HCS BILLING GUIDELINES You can find the newest version on the DADS website: 1

HCS BILLING GUIDELINESHCS BILLING GUIDELINES

• You can find the newest version on the DADS website:

• You can find the newest version on the DADS website:

http://www.dads.state.tx.us/handbooks/hcsbg/http://www.dads.state.tx.us/handbooks/hcsbg/

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General InformationGeneral InformationDepartment of Aging and Disability Services (DADS) rules at 40 TAC §9.170 set forth requirements for Home and Community-based Services (HCS) Program providers to receive payment for HCS Program services. Specifically, 40 TAC §9.170(d) requires a program provider to prepare and submit service claims in accordance with the HCS Program Billing Guidelines. Also, Sections II. H. and II. T. of the HCS Program Provider Agreement require program providers to comply with the HCS Program Billing Guidelines. In addition, 40 TAC §9.170(k) sets forth circumstances under which a program provider will not be paid or Medicaid payments will be recouped from the program provider.

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http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=40&pt=1&ch=9&rl=170

General RequirementsGeneral RequirementsApplicable Service Components

• Specialized Therapies– Audiology; dietary; occupational therapy; physical therapy;

behavioral support; social work; and speech and language pathology.

• Day Habilitation• Nursing

– Registered; Licensed Vocational; Specialized Registered; and Specialized Licensed Vocational.

• Residential Assistance– Foster/Companion Care; Residential Support; Supervised

Living; and Supported Home Living.

• Respite • Supported Employment• Adaptive Aids• Minor Home Modifications• Dental Treatments

Applicable Service Components• Specialized Therapies

– Audiology; dietary; occupational therapy; physical therapy; behavioral support; social work; and speech and language pathology.

• Day Habilitation• Nursing

– Registered; Licensed Vocational; Specialized Registered; and Specialized Licensed Vocational.

• Residential Assistance– Foster/Companion Care; Residential Support; Supervised

Living; and Supported Home Living.

• Respite • Supported Employment• Adaptive Aids• Minor Home Modifications• Dental Treatments 3http://www.dads.state.tx.us/handbooks/hcsbg/3000/3000.htm#sec3100

Specific Requirements

Specific Requirements

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Specialized Therapies

Specialized Therapies

22http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4200

Specific RequirementsSpecific RequirementsSpecialized Therapies• Audiology services• Dietary services• Occupational therapy

services• Physical therapy services• Psychology services• Social work services• Speech and language

pathology services

Specialized Therapies• Audiology services• Dietary services• Occupational therapy

services• Physical therapy services• Psychology services• Social work services• Speech and language

pathology services23

http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4200

Specific RequirementsSpecific RequirementsSpecialized Therapies Billable

Activity• The only billable activities for the specialized therapies service

component are:• interacting face-to-face or by video conference or speaking by

telephone with an individual, based on the specialized therapies subcomponent provided, to conduct assessments or provide services within the scope of the service provider's practice;

• interacting face-to-face or by video conference or speaking by telephone with a person regarding a specialized therapies subcomponent provided to an individual, but not with: – a staff person who is not a service provider; or – a service provider of any nursing service component (registered

nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational nursing), or specialized therapies;

• writing an individualized treatment plan for an individual's specialized therapies which, for behavioral support services, is a behavior support plan;

• reviewing documents, except for a written narrative or written summary of a service component as described in Section 3820, to evaluate the quality and effectiveness of an individual's specialized therapies;

Specialized Therapies Billable Activity

• The only billable activities for the specialized therapies service component are:

• interacting face-to-face or by video conference or speaking by telephone with an individual, based on the specialized therapies subcomponent provided, to conduct assessments or provide services within the scope of the service provider's practice;

• interacting face-to-face or by video conference or speaking by telephone with a person regarding a specialized therapies subcomponent provided to an individual, but not with: – a staff person who is not a service provider; or – a service provider of any nursing service component (registered

nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational nursing), or specialized therapies;

• writing an individualized treatment plan for an individual's specialized therapies which, for behavioral support services, is a behavior support plan;

• reviewing documents, except for a written narrative or written summary of a service component as described in Section 3820, to evaluate the quality and effectiveness of an individual's specialized therapies;


http://www.dads.state.tx.us/handbooks/hcsbg/3000/3000.htm


Specific RequirementsSpecific Requirements


• training the following persons on how to provide specialized therapies treatment, including how to document the provision of treatment: – a service provider of foster/companion care, residential support,

supervised living, supported home living, day habilitation, respite, supported employment or employment assistance; or

– a person other than a service provider who is involved in serving an individual;

• reviewing documents in preparation for the training described in the bullet above;

• participating in a service planning team meeting; • participating in the development of an implementation plan; • participating in the development of an IPC; and


• training the following persons on how to provide specialized therapies treatment, including how to document the provision of treatment: – a service provider of foster/companion care, residential support,

supervised living, supported home living, day habilitation, respite, supported employment or employment assistance; or



• participating in a service planning team meeting; • participating in the development of an implementation plan; • participating in the development of an IPC; and




• for behavioral support services, in addition to the activities listed above: – assessing the targeted behavior so that a behavior support plan

may be developed; – training of and consulting with an individual, family member or

other persons involved in the individual's care regarding the implementation of the behavior support plan;

– monitoring and evaluating the effectiveness of the behavior support plan;

– modifying, as necessary, the behavior support plan based on the monitoring and evaluation of the plan's effectiveness; and

– educating an individual, family members or other persons involved in the individual's care about the techniques to use in assisting the individual to control maladaptive or socially unacceptable behaviors exhibited by the individual.


• for behavioral support services, in addition to the activities listed above: – assessing the targeted behavior so that a behavior support plan

may be developed; – training of and consulting with an individual, family member or

other persons involved in the individual's care regarding the implementation of the behavior support plan;

– monitoring and evaluating the effectiveness of the behavior support plan;

– modifying, as necessary, the behavior support plan based on the monitoring and evaluation of the plan's effectiveness; and

– educating an individual, family members or other persons involved in the individual's care about the techniques to use in assisting the individual to control maladaptive or socially unacceptable behaviors exhibited by the individual.


Specific RequirementsSpecific RequirementsNot Billable as Specialized

Therapies The following are examples of activities that are not billable for the specialized therapies service component:

– providing services outside the scope of the service provider's practice;

– providing services that are performed by a service coordinator or were performed by a former case manager;

– scheduling an appointment; – transporting an individual; – traveling or waiting to provide a specialized therapies

subcomponent; – training or interacting about general topics unrelated to a specific

individual, such as principles of behavior management, or general use and maintenance of an adaptive aid or equipment;

– creating written documentation as described in Section 4260; – reviewing a written narrative or written summary of a service

component as described in Section 3820; and

Not Billable as Specialized Therapies

The following are examples of activities that are not billable for the specialized therapies service component:







component as described in Section 3820; and 27






Specific RequirementsSpecific RequirementsNot Billable as Specialized Therapies The following are examples of activities that are not billable for the specialized therapies service component (continued):

– interacting with: • a staff person who is not a service provider; or • a service provider of any nursing service component

(registered nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational nursing) or specialized therapies, if not during a service planning team meeting or during the development of an IPC or an implementation plan.

Activities in Section 3300 – The activities listed in Section 3300, Activity Not Billable, are not

billable for the specialized therapies service component.

Activities Not Listed in Section 4220 – Any activity not described in Section 4220, Billable Activity, is not


Not Billable as Specialized Therapies The following are examples of activities that are not billable for the specialized therapies service component (continued):

– interacting with: • a staff person who is not a service provider; or • a service provider of any nursing service component

(registered nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational nursing) or specialized therapies, if not during a service planning team meeting or during the development of an IPC or an implementation plan.

Activities in Section 3300 – The activities listed in Section 3300, Activity Not Billable, are not


Activities Not Listed in Section 4220 – Any activity not described in Section 4220, Billable Activity, is not



Specific RequirementsSpecific Requirements Examples of Activity Not Billable







component as described in Section 3820; and – interacting with:

• a staff person who is not a service provider; or • a service provider of any nursing service component (registered

nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational nursing) or specialized therapies, if not during a service planning team meeting or during the development of an IPC or an implementation plan.

Examples of Activity Not Billable– providing services outside the scope of the service provider's

practice; – providing services that are performed by a service coordinator or

were performed by a former case manager; – scheduling an appointment; – transporting an individual; – traveling or waiting to provide a specialized therapies




component as described in Section 3820; and – interacting with:

• a staff person who is not a service provider; or • a service provider of any nursing service component (registered

nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational nursing) or specialized therapies, if not during a service planning team meeting or during the development of an IPC or an implementation plan.

