Department of Assistive and Rehabilitative Services Early Childhood Intervention Services Medicaid Billing Guidelines Effective: October 1, 2011

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1 Department of Assistive and Rehabilitative Services Early Childhood Intervention Services Medicaid Billing Guidelines Effective: October 1, 2011 The purpose of this guide is to provide Early Childhood Intervention (ECI) contractors with information to assist in billing services to Medicaid effective October 1, ECI Program Rules: The rules for the Targeted Case Management services and Specialized Skills Training services are located in 40 TAC Part 2, Chapter 108, Subchapter D, Case Management for Infants and Toddlers with Developmental Disabilities, and 40 TAC Part 2, Chapter 108, Subchapter E, Specialized Skills Training. ECI Rate Rules: The reimbursement methodology Targeted Case Management (TCM) for Early Childhood Intervention (ECI) Program is based on the proposed reimbursement rules on 1 TAC The reimbursement methodology Specialized Skills Training (SST) for Early Childhood Intervention (ECI) Program is based on the proposed reimbursement rules on 1 TAC The proposed rates for SST and TCM were calculated in accordance with the reimbursement methodology rules in Title 1 of the Texas Administrative Code (1 TAC) which addresses the reimbursement methodology for the Early Childhood Intervention Program. TMHP and HHSC Notices A Banner message was posted on the TMHP website on June 17 th, 2011, and the same information appears in an article, Claims for Early Childhood Intervention Services to be Submitted to TMHP Effective October 1, 2011 which appears in the September/October Medicaid Bulletin # 237 beginning on page 20. The banner message can be located at: 11%20Claims%20for%20Early%20Childhood%20Intervention%20Services%20to%20B e%20submitted%20to%20tmhp%20effective%20october%201,% pdf The Medicaid Bulletin article can be located at: 1

2 On July 21 st, 2011, the HHSC Rate Analysis Division posted notices about the rates for TCM and SST on the HHSC website at: and at: Additional Guidance for Targeted Case Management Services Use the U1 modifier when you are billing a face-to-face contact. TCM is always billed to TMHP. Bill the case management services under the agency case management TPI enrollment number. Contact must be with the parent or routine caregiver or in the presence of the parent or routine caregiver. Case management services performed prior to the determination of ECI eligibility do not qualify as TCM. and bill for prior case management services as long the activities occurred at a point in time after the child s ECI eligibility had been determined and the child s retroactive eligibility for Medicaid includes the period of time that the service was delivered. For example, assume that a family had not applied for Medicaid when the child was determined eligible for ECI via the comprehensive evaluation. Due to the Service Coordinator s encouragement, the family applied a month later and was determined eligible 1 and ½ months after applying. Since the family had major medical expenses that extended 3 months prior to the Medicaid eligibility determination, they were determined to be retroactively eligible for Medicaid. If case management services occurred after ECI eligibility and within the prior period, the ECI Contractor can go back and bill Medicaid for the case management services provided after ECI eligibility had been determined. Activity must benefit the child. See ECI program rules for Service Coordinator s required qualifications and training in order to qualify for billing the case management. Additional Guidance for Specialized Skills Training Services Use the U1 modifier when billing for individual services. 2

3 SST is always billed to TMHP. Bill the SST services under the agency TPI enrollment number (the same number that is used for billing targeted case management services). You cannot bill SST when an evaluation or re evaluation is occurring at the same time. SST can be billed as a co-therapy treatment if it occurs at the same time as a PT, OT or ST treatment but not when it occurs when a therapist bills an evaluation or re evaluation (See 40 TAC ). IFSP documents the frequency, intensity, location, method and duration as determined by the Interdisciplinary Team. and bill for prior SST services that were delivered during the prior period as long the services occurred at a point in time after the child s ECI eligibility had been determined and the retroactive eligibility period for Medicaid includes the period of time during which the services were delivered. For example, assume that SST services were initiated the week after the IFSP was signed. The child s family didn t apply for Medicaid until after the Service Coordinator started working with the family and encouraged the family to apply. The family was determined retroactively eligible for Medicaid 2 months after they applied. Since the SST had occurred within the 3 month period of retroactive eligibility, the ECI Contractor can bill Medicaid for all the SST services that occurred during that period. See program rules for the Early Childhood Intervention Specialist s required qualifications and training. Additional Guidance on Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) The Provider Notification, Claims for Early Childhood Intervention Services to be Submitted to TMHP Effective October 1, 2011, and the September/October Medicaid Bulletin # 237 by the same title posted on the TMHP website on July 20, 2011, provide information about the ongoing PT, OT and ST services. The article also references the PT, OT and ST evaluations and re-evaluations that are billed to the Comprehensive Care Program (CCP). Use the correct procedural modifier. PT, OT and ST ongoing therapy services are billed to TMHP. 3

4 Bill the therapy services under the agency TPI enrollment number (the same number that is used for billing Targeted Case Management services to TMHP). The only procedure codes that may be reimbursed for therapy sessions are specified in the TMHP Provider Notification and September/October Medicaid Bulletin #237 article Claims for Early Childhood Intervention Services to be Submitted to TMHP Effective October 1, Evaluation and re-evaluation codes will deny if billed under the agency TPI enrollment number (the same number used for billing Targeted Case Management services to TMHP). Evaluations and re evaluations must be billed under the ECI CCP enrollment. The IFSP acts as the authorization for the services, so no prior authorization is required from TMHP. IFSP documents the frequency, intensity, location, method and duration as determined by the Interdisciplinary Team. Co-therapy visits are allowed when: o the IFSP indicates medical necessity, o the parent(s) or other routine caregiver(s) have agreed to the co-therapy treatment, and o the services meet the requirements in 40 TAC Group therapy is allowed when the services meet the requirements in 40 TAC and bill for prior PT, OT and ST services that may have been delivered during the prior period as long the services occurred at a point in time after the child s ECI eligibility had been determined and the retroactive eligibility period for Medicaid includes the period of time during which the service was delivered. For example, assume that speech therapy services were initiated two weeks after the IFSP was signed. The child s family didn t apply for Medicaid until after the Service Coordinator encouraged the family to apply. The family is determined retroactively eligible for Medicaid 2 months after they apply. Since the speech therapy occurred within the 3 month period of retroactive eligibility, the ECI Contractor can bill Medicaid for the speech therapy services that occurred during the retroactive eligibility period. See program rules for the Early Childhood Intervention Specialist s required qualifications and training. 4

5 Updates to the ECI Billing Guide This document may be updated as needed. If updates are needed, the document will be revised and distributed at a later date. 5