Medicaid Administrative Claiming Training - cmsmac.com

Medicaid Administrative Claiming Training
January 1, 2017
MAC TrainingMAC101There aretwowaysyour district getsreimbursed from the Medicaid program:Afee/rate for a direct Medicaid covered service for a Medicaid eligible student. Utah uses a bundled rate for school based health related services.(Nursinghas a separaterate for one on one nursing).Each District has a statedaily ratebased on historical cost.Foradministrative time/cost associated with Medicaid outreach, assistance with Medicaid eligibility, training associated with Medical/Medicaid services, program planning related to Medical/Medicaid services in the school setting, and coordination of Medicaid covered services within and with Medicaid providers outside the school system. Administrative cost must be allocated to the program using a federally approved time study process.Utahuses one time study to fulfill both cost settlement and cost allocation requirements.
Time Study ProcessWe time study three quarters of the year one week each quarter: Oct-Dec, Jan-Mar, Apr-June. An average of those three quarters is used to allocate the summer months (July-Sept).CMS works with coordinators in each district to update the list of time study participants and to coordinate completion of the quarterly time studies and other federal requirements.Persons included in the time study universe include: all OT, PT, Speech Language Therapists, therapist assistants and aides (OT, PT, SLP), Audiologists, Psychologists, Social Workers, Teachers, Para- Educators, Counselors, and Nurses. Other titles are included based on activities they perform. This may include directors and coordinators. Persons that specialize in assisting families with Medicaid applications are also included in the time study. If there is a question if a person should be included in the time study, there is a discussion between CMS and the district coordinator to make that decision. A second cost pool consisting of Directors (if not included in the time study), support personnel and principals and assistant principals involved directly with special education students in part of the claim but not part of the time study. These individual’s salaries are allocated based on the results of the time study.
F1 – IEP Health Related Direct Service ActivitiesF1 is forHEALTHrelated (OT/PT/Speech/Nursing/Audiology/Behavioral/Personal Care) direct services only. EDUCATIONAL Special Education service is E. Just because it isdocumented inan IEP and you are working directly with a student does not make it F1. The activity needs to relate back toahealth related goal.Examples:“Teaching math class” is E not F1“Assisting student with fine motor skills”. This is F1.“Eating lunch with student”. Sounds like Q (if paid for lunch), but if the Para isassistingthe student with fine motor skillssuch as usingutensils it should be F1.“Helping student with art”. Isthis for the purpose ofa health related IEPgoal(OT/PT)?“Helping student with reading”. Isthis fora speech goal or is this an education goal?Time spent writing and developing the IEP for the health related goal is F1.
P – Referral, Coordination, Monitoring of Medicaid ServicesConversations to coordinate and monitor the Medicaid service includes:Meetings, phone calls, or conversations regarding a specific student’s service, progress, lack of progress, technique, need to change service, feedback to parent or therapist should all be coded P.Therapists, teachers, para-educators, social workers, team members, supervisors, and coordinators involved with coordinating and monitoring the health related services for students should code this time as P.P is coded for IEP meetings when the health related service is discussed. Time in the IEP meeting discussing the academic goals is E.Referrals and communication with the student’s primary care physician or referrals and coordination with mental health providers outside the school should be coded P.
MedicaidAdministrative Claiming
ACTIVITY CODESCode ANon-MedicaidOutreachCodeB MedicaidOutreachCode CFacilitatingApplication ForNon-Medicaid ProgramsCode DFacilitatingMedicaid Eligibility DeterminationCode ESchoolRelated And Educational ActivitiesCode FDirectMedical ServicesCode GTransportationFor Non-Medicaid ServicesCode HTransportation-RelatedActivities In Support Of MedicaidCoveredServices
Code INon-MedicaidTranslationCode JTranslationRelated To Medicaid ServicesCode KProgramPlanning, Policy Development, And Interagency CoordinationRelatedToNon-Medical ServicesCode LProgramPlanning, Policy Development, And Interagency CoordinationRelatedToMedical ServicesCode M Non-Medical/Non-Medicaid Related TrainingCode NMedical/MedicaidRelated TrainingCode OReferral, Coordination, And Monitoring Of Non-Medicaid ServicesCode PReferral, Coordination, And Monitoring Of Medicaid ServicesCode QGeneral Administration
The listing of activity codes looks long because it makes use of ‘parallel’ codes. Many activities are listed twice, once when related to Medicaid, and again for when the activity is not related to Medicaid. Think of it as 8 activities with their parallel codes, plus an administrative code for paid leave or other time away from your normal duties.