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Specialized Therapies Written Documentation

• Except as provided in Section 4270, Insurance Co-payment and Deductible (see No. 1, Item c and No. 2, Item c), a program provider must have written documentation to support a service claim for specialized therapies that:

• meets the requirements set forth in Section 3800, Written Documentation;

• includes the exact time the service event began and the exact time the service event ended documented by the service provider making the written service log; and

• for any activity performed by multiple service providers at the same time for the same individual, includes a written justification in the individual's implementation plan for the use of multiple service providers.

Specialized Therapies Written Documentation

• Except as provided in Section 4270, Insurance Co-payment and Deductible (see No. 1, Item c and No. 2, Item c), a program provider must have written documentation to support a service claim for specialized therapies that:

• meets the requirements set forth in Section 3800, Written Documentation;

• includes the exact time the service event began and the exact time the service event ended documented by the service provider making the written service log; and

• for any activity performed by multiple service providers at the same time for the same individual, includes a written justification in the individual's implementation plan for the use of multiple service providers. 30






Common ErrorsCommon Errors• No begin and/or end times• No location of service provided• Reviewing or creating service delivery

records• Family paying for rate differential• No Progress Note

• No begin and/or end times• No location of service provided• Reviewing or creating service delivery

records• Family paying for rate differential• No Progress Note

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Day HabilitationDay Habilitation


Specific RequirementsSpecific RequirementsDay Habilitation Billable Activity• The only billable activities for the day habilitation service

component are:• interacting face-to-face with an individual to assist the

individual in achieving objectives to: – acquire, retain or improve self-help skills, socialization skills or adaptive

skills that are necessary to for the individual to successfully reside, integrate and participate in the community;

– reinforce a skill taught in school, specialized therapies; and – develop opportunities for employment in the community (for example,

completing a job application, assessing employment skills and training on employment-related issues);

• transporting an individual between settings at which day habilitation is provided to the individual;

• assisting an individual with his or her personal care activities if the individual cannot perform such activities without assistance;

• participating in a service planning team meeting; • participating in the development of an implementation plan;

and • participating in the development of an IPC.

Day Habilitation Billable Activity• The only billable activities for the day habilitation service

component are:• interacting face-to-face with an individual to assist the

individual in achieving objectives to: – acquire, retain or improve self-help skills, socialization skills or adaptive

skills that are necessary to for the individual to successfully reside, integrate and participate in the community;

– reinforce a skill taught in school, specialized therapies; and – develop opportunities for employment in the community (for example,

completing a job application, assessing employment skills and training on employment-related issues);

• transporting an individual between settings at which day habilitation is provided to the individual;

• assisting an individual with his or her personal care activities if the individual cannot perform such activities without assistance;

• participating in a service planning team meeting; • participating in the development of an implementation plan;

and • participating in the development of an IPC.


Specific RequirementsSpecific RequirementsNot Billable as Day

Habilitation

• Travel time (except from one Day Habilitation site to another)

• Written documentation• Reviewing records• Drafting Implementation

Plans• Staff Training/Conferences• Processing service claims• Assisting an individual for

the sole purpose of meeting vocational goals

Not Billable as Day Habilitation

• Travel time (except from one Day Habilitation site to another)

• Written documentation• Reviewing records• Drafting Implementation

Plans• Staff Training/Conferences• Processing service claims• Assisting an individual for

the sole purpose of meeting vocational goals



May not submit DH service claim for:

• An individual who refuses to participate

• An individual who is sleeping• Assisting an individual in

achieving goals not documented in their IP

• More than five units of service in a calendar week

• More than 260 units of service per IPC year

• Day habilitation that is funded by another source other than HCS

May not submit DH service claim for:

• An individual who refuses to participate

• An individual who is sleeping• Assisting an individual in

achieving goals not documented in their IP

• More than five units of service in a calendar week

• More than 260 units of service per IPC year

• Day habilitation that is funded by another source other than HCS


Specific RequirementsSpecific RequirementsDay Habilitation Unit of

ServiceA unit of service for Day Habilitation is one day• One-quarter unit of service if service is

provided at least one and one-quarter hours of consecutive day habilitation on a calendar day

• One-half unit of service may be billed if service is provided for at least two and one-half hours on a calendar day. Two of the two and one-half hours must be consecutive.

• Three-quarters unit of service may be billed if service is provided for at least three and three-quarter hours on a calendar day. Two of the three and three-quarter hours must be consecutive.

• One unit may be billed if service is provided for at least five hours on a calendar day. Two of the five hours must be consecutive.

Day Habilitation Unit of Service

A unit of service for Day Habilitation is one day• One-quarter unit of service if service is

provided at least one and one-quarter hours of consecutive day habilitation on a calendar day

• One-half unit of service may be billed if service is provided for at least two and one-half hours on a calendar day. Two of the two and one-half hours must be consecutive.

• Three-quarters unit of service may be billed if service is provided for at least three and three-quarter hours on a calendar day. Two of the three and three-quarter hours must be consecutive.

• One unit may be billed if service is provided for at least five hours on a calendar day. Two of the five hours must be consecutive.


Common ErrorsCommon Errors• Individual sleeping• Not signing individual out of Day Habilitation

for other services provided (NU, SHL, etc.)• No description of service provided (details

about interactions, activities, behaviors, successes, refusals, etc.)

• Vocational Goals – Sheltered Workshops• No Progress Note

• Individual sleeping• Not signing individual out of Day Habilitation

for other services provided (NU, SHL, etc.)• No description of service provided (details

about interactions, activities, behaviors, successes, refusals, etc.)

• Vocational Goals – Sheltered Workshops• No Progress Note

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Supported EmploymentSupported

Employment


Specific RequirementsSpecific RequirementsSupported Employment• Supported employment is a

service that assists an individual to sustain competitive, integrated employment.

Supported Employment• Supported employment is a

service that assists an individual to sustain competitive, integrated employment.



Supported Employment Billable Activity

• The only billable activities for the supported employment service component are:

• interacting face-to-face with an individual at the individual's work site to provide training, support and intervention necessary to sustain the individual's employment;

• interacting face-to-face or by telephone with an individual's employment supervisor as necessary to sustain the individual's employment;

• transporting an individual to and from the individual’s work site;

• participating in a service planning team meeting; • participating in the development of an implementation

plan; and • participating in the development of an IPC.

Supported Employment Billable Activity

• The only billable activities for the supported employment service component are:

• interacting face-to-face with an individual at the individual's work site to provide training, support and intervention necessary to sustain the individual's employment;

• interacting face-to-face or by telephone with an individual's employment supervisor as necessary to sustain the individual's employment;

• transporting an individual to and from the individual’s work site;





Examples of Activities Not Billable under SE

• The following are examples of activities that are not billable for the supported employment service component:– interacting with an individual prior to the individual's

employment; – conducting employment interest assessments, assisting

with or arranging interviews, and completing job applications;

– interacting with an individual when the individual is not on duty; and

– transporting an individual to a job interview.

Examples of Activities Not Billable under SE

• The following are examples of activities that are not billable for the supported employment service component:– interacting with an individual prior to the individual's

employment; – conducting employment interest assessments, assisting

with or arranging interviews, and completing job applications;

– interacting with an individual when the individual is not on duty; and

– transporting an individual to a job interview.


Specific RequirementsSpecific RequirementsRestrictions (SE):A program provider may not submit a service claim for supported employment provided to an individual:• while the individual is employed by the program

provider; • in excess of 600 units of service (150 hours) per IPC

year; or • if supported employment is available to the

individual through the public school system or the Department of Assistive and Rehabilitative Services.

Restrictions (SE):A program provider may not submit a service claim for supported employment provided to an individual:• while the individual is employed by the program

provider; • in excess of 600 units of service (150 hours) per IPC

year; or • if supported employment is available to the

individual through the public school system or the Department of Assistive and Rehabilitative Services.


Common ErrorsCommon Errors• Training not occurring at the job site• Pre-vocational training• No Progress Note

• Training not occurring at the job site• Pre-vocational training• No Progress Note

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NursingNursing


Specific RequirementsSpecific RequirementsRegistered Nursing Billable

Activity• The only billable activities for the registered nursing

service component are:• interacting face-to-face with an individual who has a

medical need for registered nursing, including: – preparing and administering medication or treatment

ordered by a physician, podiatrist or dentist; – assisting or observing administration of medication;

and – assessing the individual's health status, including

conducting a focused assessment or a comprehensive assessment;

• speaking by telephone with an individual who has a medical need for registered nursing, including assessing the individual's health status;

• interacting by video conference with an individual who has a medical need for registered nursing, including: – observing administration of medication; and – assessing the individual's health status, including


Registered Nursing Billable Activity

• The only billable activities for the registered nursing service component are:

• interacting face-to-face with an individual who has a medical need for registered nursing, including: – preparing and administering medication or treatment

ordered by a physician, podiatrist or dentist; – assisting or observing administration of medication;

and – assessing the individual's health status, including


• speaking by telephone with an individual who has a medical need for registered nursing, including assessing the individual's health status;

• interacting by video conference with an individual who has a medical need for registered nursing, including: – observing administration of medication; and – assessing the individual's health status, including




Activity (cont.)• at the time an individual receives medication from a

pharmacy, ensuring the accuracy of: – the type and amount of medication; and – the dosage instructions;

• researching medical information for an individual who has a medical need for registered nursing, including: – reviewing documents, except for a written service log

or written summary log of a service component as described in Section 3820, to evaluate the quality and effectiveness of the medical treatment the individual is receiving; and

– completing a comprehensive assessment;

Registered Nursing Billable Activity (cont.)

