Targeted Case Management

School Based Health Services

Home and Community Based Health Services2014

Cynthia Parsons, Program Manager Behavioral Health Services and School Based Health Services WV Medicaid (BMS)

Teresa McDonough, Program Manager, Traumatic Brain Injury, School Based Health Services Committee WV Medicaid (BMS)

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Introductions

TCM-School Based Health

• T2022 Code Case Management per month will be no longer in use and will be replaced by T1017, Targeted Case Management per 15 minutes

• Effective Date October 1, 2014

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Medical Necessity is services and supplies that are: 1. appropriate and necessary for the symptoms,

diagnosis or treatment of an illness;2. provided for the diagnosis or direct care of an illness;3. within the standards of good practice; 4. not primarily for the convenience of the Medicaid

Member (Student) or Provider (School); and 5. the most appropriate level of care that can be safely

provided in the school setting.

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Medical Necessity

TCM DefinitionTargeted Case Management Services are federally defined as

"those services which assist Medicaid eligible recipients in the target group to gain access to needed medical, behavioral health, social, educational and other services”.

*Targeted Case Management is not a direct service

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The relationship of the TCM Case Manager (Teacher or individual that meets the staff credentialing to render TCM Services) with a Medicaid member should be one of a partnership with the student, teacher, and the student’s family or guardians.

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TCM Definition (cont.)

Eligibility Criteria for ChildrenChildren in the schools must meet 2 of the criteria listed below to establish medical necessity.Category 1:

The child is between the ages of 3 through 17, and The child demonstrates a serious and persistent

emotional, behavioral, developmental and/or substance abuse or dependence disturbance as exemplified by a valid and documented Axis I diagnosis and/or diagnosis of developmental disability as described in the language of the current Diagnostic and Statistical Manual of the American Psychiatric Association (See Appendix A for list of eligible diagnoses); and

The Designated Legal Representative or older child member is documented to be unable to access/provide the service proposed without training or support; and

By virtue of age and effects of the emotional and/or developmental impairments, the child is unable to perform age-appropriate activities of daily living (ADL) without assistance and/or prompting

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Eligibility Criteria for Children (cont.)

OR Children in the schools must meet 2 of the criteria listed below to

meet eligibilityCategory 2: Documentation indicates that the Child is eligible due to actual or

pending removal from placement and: The child is between the ages of 3 and 17 inclusively

and/or is in the custody of the DHHR and; The child is removed or is pending removal from

placement due to allegations of abuse and neglect; and The appointed foster care entity is not able or qualified to

perform the case management task in question.

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A student is excluded from TCM Services if they are currently eligible for case management services through:

West Virginia Birth to Three Program, or is in a residential treatment facility, or is in a Psychiatric Residential Treatment Facility (PRTF), or Long-Term Care, or is receiving acute psychiatric care, or and/or is enrolled through the Intellectual/Developmental

Disabilities I/DD), Traumatic Brain Injury (TBI) or Aged and Disabled (AD) waiver programs, or is residing in an ICF/IID provided that the community-based provider may supply discharge planning services through Targeted Case Management for eligible children 10 days prior to discharge from acute psychiatric care and 30 days prior to discharge from a long- term care program.

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TCM Exclusions for Children

Eligibility Criteria For Adult StudentsAdult students must meet 3 of the criteria listed below:

The adult is age 18 or older; and The adult demonstrates a serious and persistent

emotional, behavioral, developmental and/or substance abuse or dependence disturbance as exemplified by a valid and documented Axis I diagnosis and/or diagnosis of developmental disability as described in the language of the current Diagnostic and Statistical Manual of the American Psychiatric Association (See Appendix A for list of eligible diagnoses); and

By virtue of age and effects of the emotional and/or developmental impairments, the adult is unable to perform age-appropriate activities of daily living (ADL) without assistance and/or prompting; and

The Designated Legal Representative or spouse is documented to be unable to provide the service proposed without training or support.

OR

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Eligibility Criteria For Adult Students (cont.) Documentation indicates that the adult student is approved

for but pending initiation of I/DD, TBI, and Aged/Disabled Waiver Services.

The adult is determined to be eligible to receive services through the I/DD, TBI, and AD waiver programs however is not yet receiving services.