Time Study Activity Codes Defined
ActivityANon-Medicaid OutreachUse codeAwhen performing activities that inform potentially eligible individuals about NON-Medicaid programs and how to access them.Informing families of the existence of non-Medicaid programs that may address non-health needs (e.g. SSI and TANF for financial assistance)Conducting outreach programs directed toward encouraging persons to access social, educational, or other services that not medically related;Assisting in early identification of children with special health needs through various Child Search (Child Find) activities;Activity BMedicaid OutreachUse codeBwhen performing activities that inform potentially eligible individuals about Medicaid and how to access it.Informing families of the existence of the Medicaid program, and the benefits it provides.Providing information to students and families on available Medicaid services and how to access them. (For our purposes in this project, Medicaid and CHEC (EPSDT) can be used interchangeably.)Handing out Medicaid brochures.NOTE:Paperwork and travel time related to an activity is coded the same way as the activity. If I speak to a group on the Medicaid program, thisisactivity B. My travel time getting there is also coded B. If I spend time creating and copying handouts for a presentation on Medicaid, this is also coded B. Paperwork and travel time are coded the same way as the activity they support.
ActivityCFacilitating application for non-Medicaid programsCodeCis used when helping an individual to become eligible for NON-Medicaid programs such as TANF, Food Stamps, WIC, day care, and other programs.Assisting an applicant to fill out eligibility applications for NON-Medicaid programs such as TANF and food stamps;Gathering information related to the application and eligibility determination for NON-Medicaid programs for a client;Activity DFacilitating Medicaid Eligibility DeterminationHelping a family apply for Medicaid? Code this timeD.Assisting an applicant to fill out a Medicaid eligibility application;Providing necessary forms and packaging all forms in preparation for the Medicaid eligibility determination;It doesn’t matter if the family is eligible, or even if they follow through with the application. If you spend time assisting a family relating to a Medicaid application, you code this time D.
ActivityESchool related and Educational ActivitiesThe codeEcaptures time spent on school-related and educational activities.Providing classroom or individualized instruction (including lesson planning).Testing, correcting papers.Providing general supervision of students (duty).Monitoring student academic achievement.Conferring with students or parents about academic performance.CODE CLARIFICATIONAcademic“lesson planning”Discussing academicsIEP meeting discussing academicsIQ testing not part of a special education assessmentGeneral supervision of students (duty)Interpreting/translation for the purpose of academics
ActivityF1– IEPHealthRelated Direct Service activitiesProviding health/mental health services contained in an IEP.Medical/health assessment and evaluation as part of the development of an IEPConducting medical/health assessments/evaluations and diagnostic testing and preparing related reportsProviding speech therapy, occupational therapy, physical therapy, personal care services, behavioral health services, nursing services and audiology servicesPerforming developmental assessmentsProviding counseling services to treat health, mental health, or substance abuse conditionsTransportation (if covered as a medical service under Medicaid)CODE CLARIFICATIONSProvidingtherapy group/individualDocumentation/notes of results of therapyPreparing for therapy sessionPreparing “exercises/plans” to reach Health related servicegoals(“Lesson Planning” terminology by therapist should be avoided)Assessments, evaluations, testing and preparing reports, for OT/PT/ Speech/Audiology/Behavior/Personal CareIQ testing is F1 if it is part of an overall assessment to determine the need forhealthrelatedservices including ED, TBI or other health impairments. (Testing for learning and intellectual disabilities is E)Teaching a student how to use braille (preparing braille for class is E)Traveltime and paperwork associated with theseactivities
Activity F2– Non IEP - Direct Service activities:Administering first aid, or prescribed injections or medications to a studentProviding direct clinical/treatment servicesDeveloping a treatment plan (medical plan of care) for a student if provided as a medical servicePerforming routine or mandated child health screens including buy not limited to vision, hearing, dental, scoliosis, and EPSDT screensProviding immunizations
ActivityGTransportation for non-Medicaid ServicesUse codeGwhen assisting an individual to obtain transportation to non medical services.Scheduling or arranging transportation to social, vocational, and/or educational programs and activities.Activity HTransportation-Related Activities is support of Medicaid covered servicesCode itHwhen assisting an individual to obtain transportation to services covered by Medicaid.Scheduling or arranging transportation to Medicaid covered services.Accompanying the individual to a Medicaid covered service. This includes walking a child to a nurse’s office, a therapist appointment, etc.