• at the time an individual receives medication from a pharmacy, ensuring the accuracy of: – the type and amount of medication; and – the dosage instructions;

• researching medical information for an individual who has a medical need for registered nursing, including: – reviewing documents, except for a written service log

or written summary log of a service component as described in Section 3820, to evaluate the quality and effectiveness of the medical treatment the individual is receiving; and

– completing a comprehensive assessment;





Activity (cont.)• training the following persons how to perform nursing

tasks: – a service provider of foster/companion care,

residential support, supervised living, supported home living, day habilitation, respite, supported employment or employment assistance; or


– reviewing documents in preparation for the training described in the bullet above;


• training the following persons how to perform nursing tasks: – a service provider of foster/companion care,

residential support, supervised living, supported home living, day habilitation, respite, supported employment or employment assistance; or


– reviewing documents in preparation for the training described in the bullet above;



Activity (cont.)• interacting face-to-face or by video conference or

speaking by telephone with a person regarding the health status of an individual, but not with: – a staff person who is not a service provider; or – a service provider of:

• registered nursing; • licensed vocational nursing unless supervised by

the registered nurse; • specialized registered nursing; • specialized licensed vocational nursing unless

supervised by the registered nurse; or • specialized therapies;


• interacting face-to-face or by video conference or speaking by telephone with a person regarding the health status of an individual, but not with: – a staff person who is not a service provider; or – a service provider of:

• registered nursing; • licensed vocational nursing unless supervised by

the registered nurse; • specialized registered nursing; • specialized licensed vocational nursing unless

supervised by the registered nurse; or • specialized therapies;



Activity (cont.)• interacting face-to-face or speaking by telephone with a

pharmacist or representative of a health insurance provider, including the Social Security Administration, about an individual's insurance benefits for medication if the registered nurse justifies, in writing, the need for the registered nurse to perform the activity;

• instructing a service provider, except a service provider of registered nursing or specialized registered nursing, on a topic that is specific to an individual such as choking risks for an individual who has cerebral palsy;

• supervising a licensed vocational nurse regarding an individual's nursing services or health status;

• instructing, supervising or verifying the competency of an unlicensed person in the performance of a task delegated in accordance with rules of the Texas Board of Nursing at 22 TAC, Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions) or the Human Resources Code, §§161.091-.093, as applicable;


• interacting face-to-face or speaking by telephone with a pharmacist or representative of a health insurance provider, including the Social Security Administration, about an individual's insurance benefits for medication if the registered nurse justifies, in writing, the need for the registered nurse to perform the activity;

• instructing a service provider, except a service provider of registered nursing or specialized registered nursing, on a topic that is specific to an individual such as choking risks for an individual who has cerebral palsy;

• supervising a licensed vocational nurse regarding an individual's nursing services or health status;

• instructing, supervising or verifying the competency of an unlicensed person in the performance of a task delegated in accordance with rules of the Texas Board of Nursing at 22 TAC, Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions) or the Human Resources Code, §§161.091-.093, as applicable;



Activity (cont.)• participating in a service planning team meeting; • participating in the development of an implementation






Specific RequirementsSpecific RequirementsLicensed Vocational

Nursing Billable Activity • interacting face-to-face with an individual who has a

medical need for licensed vocational nursing, including: – preparing and administering medication or

treatment ordered by a physician, podiatrist or dentist;

– assisting or observing administration of medication; and

– conducting a focused assessment of the individual's health status;

• speaking by telephone with an individual who has a medical need for licensed vocational nursing, which may include conducting an assessment of an individual if: – the assessment is conducted using protocol

approved by DADS; and – the licensed vocational nurse has been trained

by a registered nurse on using the protocol;

Licensed Vocational Nursing Billable Activity

• interacting face-to-face with an individual who has a medical need for licensed vocational nursing, including: – preparing and administering medication or

treatment ordered by a physician, podiatrist or dentist;

– assisting or observing administration of medication; and

– conducting a focused assessment of the individual's health status;

• speaking by telephone with an individual who has a medical need for licensed vocational nursing, which may include conducting an assessment of an individual if: – the assessment is conducted using protocol

approved by DADS; and – the licensed vocational nurse has been trained

by a registered nurse on using the protocol;

54http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4471.2

Specific RequirementsSpecific RequirementsLicensed Vocational

Nursing Billable Activity (cont.)

• interacting by video conference with an individual who has a medical need for licensed vocational nursing, including: – observing administration of medication; and – conducting a focused assessment of the

individual's health status; • at the time an individual receives medication from a


Licensed Vocational Nursing Billable Activity (cont.)

• interacting by video conference with an individual who has a medical need for licensed vocational nursing, including: – observing administration of medication; and – conducting a focused assessment of the

individual's health status; • at the time an individual receives medication from a





• researching medical information for an individual who has a medical need for licensed vocational nursing, including: – reviewing documents, except for a written

service log or written summary log of a service component as described in Section 3820, to evaluate the quality and effectiveness of the medical treatment the individual is receiving; and

– completing a focused assessment; • training a service provider of residential assistance,

day habilitation, respite or supported employment, or a person other than a service provider who is involved in serving an individual, regarding how to perform nursing tasks;





























• interacting face-to-face or by video conference or speaking by telephone with a person regarding the health status of an individual, but not with: – a staff person who is not a service provider; or – a service provider of any nursing service

component (registered nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational nursing) or specialized therapies;

• interacting face-to-face or speaking by telephone with a pharmacist or representative of a health insurance provider, including the Social Security Administration, about an individual's insurance benefits for medication if the licensed vocational nurse justifies, in writing, the need for the licensed vocational nurse to perform the activity;


• interacting face-to-face or by video conference or speaking by telephone with a person regarding the health status of an individual, but not with: – a staff person who is not a service provider; or – a service provider of any nursing service

component (registered nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational nursing) or specialized therapies;

• interacting face-to-face or speaking by telephone with a pharmacist or representative of a health insurance provider, including the Social Security Administration, about an individual's insurance benefits for medication if the licensed vocational nurse justifies, in writing, the need for the licensed vocational nurse to perform the activity;




• instructing a service provider, except a service provider of registered nursing or specialized registered nursing, on a topic specific to an individual such as choking risks for an individual who has cerebral palsy;

• participating in a service planning team meeting; • participating in the development of an

implementation plan; and • participating in the development of an IPC.


• instructing a service provider, except a service provider of registered nursing or specialized registered nursing, on a topic specific to an individual such as choking risks for an individual who has cerebral palsy;

• participating in a service planning team meeting; • participating in the development of an

implementation plan; and • participating in the development of an IPC.


Specific RequirementsSpecific RequirementsSpecialized Registered and Licensed Vocational Nursing• Follow respective sections only for an

individual who has a tracheostomy or is dependent on a ventilator.

Specialized Registered and Licensed Vocational Nursing• Follow respective sections only for an

individual who has a tracheostomy or is dependent on a ventilator.

60http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4472.2 &http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4473.2



Examples of Non-Billable Activities:

• performing or supervising an activity that does not constitute the practice of licensed vocational nursing, including:

• performing an activity that constitutes the practice of professional nursing and must be performed by a registered nurse;

• transporting an individual; • waiting to perform a billable activity; and • waiting with an individual at a medical appointment; • making a medical appointment; • instructing on general topics unrelated to a specific

individual, such as cardiopulmonary resuscitation, or infection control;

• preparing a treatment or medication for administration and not interacting face-to-face with an individual;

• storing, counting, reordering, refilling or delivering medication except as allowed in the fourth bullet of Section 4471.2;

• creating written documentation as described in Section 4471.7;


• performing or supervising an activity that does not constitute the practice of licensed vocational nursing, including:

• performing an activity that constitutes the practice of professional nursing and must be performed by a registered nurse;

• transporting an individual; • waiting to perform a billable activity; and • waiting with an individual at a medical appointment; • making a medical appointment; • instructing on general topics unrelated to a specific

individual, such as cardiopulmonary resuscitation, or infection control;

• preparing a treatment or medication for administration and not interacting face-to-face with an individual;

• storing, counting, reordering, refilling or delivering medication except as allowed in the fourth bullet of Section 4471.2;

• creating written documentation as described in Section 4471.7;




• reviewing a written service log or written summary log of a service component as described in Section 3820;

• interacting with: • a staff person who is not a service provider; or • a service provider of any nursing service component

(registered nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational nursing), or specialized therapies, if not during a service planning team meeting or during the development of an IPC or an implementation plan; and

• performing an activity for which there is no medical need.


