/15 minutes $4.95
  • A0090 Non-emergency transport; per mile no max listed
  • A0100 Taxi no max listed
  • A0110 Bus no max listed
  • A0120 Mini Bus no max listed
  • A0130 Wheelchair van no max listed

These are the definitions from the manual to help you decide.

Personal Health Services
"Personal health services primarily involve hands-on assistance with a student’s physical dependency needs. Services are related to a student’s physical requirements for activities of daily living, such as assistance with eating, bathing, dressing, personal hygiene, bladder and bowel requirements, and taking medications.

The services must be included in a treatment plan developed by the licensed health care professional, but are provided by paraprofessional staff.

Personal health services may include assistance with communication, eating, personal hygiene, mobility, bladder and bowel requirements, and medication administration. Services may include assistance with preparation of meals but do not include the cost of the meals themselves."

^ NOTE: Use billing code T1020 when services are provided for 50 percent or more of a school day.

* "Bill all procedures in whole units of service. Except as noted in the coding chart, 15 minutes equals one unit. Round remainders of seven minutes or less down to the lower unit and remainders of more than seven minutes up to the next unit." (p.73 LEA Manual)

Behavior Services
Behavior services consist of formal programs designed to prevent or correct maladaptive behavior on the part of the student. The interventions are used to change specific behaviors. They are monitored by a mental health professional, and are carried out by staff. The behavior plan must be in a separate document from just a goal in the IEP. The plan provides a description of the behavior to be addressed and positive or negative incentives to encourage proper behavior. Direct care staff records the nature and severity of the problem behaviors and the response of the direct care staff and the student. The documentation provides the basis for evaluation and revision of the plan as necessary.

BUT third party billing companies must use modifiers accurately to reflect actual service. These are examples of modifiers:

  • HO Master's degree (use for guidance counselor)
  • HQ Group setting
  • TD RN
  • TE LPN
  • TM Individual Education Program contracted services
  • U9 Other health Associate

Hope this was helpful to you. I sure learned a lot!


Categories: Section 504

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