ActivityINon-Medicaid translationEmployees who provide translation services for non-Medicaid activities should useI.Arranging for or providing translation services (oral or signing services) that assist the individual to access and understand social, educational, and vocational services.Activity JTranslation related to Medicaid ServicesEmployees who provide translation services for Medicaid activities should useJ.Arranging for or providing translation services (oral and signing) that assist an individual or family to access and understand necessary care or treatment.Interpreters being used by medical staff.
[K and L are bothnotchild specific. These are for times when you as a member of the school system are meeting/ communicating with members of an organization that is outside of the school system.]ActivityKProgram Planning, Policy Development, Interagency Coordination related to Non-Medical ServicesCodeKis for efforts to improve the coordination and delivery of non-medical services to school age children. Non-medical services may include educational services or vocational services.Working with other agencies who provide non-medical services, to improve the coordination and delivery of these services.Participating in advisory or work groups regarding the delivery of non-medical services.Coordinating with interagency committees to identify, promote and develop non-medical services.Activity LProgram Planning, Policy Development, Interagency Coordination related to Medical ServicesCodeLis used when performing activities to improve the coordination and delivery of medical/dental/mental health services to school age children.Developing strategies to increase the capacity of school health programs.Monitoring the medical/dental/mental health delivery systems in schools.Working with other agencies or providers that provide health related services to improve the coordination and delivery of these services.Participating in advisory or work groups of health professionals regarding the delivery of health care services to the school population.An example – A new Substance Abuse clinic opens and has an ‘open house’ and a counselor or social worker attends to learn of the services they offer.
ActivityMOutreach Training not related to Medicaid or Medical topicsThis codeMis for conducting or participating in training events and seminars for outreach staff regarding the benefit of the programs other than the Medicaid program. For example, training may include how to assist families to access the services of education programs.Participating in or coordinating training that improves the delivery of services for programs other than Medicaid.Participating in or coordinating training that enhances IDEA child find programs.Activity NTraining related to Medicaid or Medical topicsCode itNwhen conducting or participating in training or seminars for outreach staff regarding the benefits of medical or Medicaid related services.Participating in or coordinating training that enhances early identification, intervention, screening and referral of students with special health needs to such services (e.g., Medicaid EPSDT services).Participating in or coordinating training that improves the delivery of medical related services.Participating in training on administrative requirements related to Medicaid. (Such as training in MAC, or how to bill for services.)An example is attending a presentation by Utah State on Augmentative Communication Devices.
ActivityOReferral, Coordination, Monitoring of non-Medicaid ServicesUse codeOwhen making referrals for, coordinating, or monitoring the delivery of non-medical services, such as educational services. This includes state mandated across the board vision and hearing screenings.Making referrals for and coordinating access to social and educational services such as child care, employment, job training, and housing.Preparation of an ITP as it relates to coordinating vocational or other non-medical services.Activity PReferral, Coordination, Monitoring of Medicaid ServicesCodePis used when making referrals to, planning for, or coordinating the delivery of Medicaid covered services. This includes discussions and meetings on the health needs of a child, and the process to determine what services may be needed to address these needs.[Remember as well that you never need concern yourself with whether or not a child is on Medicaid. The time study is about howyouspendyourtime, not the eligibility status of the child. When we refer to a Medicaid covered service it means that the service is included in the Medicaid state plan. It does not mean that the particular child will necessarily have the service paid by Medicaid.]Working with individuals, their families, other staff, and providers to identify, arrange for, or coordinate services covered under Medicaid that may be required as the result of screens, evaluations, or examinations.