• reviewing a written service log or written summary log of a service component as described in Section 3820;

• interacting with: • a staff person who is not a service provider; or • a service provider of any nursing service component

(registered nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational nursing), or specialized therapies, if not during a service planning team meeting or during the development of an IPC or an implementation plan; and

• performing an activity for which there is no medical need.


Specific RequirementsSpecific RequirementsNursing Rule of Thumb:

If it does not require a nursing license to perform a task, it is not billable.

Nursing Rule of Thumb:

If it does not require a nursing license to perform a task, it is not billable.

63


Nursing Unit of Service• 15 Minute of Service

A service claim cannot be made for a fraction of a unit of service

• Accumulation of Service TimesCan be accumulated for nursing provided to one individual on a single calendar day

Nursing Unit of Service• 15 Minute of Service

A service claim cannot be made for a fraction of a unit of service

• Accumulation of Service TimesCan be accumulated for nursing provided to one individual on a single calendar day


Common ErrorsCommon Errors• Billing for creating and reviewing service records.• No medical necessity shown when residential staff

calls nurse to administer over the counter medication to individual

• No medical necessity for follow-up phone call• Billing for services without Face-to-Face, Telephone

or Video conferencing contact• Providing any activity not requiring a nursing license• One note used for multiple service events• No Progress Note

• Billing for creating and reviewing service records.• No medical necessity shown when residential staff

calls nurse to administer over the counter medication to individual

• No medical necessity for follow-up phone call• Billing for services without Face-to-Face, Telephone

or Video conferencing contact• Providing any activity not requiring a nursing license• One note used for multiple service events• No Progress Note

68

Residential AssistanceResidential Assistance



Residential Assistance Residential Location

• Own Home/Family Home – if no foster/companion care, residential support or supervised living is provided to the individual

• Foster/Companion Care – is not owned or leased by the program provider, a service provider provides care to the individual; and the care provider and the individual have the same address


• Own Home/Family Home – if no foster/companion care, residential support or supervised living is provided to the individual

• Foster/Companion Care – is not owned or leased by the program provider, a service provider provides care to the individual; and the care provider and the individual have the same address


Specific RequirementsSpecific RequirementsResidential Assistance

Residential Location• 3-Person Home – the

individual’s residence is a 3-person residence and a service provider provides residential support or supervised living to the individual

• 4-person Home – the individual’s residence is a 4-person residence and a service provider provides residential support or supervised living to the individual (one must be RSS)


• 3-Person Home – the individual’s residence is a 3-person residence and a service provider provides residential support or supervised living to the individual

• 4-person Home – the individual’s residence is a 4-person residence and a service provider provides residential support or supervised living to the individual (one must be RSS)


Supported Home Living

Supported Home Living


Specific RequirementsSpecific RequirementsSupported Home Living Billable

ActivityInteracting face-to-face with the individual:• to assist with activities of daily living• to assist with ambulation and mobility• to reinforce counseling and therapy subcomponents• to assist with administration of medication or tasks

delegated by an RN• to conduct habilitation activities• to secure transportation for the individual• to supervise the individual’s safety and security• interactions regarding an incident directly affecting

the individual's health or safety; • performing allowable non-face-to-face activities• participating in a service planning team meeting; • participating in the development of an implementation


Supported Home Living Billable Activity

Interacting face-to-face with the individual:• to assist with activities of daily living• to assist with ambulation and mobility• to reinforce counseling and therapy subcomponents• to assist with administration of medication or tasks

delegated by an RN• to conduct habilitation activities• to secure transportation for the individual• to supervise the individual’s safety and security• interactions regarding an incident directly affecting

the individual's health or safety; • performing allowable non-face-to-face activities• participating in a service planning team meeting; • participating in the development of an implementation

plan; and • participating in the development of an IPC. 73http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4540

Specific RequirementsSpecific RequirementsSupported Home Living claims

may not be submitted for:• An individual whose IPC does not have a residential

location of “own home/family home”• the sole activity of supervising the individual's safety and

security• Transporting an individual from one DH or SE site to

another– supporting home living provided to an individual:

• in a residence in which residential support or supervised living is provided to another individual;

• by a service provider who is simultaneously providing residential support, supervised living or foster/companion care to another individual;

• if the day habilitation service component is simultaneously provided to the individual by another service provider; or

• if the respite service component is simultaneously provided to the individual by another service provider.

Supported Home Living claims may not be submitted for:

• An individual whose IPC does not have a residential location of “own home/family home”

• the sole activity of supervising the individual's safety and security

• Transporting an individual from one DH or SE site to another– supporting home living provided to an individual:

• in a residence in which residential support or supervised living is provided to another individual;

• by a service provider who is simultaneously providing residential support, supervised living or foster/companion care to another individual;

• if the day habilitation service component is simultaneously provided to the individual by another service provider; or

• if the respite service component is simultaneously provided to the individual by another service provider.


Specific RequirementsSpecific RequirementsSupported Home Living Unit

of Service

• 15 Minute of Service – may not include fraction of service

• Calculating transportation – use Method A or Method B (can only use one method on a single calendar day)

Supported Home Living Unit of Service

• 15 Minute of Service – may not include fraction of service

• Calculating transportation – use Method A or Method B (can only use one method on a single calendar day)


Transportation Method ATransportation Method AIndividual Departure

TimeArrival Time

A. Dorothy N. Kansas

7:00am 9:00am

B. Dorothy N. Kansas

3:00pm 4:30pma. Transportation time of 120 minutes (7:00am-9:00am) with 6 passengers (Dorothy + 5 others) and 1 service provider for Trip A

SERVICE TIME = (1 X 120) ÷ 6 = 20 minutesb. Transportation time of 90 minutes (3:00pm-

4:30pm) with 5 passengers (Dorothy + 4 others) and 1 service provider

SERVICE TIME = (1 X 90) ÷ 5 = 18 minutes20 min + 18 min = 38 minutes (accumulation)

According to Attachment C:

38 minutes = 3 Units Billed (accumulation)

1 Unit (20 min) + 1 Unit (18 min)= 2 Units Billed (no accumulation)

79


Transportation Method BTransportation Method BIndividual Departure

TimeArrival Time

Dorothy N. Kansas

7:00am 9:00am

Little B. Blue 7:15am 9:00am

Mary Q. Contrary 7:30am 9:00amTransportation time for Dorothy N. Kansas:a. Transportation time of 15 minutes (7:00am-7:15am) with one passenger (Dorothy only) and 1 service providerSERVICE TIME = (1 X 15) ÷ 1 = 15 minutes

b. Transportation time of 15 minutes (7:15am-7:30am) with two passengers (Dorothy and Little) and 1 service providerSERVICE TIME = (1 X 15) ÷ 2 = 7.5 minutes

c. Transportation time of 15 minutes (7:30am-9:00am) with three passengers (Dorothy, Little and Mary) and 1 service providerSERVICE TIME = (1 X 90) ÷ 3 = 30 minutes

15 min + 7.5 min + 30 min = 52.5 minutes

According to Attachment C: 52.5 minutes = 3 Units

Transportation time for Dorothy N. Kansas:a. Transportation time of 15 minutes (7:00am-7:15am) with one passenger (Dorothy only) and 1 service providerSERVICE TIME = (1 X 15) ÷ 1 = 15 minutes

b. Transportation time of 15 minutes (7:15am-7:30am) with two passengers (Dorothy and Little) and 1 service providerSERVICE TIME = (1 X 15) ÷ 2 = 7.5 minutes

c. Transportation time of 15 minutes (7:30am-9:00am) with three passengers (Dorothy, Little and Mary) and 1 service providerSERVICE TIME = (1 X 90) ÷ 3 = 30 minutes

