School-Based Occupational Therapy Billing Guidelines

This document outlines the necessary procedures for billing Medicaid for school-based occupational therapy services, including obtaining parental consent, documenting the plan of care, securing physician authorization, and maintaining detailed service records. It emphasizes the importance of accurate diagnosis coding and student demographic information.

• School-based therapy
• Medicaid billing
• Occupational therapy services
• Parental consent
• Physician authorization

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1. Cha p ter 5 38 Sc ho o l - Ba sed Hea l th Servi c es Occupational Therapy Billing Form Effective August 1, 2019

2. Co nsent to Bi l l M edi c a i d 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. 2

3. P l a n o f Ca re 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 Cerebral Palsy would not be appropriate. 3

4. P hysi c i a n Autho ri za ti o n F o rm Physician Authorization is required annually to bill for occupational therapy. The Occupational Therapist 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). 4

5. Student Dem o gra p hi c s 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 occupational therapy. 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. 5

6. Servi c e Rec o rd Servi c e Rec o rd Sc ho o l Based Oc c up ati o nal Therap y Sc ho o l Based Oc c up ati o nal Therap y Bi l l i ng F o rm Bi l l i ng F o rm Medicaid Number Last Name First Name WVEIS Number Date of Birth Provider Name County School Month/Year 6

7. Servi c e Rec o rd Servi c e Rec o rd Sc ho o l Based Oc c up ati o nal Therap y Sc ho o l Based Oc c up ati o nal Therap y Bi l l i ng F o rm Bi l l i ng F o rm Medicaid Number Last Name First Name 03900000001 Doe Brody WVEIS Number Date of Birth Provider Name 999999999 9-11-2001 William Dunton Jr County School Month/Year Vandalia 501 Sept/2019 7

8. Di a gno si s Co des Enter the OT 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. 8

9. I CD 10 Di a gno si s Co des LIST ALL DIAGNOSIS CODES RELATED TO OCCUPATIONAL THERAPY 1. 2. 3. 4. 5. 6. 9

10. I CD 10 Di a gno si s Co des LIST ALL DIAGNOSIS CODES RELATED TO OCCUPATIONAL THERAPY 1. R26.9 2. M62.81 3. R27.8 4. 5. 6. 10

11. Oc c up a ti o na l Thera p y P ro c edure Co des Code 97165 97166 97167 97168 97032 GO Procedure Occupational Therapy Evaluation Low Complexity Occupational Therapy Evaluation Moderate Complexity Occupational Therapy Evaluation High Complexity Occupational Therapy Re-evaluation Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility each 15 minutes Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception for sitting and/or standing activities, each 15 minutes Aquatic Therapy with therapeutic exercises, each 15 minutes Gait training (includes stair climbing) each 15 minutes Therapeutic procedure(s), group (2 or more individuals), each 15 minutes. Manual therapy techniques (mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions each 15 minutes Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance) each 15 minutes Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes Service Unit 1 event per calendar year 1 event per calendar year 1 event per calendar year 2 events per calendar year 20 units per month 97110 GO 20 units per month 97112 GO 20 units per month 97113 GO 97116 GO 97150 GO 97140 GO 20 units per month 20 units per month 20 units per month 20 units per month 97530 GO 20 units per month 97533 GO 20 units per month 11

12. P ro c edure Co de Cha nges Procedure Code 97532 GO is no longer a valid CPT code. 12

13. E nter Cl a i m Do c um enta ti o n Use the CPT codes and caps from slide nine to complete the claim documentation section of the billing form. In the first column list the service date. (If combining minutes from different days for a unit use the date the 15th minute occurred to complete the unit. No span dates are allowed.) Column two - enter one or more of the diagnosis code numbers that directly relates to the services. (examples 1, 1 & 3, 2) Column three - enter the CPT code including the GO modifier if appropriate. Columns four and five - enter the start and end time. In the last column enter the total number of units or event(s). 13

14. Cl a i m Do c um enta ti o n Service Date List Diagnosis Code Number(s) Procedure code Start Time End Time Units/Event 14

15. Cl a i m Do c um enta ti o n Service Date List Diagnosis Code Number(s) Procedure code Start Time End Time Units/Event 9-3-2019 9-6-2019 9-10-2019 9-13-2019 9-17-2019 9-20-2019 9-24-2019 9-27-2019 1 97116 GO 97110 GO 97116 GO 97110 GO 97116 GO 97110 GO 97116 GO 97168 GO 9:12 1:30 9:12 1:30 9:12 1:30 9:12 10:00 9:37 1:45 9:37 1:45 9:37 2:00 9:37 11:14 1 1 1 1 1 2 1 1 2,3 1 2,3 1 2,3 1 1,2,3 15

16. Thi rd P a rty Bi l l i ng 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. 16

17. Certi fied Oc c up a ti o na l Thera p y Assi sta nt ( COTA) COTAs can only bill for therapy when an Occupational Therapist (OT) certified by the WV Board of Examiners is directly supervising. Directly supervising requires the Board Certified OT to be on site when the therapy is being provided. COTA progress/therapy logs are to be co-signed by the supervising OT for therapy dates that are billed for Medicaid. This only applies to dates when the OT was directly supervising the COTA. To make this clear to the person entering billing, the OT should initial the days that they provided direct supervision. COTAs can not bill for evaluations.

18. Si gna ture a nd Credenti a l s Staff who provided or directly supervised the service will sign the form and list credentials. For COTAs, the supervising OT must co-sign the billing form and initial specific claims directly supervised. An OT is considered to be directly supervising when in the building at the time of the service. Claims initialed by the OT can be submitted for billing.

19. Si gna ture a nd Credenti a l s ____________________ Signature/Credentials Date ________________ Co-Signature/Credential (Initial dates directly supervised) Date 19

20. Si gna ture a nd Credenti a l s __William Denton Jr.____ OT___ Signature/Credentials October 1, 2019 Date Date Co-Signature/Credential (Initial dates directly supervised) 20

21. Addi ti o na l Do c um enta ti o n Progress/therapy logs will also be required. Original copies of progress/therapy logs must be on file in the special education central office. There is not a required form for documentation of progress/therapy logs.

22. Kel l ey J o hnso n Co o rdi na to r Offi c e o f Sp ec i a l E duc a ti o n kel l ey. j o hnso n@ k12 . wv. us 30 4 - 5 5 8 - 2 6 96 ext 5 35 39 W VDE M edi c a i d W eb si te: http s: / / wvde. us/ sp ec i a l - educ a ti o n/ M edi c a i d/