Activity PReferral, Coordination, Monitoring of Medicaid Services(Continued)Participatingin a meeting or discussion to assess a student’s need for a service covered by Medicaid. This includes informal hallway or lunch time discussions.Referring for medical or physical exams and necessary medical evaluations.Referring a student to a Medicaid covered service, whether or not that service is in the IEP. Include time preparing, writing, and follow up on the referral.Discussion concerning the need for a motor, speech, hearing, or other screening;Monitoring and evaluating the Medicaid service components of the IEP.Arranging for health, speech, behavioral, or other assessments as part of anEvalor Re-eval.You can see a connection between this code and the code for provision of direct services. If you providedirect health related servicesto children, activityF, you engage in activityPas well. A service is not provided without the planning, referring, discussing, and monitoring of that service.CODE CLARIFICATIONSPreparation for team meetingDiscussing health related service goals, progress, change in service deliveryIncludes discussions internally (formal or informal), with parents, with health care providers outside the school systemIEP meeting discussing health related servicesCoordinating/discussing the need for physical examinations, or medical/dental/mental health evaluationsFollowing up on needed examinations or health related servicesTravel time and paperwork associated with theseactivities
Activity QGeneral AdministrationUse code Q for administrative activities andpaidleave time.Some typical examples of general administrative activities:Taking lunch, breaks, leave, or otherpaidtime not at work.Reviewing school or district procedures and rules.Attending school or unit staff meetings.Performing administrative or clerical activities related to district operations.Providing general supervision of staff.Establishing goals and objectives of health-related programs as part of the school’s plan.Reviewing technical literature and research articles, (paper or on the internet), to keep current in your area of specialty.CODE CLARIFICATIONSLeave blanks for hours not at work or not scheduled to work (only code contract hours, or hours scheduled to work.) This is really important!Only use Q for:Paidtime off, andbreaks (leave blanks for time not scheduled to work)Reviewing of school or district proceduresAttending general staff meetings that don’t fit in O or PReviewing technical literature based on your specialtyEvaluations ofstaff
During the time study period you may be randomly selected to participate in the narrative time study log. It is important that you code the log as accurately as possible. Also, remember you do not have to write a whole lot. Be brief and concise when documenting your activity, remembering the nature and the purpose of the activity you are performing. Do not use student specific names.Good Examples Small group therapy – OT goal (F1)Reviewed: Fine motor – OT goal (F1)mobility exercise – PT goal (F1)reading with student – Speech Goal (F1)Working on Math (E)Administering First Aid (F2)IEP meeting (P)Monitoring and redirecting behavior (F1)Hallway discussion on students PT progress (P)You do not need to write on each 15 minute line. Write the description of the activity you are performing and line down the length of time you worked on that activity.
NARRATIVE LOG INTRUCTIONSPleasecomplete the narrative log on the 3rdday of the time study week.Please provide brief description of your activity for each 15-minute interval.Descriptions should convey acomplete thoughtand contain a subject andverb (Nature and purpose of the activity and how it relates back to the related activity)PLEASE READ:Examplesof good narrative descriptions:Student assessment new services or ongoing services – F1Student evaluation new services or ongoing services – F1Provided individual therapy - OT/PT/Speech/Counseling– F1Provided group therapy–OT/PT/Speech/CounselingF1Assistwith toileting, tube feeding, assistwith eating –F1Met with parent regardinghealth relatedservice progress - PCalled parent regardinghealth relatedservices- PCall with student’s primary care - PCoordinated meeting with team and parents- PStudent observation (therapist) – need for additional/new services –F1
Examplesof good narrative descriptions: (Continued)Arrange/Collaboratewith team onOT serviceneeds/delivery - PArrange/Collaborate with therapist on progress/service delivery- PPreparation for team meeting- PMet with supervisor to discuss student goals/progress- PConsult with teacher on student therapy progress/needs- PConsult with parent on grades - EIEP meeting discussing health related goals –PIEP meeting discussing academics - EFilled out Medicaid application for family - DProvided info on Medicaid to family - BPaid Lunch- QPaid Break- QOT Assist Studenton/offBus – F1Paid time off/sick leave– QReading with studentSpeech– F1If you are not paid for lunch leave it blank. This is also for the web based time study. You will be able to verify your time with a checkbox and will be allowed to move on.
Common Code Patterns
Teachers/TA’s/Paraprofessionals-E – School Related EducationalP - Referral/Coordination/Monitoring Medicaid ServicesF1 - Direct Service – IEP Health RelatedQ – General AdministrationSpecialists - Involved with Medicaid, Supervision, Program Development -K and/or L – Program Planning, Policy Development, Interagency CoordinationO and/or P – Referral, coordination, monitoring of Medicaid or non-MedicaidA and/or B – Outreach – Medicaid or non-MedicaidC and/or D – Assistance with eligibility for Medicaid or non-MedicaidE - School Related EducationalF1 or F2 – If you work with students directlyQ – General Administration
Questions?