15 min + 7.5 min + 30 min = 52.5 minutes

According to Attachment C: 52.5 minutes = 3 Units

80


Common ErrorsCommon Errors• Overlapping times with other services• Transportation method completed incorrectly• Time not divided evenly between two or more

individuals receiving services at the same time• Non-qualified Service Provider (Proof of residence,

etc.)• No justification for receiving SHL in DH facility• No begin and/or end times on documentation• No location of services provided on

documentation• No Progress Note

• Overlapping times with other services• Transportation method completed incorrectly• Time not divided evenly between two or more

individuals receiving services at the same time• Non-qualified Service Provider (Proof of residence,

etc.)• No justification for receiving SHL in DH facility• No begin and/or end times on documentation• No location of services provided on

documentation• No Progress Note

81

Foster CareFoster Care


Specific RequirementsSpecific RequirementsFoster Care Requirements of

Setting• The program provider may not

lease or own the residence• The individual receiving care must

have a residence in which no more than three persons receive: foster/companion care, a non-HCS Program service similar to foster/companion care; and

• If the individual is a minor, the parent or step-parent may not provide this service

Foster Care Requirements of Setting

• The program provider may not lease or own the residence

• The individual receiving care must have a residence in which no more than three persons receive: foster/companion care, a non-HCS Program service similar to foster/companion care; and

• If the individual is a minor, the parent or step-parent may not provide this service


Specific RequirementsSpecific RequirementsFoster Care Requirements

of Setting• The service provider must

have the same residence as the individual; and

• Ensure that foster/companion care is provided to an individual when necessary

Foster Care Requirements of Setting

• The service provider must have the same residence as the individual; and

• Ensure that foster/companion care is provided to an individual when necessary


Specific RequirementsSpecific RequirementsFoster Care Unit of Service• Unit of service is one day• May not be for more than one

day • May not have a fraction of a

unit of service

Foster Care Unit of Service• Unit of service is one day• May not be for more than one

day • May not have a fraction of a

unit of service


Specific RequirementsSpecific RequirementsFoster Care Billable

Activity• Assisting the individual with

activities of daily living (bathing, dressing, personal hygiene, eating, meal planning and preparation and housekeeping)

• Assisting the individual with ambulation and mobility

• Reinforcing any counseling and therapy subcomponent provided to the individual

• Assisting with the administration of the individual’s medication or to perform a task delegated by an RN

Foster Care Billable Activity

• Assisting the individual with activities of daily living (bathing, dressing, personal hygiene, eating, meal planning and preparation and housekeeping)

• Assisting the individual with ambulation and mobility

• Reinforcing any counseling and therapy subcomponent provided to the individual

• Assisting with the administration of the individual’s medication or to perform a task delegated by an RN


Specific RequirementsSpecific RequirementsFoster Care Billable

Activity• Conducting habilitation

activities that train the individual to:– Develop or improve skills

that allow the individual to live more independently

– Develop socially valued behaviors

– Integrate into community activities

– Use natural supports and typical community services available to the public

– Participate in leisure activities

Foster Care Billable Activity

• Conducting habilitation activities that train the individual to:– Develop or improve skills

that allow the individual to live more independently

– Develop socially valued behaviors

– Integrate into community activities

– Use natural supports and typical community services available to the public

– Participate in leisure activities


Specific RequirementsSpecific RequirementsFoster Care Service Claim for

an Individual on a Visit with Family or FriendA program provider may submit a service claim for an individual who is on a visit with a family member or friend away from their residence if the visit is for at least a calendar day. If the visit is for more than 14 consecutive calendar days, the program provider may submit a service claim for only 14 calendar days of the visit.

Foster Care Service Claim for an Individual on a Visit with Family or FriendA program provider may submit a service claim for an individual who is on a visit with a family member or friend away from their residence if the visit is for at least a calendar day. If the visit is for more than 14 consecutive calendar days, the program provider may submit a service claim for only 14 calendar days of the visit.


Specific RequirementsSpecific RequirementsFoster Care Service Claim for an

Individual on a Visit with Family or Friend Written Documentation

Written documentation must include the individual’s name, the dates the individual was visiting the family member or friend, the location of the visit and the date and signature of the service provider.

Foster Care Service Claim for an Individual on a Visit with Family or Friend Written Documentation

Written documentation must include the individual’s name, the dates the individual was visiting the family member or friend, the location of the visit and the date and signature of the service provider.


Common ErrorsCommon Errors• Failure to discharge individual while

in the hospital• Weekly summary exceeds seven

days• Not documenting location

information• No Progress Note

• Failure to discharge individual while in the hospital

• Weekly summary exceeds seven days

• Not documenting location information

• No Progress Note

91

Residential Support Services

Residential Support Services



Residential Support Requirements of Setting

• The residence must be a Three or Four person residence

• The program provider may not have the same residence as the individual

• The service provider must be available to provide residential support to an individual as needed; and

• The service provider must be present and awake in the residence when the individual is present in the residence

Residential Support Requirements of Setting

• The residence must be a Three or Four person residence

• The program provider may not have the same residence as the individual


• The service provider must be present and awake in the residence when the individual is present in the residence


Specific RequirementsSpecific RequirementsResidential Support Billable

Activity– assisting the individual with activities of daily living;– assisting the individual with ambulation and mobility; – reinforcing any specialized therapies subcomponent

provided to the individual; – assisting with the administration of the individual's

medication or to perform a task delegated by a registered nurse in accordance with rules of the Texas Board of Nursing at 22 TAC, Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions) or the Human Resources Code, §161.091-.093, as applicable;

– conducting habilitation activities that train the individual;

– securing transportation for or transporting the individual; and

– supervising the individual's safety and security.

Residential Support Billable Activity– assisting the individual with activities of daily living;– assisting the individual with ambulation and mobility; – reinforcing any specialized therapies subcomponent








Residential Support Unit of Service

• Unit of service is one day• A service claim may not be

for more than one day• A service claim may not

include a fraction of a unit of service

Residential Support Unit of Service





Specific RequirementsSpecific RequirementsResidential Support Service

Claim for an Individual on a Visit with Family or Friend

A program provider may submit a service claim for an individual who is on a visit with a family member or friend away from their residence if the visit is for at least a calendar day. If the visit is for more than 14 consecutive calendar days, the program provider may submit a service claim for only 14 calendar days of the visit.

Residential Support Service Claim for an Individual on a Visit with Family or Friend



Specific RequirementsSpecific RequirementsService Claim for an

Individual on a Visit with Family or Friend Written Documentation Written documentation must include the individual’s name, the dates the individual was visiting the family member or friend, the location of the visit and the date and signature of the service provider.

Service Claim for an Individual on a Visit with Family or Friend Written Documentation Written documentation must include the individual’s name, the dates the individual was visiting the family member or friend, the location of the visit and the date and signature of the service provider.


Common ErrorsCommon Errors• Failure to discharge individual while in the hospital• Not providing location codes• Not providing staff signatures• Not showing night shift coverage activities

• Failure to discharge individual while in the hospital• Not providing location codes• Not providing staff signatures• Not showing night shift coverage activities

99

Supervised Living

Supervised Living


Specific RequirementsSpecific RequirementsSupervised Living Requirements

of Setting• The residence must be a 3 or

4-person residence• The service provider must be

available to provide residential support to an individual as needed; and

• The service provider must be present in the residence when the individual is present in the residence

Supervised Living Requirements of Setting

• The residence must be a 3 or 4-person residence


• The service provider must be present in the residence when the individual is present in the residence


Specific RequirementsSpecific RequirementsSupervised Living Billable Activity

– assisting the individual with activities of daily living; – assisting the individual with ambulation and mobility; – reinforcing any specialized therapies subcomponent






Supervised Living Billable Activity– assisting the individual with activities of daily living; – assisting the individual with ambulation and mobility; – reinforcing any specialized therapies subcomponent





– supervising the individual's safety and security. 102


Specific RequirementsSpecific RequirementsSupervised Living Unit of

Service• Unit of service is one day• A service claim may not be



Supervised Living Unit of Service





Specific RequirementsSpecific RequirementsSupervised Living Service Claim

for an Individual on a Visit with Family or Friend


Supervised Living Service Claim for an Individual on a Visit with Family or Friend



Specific RequirementsSpecific RequirementsService Claim for an

Individual on a Visit with Family or Friend Written DocumentationWritten documentation must include the individual’s name, the dates the individual was visiting the family member or friend, the location of the visit and the date and signature of the service provider.

Service Claim for an Individual on a Visit with Family or Friend Written DocumentationWritten documentation must include the individual’s name, the dates the individual was visiting the family member or friend, the location of the visit and the date and signature of the service provider.


Common ErrorsCommon Errors• Failure to discharge consumer while

in the hospital • Not providing location• No Progress Note

• Failure to discharge consumer while in the hospital

• Not providing location• No Progress Note

107

RespiteRespite


Specific RequirementsSpecific RequirementsRespite– is the temporary provision of assistance and support

necessary for an individual to perform personal care, health maintenance and independent living tasks, participate in community activities, and develop, retain and improve community living skills; and

– provides relief for a caregiver of the individual who: • has the same residence as the individual; • routinely provides assistance and support

necessary for an individual to perform personal care, health maintenance and independent living tasks, participate in community activities, and develop, retain and improve community living skills;

• is temporarily unavailable to provide such assistance and support; and

• is not a service provider of foster/companion care, residential support or supervised living to the individual.

Respite– is the temporary provision of assistance and support

necessary for an individual to perform personal care, health maintenance and independent living tasks, participate in community activities, and develop, retain and improve community living skills; and

– provides relief for a caregiver of the individual who: • has the same residence as the individual; • routinely provides assistance and support

necessary for an individual to perform personal care, health maintenance and independent living tasks, participate in community activities, and develop, retain and improve community living skills;

• is temporarily unavailable to provide such assistance and support; and

• is not a service provider of foster/companion care, residential support or supervised living to the individual.

4.06-1109http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4610

Specific RequirementsSpecific RequirementsRespiteRoom and Board-

If respite is provided in a setting other than the individual's residence, the program provider must provide room and board to the individual free of charge.

RespiteRoom and Board-

If respite is provided in a setting other than the individual's residence, the program provider must provide room and board to the individual free of charge.

4.06-1110http://www.dads.state.tx.us/handbooks/hcsbg/4000/4000.htm#sec4600

Specific RequirementsSpecific RequirementsRespite Billable Activity• interacting face-to-face with an individual to:

– assist the individual with activities of daily living; – assist the individual with ambulation and mobility; – reinforce any specialized therapies subcomponent provided to

the individual; – assist with the administration of the individual's medication or

to perform a task delegated by a registered nurse in accordance with rules of the Texas Board of Nursing at 22 TAC, Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions) or the Human Resources Code, §161.091-.093, as applicable;

– conduct habilitation activities that teach the individual;– secure transportation for the individual; – supervise the individual's safety and security; and – transport the individual, except from one day habilitation site

to another;

Respite Billable Activity• interacting face-to-face with an individual to:

– assist the individual with activities of daily living; – assist the individual with ambulation and mobility; – reinforce any specialized therapies subcomponent provided to

the individual; – assist with the administration of the individual's medication or

to perform a task delegated by a registered nurse in accordance with rules of the Texas Board of Nursing at 22 TAC, Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions) or the Human Resources Code, §161.091-.093, as applicable;

– conduct habilitation activities that teach the individual;– secure transportation for the individual; – supervise the individual's safety and security; and – transport the individual, except from one day habilitation site

to another;


Specific RequirementsSpecific RequirementsRespite Billable Activity• interacting face-to-face or by telephone with an

individual or an involved person regarding an incident that directly affects the individual's health or safety; and

• performing activities that does not involve interacting face-to-face with an individual described in Section 4620.

Respite Billable Activity• interacting face-to-face or by telephone with an

individual or an involved person regarding an incident that directly affects the individual's health or safety; and

• performing activities that does not involve interacting face-to-face with an individual described in Section 4620.


Specific RequirementsSpecific RequirementsRespite must be provided:Residence • If an individual receives respite in a residence, the residence must

be:– the individual's residence; – a three-person residence; – a four-person residence; or – the residence of another person (other than a three-person

residence or a four-person residence) in which no more than three persons are receiving HCS Program services or a non-HCS program service similar to HCS Program services.

Non-residence • If an individual is receiving respite during an overnight stay in a

setting that is not the residence of any person, no more than six persons receiving HCS Program services or a non-HCS Program service similar to HCS Program services may be in the setting.

Respite must be provided:Residence • If an individual receives respite in a residence, the residence must

be:– the individual's residence; – a three-person residence; – a four-person residence; or – the residence of another person (other than a three-person

residence or a four-person residence) in which no more than three persons are receiving HCS Program services or a non-HCS program service similar to HCS Program services.

Non-residence • If an individual is receiving respite during an overnight stay in a

setting that is not the residence of any person, no more than six persons receiving HCS Program services or a non-HCS Program service similar to HCS Program services may be in the setting.



Submitting a Service Claim for Respite

Respite Provided in an Individual's Residence • If a program provider provides respite in an

individual's residence, the program provider may submit a service claim for no more than 96 units of service (24 hours) in one calendar day.

Respite Provided in Location Other Than the Individual's Residence • If a program provider provides 10 hours or

more of respite to an individual in one calendar day in a location other than the individual's residence, the program provider may submit a service claim for no more than 40 units of service.

Submitting a Service Claim for Respite

Respite Provided in an Individual's Residence • If a program provider provides respite in an

individual's residence, the program provider may submit a service claim for no more than 96 units of service (24 hours) in one calendar day.

Respite Provided in Location Other Than the Individual's Residence • If a program provider provides 10 hours or

more of respite to an individual in one calendar day in a location other than the individual's residence, the program provider may submit a service claim for no more than 40 units of service.


Common ErrorsCommon Errors• Location of service not on documentation• Billing more than 10 hours for respite occurring

out of the individuals home• Individual lives alone without a live-in caregiver• No begin and/or end times • Non Qualified Service Provider (Proof of

residence, etc.)• Not providing location information• No Progress Note

• Location of service not on documentation• Billing more than 10 hours for respite occurring

out of the individuals home• Individual lives alone without a live-in caregiver• No begin and/or end times • Non Qualified Service Provider (Proof of

residence, etc.)• Not providing location information• No Progress Note

116

Billing & Payment

Review Protocol117

Billing and Payment Review•Conducted by DADS Billing and Payment staff

•Review of authorization and written documentation of service delivery maintained by program provider

118

Purpose:To determine whether the program provider is in compliance with the HCS Program Billing Guidelines

Outcome:

DADS will recoup non-verified claims that were not supported by authorization and/or written documentation and may require a corrective action plan (CAP) by the program provider.

119

Types of Reviews:• Routine

Once every 2 years, all services are reviewed with the number of individuals reviewed and review period determined by previous error rates or number of individuals served

• Special As determined by DADS, result of a complaint, referral or billing anomalies

120

Routine or special review can be either:

• On-site – conducted at provider’s place of business

• Desk – conducted at DADS Headquarters (documentation submitted by mail )

121

Samples are chosen based upon documentation error rate:

Error Rate = non-verified dollars divided by the total amount billed during the review period

122

Example of Error Rate:

Non-Verified Claims Total..................$15,400.00

Total Claims Billed...............................$125,600.00

$15,400.00 ÷ $125,600.00 = .1226

Error Rate:12.26%

123

BPR sample size:Error Rate Less Than Ten Percent (10%):

• Provider serves more than 10 individuals – 5 + 5% reviewed

• Provider serves less than 10 individuals – All reviewed

124

BPR sample size--Error Rate More Than Ten Percent (10%):

• Provider serves more than 10 individuals – 10 + 10% reviewed

• Provider serves less than 10 individuals – All reviewed

125

BPR sample sizeNever Reviewed:

• Provider serves more than 10 individuals-5 + 10%

• Provider serves less than 10 individuals-up to 5

126

On-site Reviews:

Notification:

•Routine: • At least fourteen(14) days notice by phone and

followed by a faxed letter.• Individual sample list from outside of Waiver Contract

Area (WCA) of review location provided two business days prior to Entrance Conference.

•Special: • Will be conducted without notice.

127

On-site Reviews:

List of individuals within the review location’s WCA are identified at Entrance Conference.

PROVIDERS ARE NOT PERMITTED TO CREATE ANY DOCUMENTATION AT ANY TIME WHILE REVIEW IS IN PROGRESS

128

Error Sheet Forms

129

Refuting – On-site Reviews

•Refuting is conducted while on-site.

•DADS will not accept additional documentation or refute any unverified claims after the Exit Conference.

130

Demand for Payment-on-site review:

Following the Exit Conference, generally within 30 days, DADS will send a certified letter (Demand for Payment) to the provider detailing any unverified claims. The letter includes the amount to be recouped, any required corrective action and notice of the right to request an Administrative Hearing.

131

On-Site Review:

Request for Administrative Hearing (appeal)

Must be made within 15 calendar days from receipt of certified green card from Demand for Payment letter

132

Payment of unverified claims:

Recoupment is done electronically through the automated billing system (CARE)

Please do not send checks.

133

Desk reviews:

Notification:

•Telephone and Certified Mail

134

Timeframe to Provide Documentation-desk review

14 calendar days from receipt of certified green card from notification letter.

Documentation received after 14 days has elapsed will not be accepted and all services requested will be subject to recoupment.

135

Results-desk review:

Provider notified of results in certified letter

Refuting-desk review:Additional documentation must be submitted within 14 calendar days of receipt of certified green card from results letter

Late submissions are not accepted

136

Demand for Payment-desk review:

Certified letter notifies provider of final account of unverified claims after considering refuting documentation (if any submitted)

137

Desk Reviews:

Request for Administrative Hearing (appeal):Must be made within 15 calendar days from receipt of certified green card from Demand for Payment letter

138

Payment of unverified claims:

Recoupment is done electronically through the automated billing system.

Please do not send checks.

139

HCS BILLING GUIDELINE REVISION

Misti J. Ackermann, Billing & Payment Manager

2011 Billing Guidelines

Guidelines: http://www.dads.state.tx.us/handbooks/h

csbg/index.htm

Guideline Changes: http://www.dads.state.tx.us/handbooks/h

csbg/rmemo/11-1.htm

http://www.dads.state.tx.us/handbooks/hcsbg/index.htm

http://www.dads.state.tx.us/handbooks/hcsbg/index.htm

http://www.dads.state.tx.us/handbooks/hcsbg/rmemo/11-1.htm

http://www.dads.state.tx.us/handbooks/hcsbg/rmemo/11-1.htm

Section Title Change2000 Definitions Adds definitions for competitive employment, comprehensive assessment, focused assessment,

integrated employment, service coordination and service coordinator.

3210 General Requirements Updated references.3230 Service Claim for Day Habilitation for

Individual Receiving Supported Employment

Deleted.

3230 Service Claim for Foster/Companion Care, Residential Support or Supervised Living for Individual on a Visit with Family or Friend

Section 3240 is renumbered to 3230.

3430 Relative, Guardian or Managing Conservator Qualified as Service Provider

Updates information in the first paragraph and deletes outdated information.

3610 15-Minute Unit of Service Defines “person” under No. 2, Service Time.3620 Daily Unit of Service Updates billable units of service.3700 Billing Service Components Provided at

the Same Time and Billing Day Habilitation Provided at the Same Time as Service Coordination

Revises section heading.

3730 Service Coordination and Day Habilitation Provided at the Same Time

Adds new section.

3810 General Requirements Adds new information and deletes outdated material.3820 Written Service Log and Written

SummaryUpdates section title; adds new information; deletes outdated material.

3850 Example Forms Updates title and adds new information.4210 General Description of Service

ComponentDefines specialized therapies subcomponents.

4220 Billable Activity Updates billable activities for the specialized therapies.4230 Activity Not Billable Updates examples of non-billable activities.4250 Unit of Service Adds service time information.4260 Written Documentation Updates documentation required to support a service claim for specialized therapies.4320 Requirements of Setting Adds retirement age as justification for providing day habilitation at the individual’s residence.

4370 Unit of Service Updates billable units of service.4380 Written Documentation Deletes outdated information and clarifies required documentation to support a service claim for day

habilitation.




















4390 Submitting a Service Claim for Individuals Receiving Supported Employment

Deleted.

4420 Billable Activity Updates billable activities for the licensed registered nursing service component.4430 Activity Not Billable Updates text.4450 Unit of Service Adds No. 3, Service Time.4470 Written Documentation Deletes outdated information.4471.2 Billable Activity Updates billable activities for the licensed vocational nursing service component.4471.3 Activity Not Billable Updates examples of non-billable activities.4471.5 Unit of Service Adds No. 3, Service Time.4471.7 Written Documentation Deletes outdated information.4472.2 Billable Activity Updates billable activities for the specialized registered nursing service component.4472.3 Activity Not Billable Updates text.4472.5 Unit of Service Adds No. 3, Service Time.4472.7 Written Documentation Deletes outdated information.4473.2 Billable Activity Updates bill activities for the specialized licensed vocational nursing service component.4473.3 Activity Not Billable Updates text.4473.5 Unit of Service Adds No. 3, Service Time.4473.7 Written Documentation Deletes outdated information.4540 Supported Home Living Subcomponent Updates rule citations; adds new requirements; deletes outdated information.4550 Foster/Companion Care Subcomponent Updates rule citations; clarifies requirements for service provider; updates text in No. 5, Restrictions

Regarding Submission of Claims for Foster/Companion Care; and clarifies required documentation in No. 8, Written Documentation.

4560 Residential Support Subcomponent Deletes text under No. 1(d), Service Provider Shifts; updates rule citations under No. 2, Billable Activity; updates information in No. 5, Restrictions Regarding Submission of Claims for Residential Support; adds new bullet under No. 8, Written Documentation; and makes minor wording changes to No. 9, Submitting a Service Claim for an Individual on a Visit with Family or Friend.

4570 Supervised Living Subcomponent Updates rule citations under No. 2, Billable Activity; updates information in No. 5, Restrictions Regarding Submission of Claims for Supervised Living; adds new bullet under No. 8, Written Documentation; and makes minor wording changes to No. 9, Submitting a Service Claim for an Individual on a Visit with Family or Friend.

4610 General Description of Service Component

Updates information in No. 1, Temporary Provision of Assistance, and No. 2, Room and Board.

4620 Billable Activity Updates rule citations.4651 Restrictions Regarding Submission of

Claims for RespiteAdds reasons for which a program provider may not submit a service claim.

4690 Written Documentation Deletes a bulleted item and makes minor wording changes.4710 General Description of Service

ComponentUpdates definition of supported employment.

4730 Billable Activity Adds transporting individual to and from the individual’s work site as a billable activity for the supported employment service component.

4740 Activity Not Billable Adds transporting an individual to a job interview as a non-billable activity.




























4760 Restrictions Regarding Submission of Claims for Supported Employment

Deletes outdated information.

4770 Unit of Service Adds No. 3, Service Time4780 Written Documentation Updates information.4790 Submitting a Service Claim for Day

HabilitationDeleted.

6160 Required Documentation for an Adaptive Aid

Updates section reference and removes prior approval requirement.

6170 Prior Approval Deleted.6170 Authorization for Payment Updates section number; adds new information and deletes outdated text. 6240 Payment Limit Deletes outdated information.6250 Required Documentation for a Minor

Home ModificationRemoves prior approval requirement.

6260 Prior Approval Deleted.6260 Authorization for Payment Updates section number; adds new information and deletes outdated material.Appendix IBilling and Payment Review Protocol Updates information.Appendix IV

Example of Service Delivery Log with Written Narrative

Deletes appendix and reserves it for future use.

Appendix VII

Billable Adaptive Aids Updates abbreviations and number codes.Appendix VIII

Instructions for AA/MHM Request for Prior Approval

Deletes appendix and reserves it for future use.

Appendix X

Billable Minor Home Modifications Updates abbreviations.Form 4116-Dental, Instructions

Home and Community-based Services/Texas Home Living Dental Summary Sheet

Deletes outdated information and adds instruction for signature/date line.

Form 4116-MHM-AA, Instructions

Home and Community-Based Services/Texas Home Living Minor Home Modification/Adaptive Aids Summary Sheet

Deletes outdated information, updates references and adds instruction for signature/date line.









http://www.dads.state.tx.us/handbooks/hcsbg/appendix/I/index.htm

http://www.dads.state.tx.us/handbooks/hcsbg/appendix/IV/index.htm

http://www.dads.state.tx.us/handbooks/hcsbg/appendix/IV/index.htm

http://www.dads.state.tx.us/handbooks/hcsbg/appendix/VII/index.htm

http://www.dads.state.tx.us/handbooks/hcsbg/appendix/VII/index.htm

http://www.dads.state.tx.us/handbooks/hcsbg/appendix/X/index.htm

http://www.dads.state.tx.us/handbooks/hcsbg/appendix/X/index.htm

http://www.dads.state.tx.us/handbooks/instr/4000/F4116-Dental/



http://www.dads.state.tx.us/handbooks/instr/4000/F4116-MHM-AA/




Changes to Billing Guidelines

Section 2000 - Definition Additions Competitive employment — Employment that pays an individual at or

above the greater of: (A) the applicable minimum wage; or (B) the prevailing wage paid to individuals without disabilities performing the same or

similar work.

Comprehensive Assessment: An extensive evaluation of an individual's health status that: (A) addresses anticipated changes in the conditions of the individual as well as emergent

changes in the individual's health status; (B) recognizes changes to previous conditions of the individual; (C) synthesizes the biological, psychological, spiritual and social aspects of the

individual's condition; (D) collects information regarding the individual's health status; (E) analyzes information collected about the individual's health status to make nursing

diagnoses and independent decisions regarding nursing services provided to the individual;

(F) plans nursing interventions and evaluates the need for different interventions; and (G) determines the need to communicate and consult with other service providers or

other persons who provide supports to the individual.

Changes to Billing GuidelinesSection 2000 - Definition Addition Focused Assessment: An appraisal of an individual's current health

status that: (A) contributes to a comprehensive assessment conducted by a registered nurse; (B) collects information regarding the individual's health status; and (C) determines the appropriate health care professionals or other persons who

need the information and when the information should be provided.

Integrated employment — Employment at a work site at which an individual routinely interacts with people without disabilities other than the individual's work site supervisor or service providers.

Changes to Billing GuidelinesSection 3000 Supported Employment/Day Habilitation Division of Time Between Individuals Service Coordination & Day Habilitation Written Documentation for non-nursing

services Other Changes to Section 3000

Changes to Billing GuidelinesSection 4000 Specialized Therapies

Definitions Video Conference

Day Habilitation In-Home Exception Time Change Supported Employment Dual Billing Removal

Nursing (See Next Slides) Residential Services (See Next Slides) Respite

Clarification Supported Employment

Transportation included

Changes to Billing GuidelinesSection 4400 – Nursing Services Registered Nursing

Assessments & Comprehensive AssessmentsMedication ReviewInsurance Provider CommunicationSupervising LVN (RN can only bill)

Licensed Vocational NursingFocused AssessmentsMedication ReviewInsurance Provider Communication

Changes to Billing GuidelinesSection 4500 – Residential Services Foster Care & Supervised Living

No Significant Changes Residential Support Services

Service Provider ShiftsOff Duty RequirementNo Shifts of More than 24 Hours

Supported Home LivingSafety & SupervisionNo Volunteer Hour Limit

Changes to Billing GuidelinesSection 6000 Adaptive Aids

Prior Approval RemovalAuthorization for Payment Requirements

Minor Home ModificationsPrior Approval RemovalAuthorization for Payment Requirements

Changes to Billing GuidelinesOther Changes

Guideline FormatBilling and Payment Review ProcessForm Updates

○ 2122 Service Delivery Log with Written Narrative/Written Summary ○ 2124 Community Support Transportation Log ○ 4116-Dental Dental Summary Sheet ○ 4116-MHM-AA Minor Home Modification/Adaptive Aids Summary Sheet ○ 4117 HCS Supported Employment Service Delivery Log ○ 4118 HCS Respite Service Delivery Log ○ 4119 HCS Residential Support Services (RSS) and Supervised Living (SL) ○ 4120 HCS Day Habilitation (DH) ○ 4121 HCS Supported Home Living○ 4122 Foster/Companion Service Delivery Log

http://www.dads.state.tx.us/forms/2122/2122.pdf


http://www.dads.state.tx.us/forms/4116-Dental/4116-Dental.pdf

http://www.dads.state.tx.us/forms/4116-MHM-AA/4116-MHM-AA.pdf






http://www.dads.state.tx.us/forms/4122

Vivian Griffor, Billing and Payment Team Leader

Guide to Purchasing Adaptive Aids & Minor Home

Modifications

153

http://www.dads.state.tx.us/handbooks/hcsbg/6000/index.htm

Adaptive Aids & Minor Home Modifications

Documentation required before purchasing any AA/MHM:Documentation required before purchasing any AA/MHM:

Written assessment Not required for AA under $500 or MHM under $1000

Individual and Program Provider Agreement

Three Bids 3 bids are required no matter the cost need an explanation if 3 bids have not been

obtained

Proof of non-coverage by private insurance, Medicare, and Medicaid (AA only-as applicable)

Written assessment Not required for AA under $500 or MHM under $1000

Individual and Program Provider Agreement

Three Bids 3 bids are required no matter the cost need an explanation if 3 bids have not been

obtained

Proof of non-coverage by private insurance, Medicare, and Medicaid (AA only-as applicable)

154

Griffor,Vivian L (DADS)



The Written Assessment must:

• be based on a face-to-face evaluation

• be done in the home if a MHM is being requested

• be done by a qualified medical professional-

See Appendix VII for Adaptive Aids & Appendix X for Minor Home Modifications

• include a description of AND a recommendation for the specific AA/MHM being requested

• be based on a face-to-face evaluation

• be done in the home if a MHM is being requested

• be done by a qualified medical professional-

See Appendix VII for Adaptive Aids & Appendix X for Minor Home Modifications

• include a description of AND a recommendation for the specific AA/MHM being requested 155

Assuming that a recommended item is a covered item

**Obtaining an assessment that is not current

**Obtaining an assessment that does not contain sufficient medical justification

Assuming that a doctor’s prescription is sufficient

**Obtaining an assessment that is not legible

**Obtaining an assessment done by an unauthorized professionalhttp://www.dads.state.tx.us/handbooks/hcsbg/6000/index.htm

Avoid These Common ErrorsAvoid These Common Errors

156



Individual and Program Provider Agreement Must

• consider the written assessment

• document any discussion about the recommended item(s)

• agree that the recommended item is necessary and should be purchased

• document their agreement in writing

• consider the written assessment

• document any discussion about the recommended item(s)

• agree that the recommended item is necessary and should be purchased

• document their agreement in writing

157

Failure to include signatures

Team meeting/Staffing/Individual and Program Provider Agreement

Failure to document discussion of need for item requested



158



Bids :

• Three (3) bids are required, regardless of cost

• Bids must be comparable (for like or very similar items)

• Bids must state the total cost of the requested AA/MHM and, if it includes more than one AA/MHM, state the itemized cost of each AA/MHM listed by service code

• Bids must include the name, address and telephone number of the vendor/contractor

• Three (3) bids are required, regardless of cost

• Bids must be comparable (for like or very similar items)

• Bids must state the total cost of the requested AA/MHM and, if it includes more than one AA/MHM, state the itemized cost of each AA/MHM listed by service code

• Bids must include the name, address and telephone number of the vendor/contractor

159

Exceptions to bid requirements:

Less than three bids for an AA/MHM may be acceptable IF there is written justification stating the AA/MHM is available from only a limited number of vendors/contractors

A single bid from the custom fitting vendor is acceptable for eyeglasses (220), hearing aids, batteries and repairs (260) and orthotic devices, orthopedic shoes, and braces (107)



160

Annual Vendor:Will there still be an Annual Vendor?

Yes.

A Program Provider:May be exempted from bid requirement for

frequently purchased consumable items with an approval for Annual Vendor status

Will submit application for Annual Vendor by January 31 for current calendar year



161

Failure to obtain three bids (no justification)*

Obtaining bids that contain items not recommended in the assessment**

Obtaining bids that contain items not covered on the waiver**

Obtaining bids that are not for the same item or list of items**



162

Pursuing alternate funding sources:

Written proof of non-coverage from Medicare/Medicaid must be obtained for any AA denoted with a (1) or (2) on the “List of Billable (Reimbursable) Adaptive Aids”



163

Obtaining a statement by a DME vendor that an item is not covered**

Obtaining a denial letter that indicates that insufficient documentation was submitted with claim**

Obtaining a Medicaid denial letter that indicates that consumer is eligible for Medicare (primary)**



164

Texas Department of Aging and Disability Services Home and Community-Based Services/Texas Home Living

Minor Home Modification/Adaptive Aids Summary Sheet

Form 4116-MHM-AA September 2011

Service Month and Year Component Code Contract No. Contact Person Area Code and Telephone No.

September 2011 000 00100XXXX Ima Provider 512-555-5555

Name (Last, First, Initial) Client

Care ID No.

Service Date (MM,DD,YY)

Prior Approval

Tracking No.

Service Description Service Description

Minor Home Modification

Service Code

Dollars Spent

Req. Fee Adaptive Aids Service Code

Dollars

Spent Req. Fee

1. Anita N. Item 12345 09/01/11 N/A Leg Brace 107 $180.00 $18.00

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

Total

I certify by submission of this form that it meets all requirements set forth in the Home and Community-Based Services/Texas Home Living Billing Guidelines.

Ima Provider 9/22/11

Signature Date

165

Submit reimbursement claims (4116) to:

DADSProvider Claims ServicesPO BOX 149030 MC W-400Austin, TX 78714-9030

For questions contact Provider Claims Services at

512-438-2200 option 5http://www.dads.state.tx.us/handbooks/hcsbg/6000/index.htm


166

ManagerMisti J. Ackermann [email protected]

HCS Team LeadersVivian Griffor -Adaptive Aids Contact [email protected]

Willie Mae Jones [email protected]. Sam Montgomery [email protected] Sifuentes [email protected] Solis – Cost Report Contact [email protected]

Program SpecialistsKarri Henager [email protected] Rehagen [email protected] Santos-Vela [email protected] Vekris– Cost Report Contact [email protected]

Additional InformationBilling and Payment Email & Hotline

[email protected] [512-438-5359]

Fax 512-438-2695

Mailing Address

Department of Aging and Disability ServicesCommunity Services, Billing and PaymentPO BOX 149030, Mail Code W-200Austin, Texas 78714-9030

Documents

HCS BILLING GUIDELINES You can find the newest version on the DADS website: 1