Documentation indicates that the adult student is currently and temporarily residing in a licensed domestic violence shelter

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TCM Exclusions For Adult StudentsThe adult student is currently receiving services through:

an acute psychiatric care facility; or a state-operated psychiatric facility; or a long-term care facility; or is enrolled through the I/DD, TBI or AD waiver program; or or is an active recipient of Assertive Community

Treatment (ACT); Provided that the community-based provider may supply discharge planning services through Targeted Case Management for eligible individuals 10 days prior to discharge from acute psychiatric care and 30 days prior to discharge from a longer term care program.

The adult student is receiving TCM services from another entity.

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A psychologist with a Master's’ or Doctoral degree from an accredited program

A licensed social worker A licensed registered nurse A Master's’ or Bachelor's’ degree granted by an accredited college

or university in one of the following human services fields: PsychologyCriminal JusticeBoard of Regents with health specializationRecreational TherapyPolitical ScienceNursingSociologySocial WorkCounselingTeacher EducationBehavioral HealthLiberal Arts or;Other Degrees approved by the West Virginia Board of Social Work.

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Credentals To Bill for TCM

TCM Student Enrollment Form• The student/parent/guardian must be given an opportunity to

choose only one approved Targeted Case Management provider and must indicate this choice on the BMS- approved “Medicaid Targeted Case Management Student Enrollment” form.

• A signed copy of the “Annual Medicaid Targeted Case Management Student Enrollment” form must be retained in the student’s billing record and must serve as an enrollment, disenrollment, or re-enrollment of the student with the school system.

• Must be completed prior to providing TCM activities

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A TCM unit of service consists of a 15-minute period of time.

Claims must not be processed for less than a full unit of service.

Consequently, in filing claims for Medicaid reimbursement, the amount of

time documented in minutes must be totaled and divided by 15.

Partial units must be rounded down to arrive at the number of units billed.

After arriving at the number of billable units, the last date of service

provision must be billed as the date of service.

Rounding up to the next 15 minute unit it prohibited.

The billing period cannot overlap calendar months.

All payments will be recovered by BMS for services that do not meet the

criteria and that are billed inappropriately.

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TCM Billing Issues

Components OF TCMAssessment:• The case manager ensures an on-going formal and informal

process to collect and interpret information about a member's strengths, needs, resources, and life goals. This process is to be used in the development of an individualized service plan. Assessment is a collaborative process between the member, his/her family, and the case manager.

• Continued “assessments” without assisting the client in gaining access to needed services does not meet service definition.

• Generally not “scheduled” or “routine”.• Not for completion of testing assessments that are covered

within the psychological testing code (96101).• Not for completion of screeners when H0031/intake is

completed.• Completion of screeners is part of intake process and should

not be separated into another code.

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Components OF TCM (cont.)IEP/Service Planning:• The case manager ensures and facilitates the development

of a comprehensive, individualized education/service plan.• Not utilized for documentation time (i.e. actual writing of

the plan—part of treatment planning meetings) but for formulation of the plan with the consumer

• The individualized education/service plan records the full range of services, treatment, and/or other support needs necessary to meet the member’s goals.

• The case manager is responsible for regular service planning reviews based on the member’s needs and at regularly scheduled intervals.

• To coordinate time and date for treatment team meeting.

(Note: When the case manager participates in a treatment team meeting, the services provided are not billable as Targeted Case Management.)

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Components OF TCM (cont.)Linkage/Referral:• Case managers ensure linkage to all internal and external

services and supports identified in the member’s service plan.• Linkage/Referral is to appointments/services, not to the

consumer themselves.

Advocacy:• Targeted Case Management advocacy refers to the actions

undertaken on behalf of the member in order to ensure continuity of services, system flexibility, integrated services, proper utilization of facilities, and resources, and accessibility to services. This includes assuring that the member's legal and human rights are protected.

• Advocacy is not just asking permission from the DHHR worker/guardian for the client to participate in a service/activity (i.e. can a client go on a home visit) but there is clear documentation that there is a concern/threat related to the consumer’s continuity of services/legal or human rights.

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Crisis Response Planning:• The case manager must ensure that adequate and appropriate crisis

response procedures are available to the member and identified in the individual service plan.

• The case manager assists the member as necessary in accessing crisis support services and interventions.

• There is a final product that can be found within the consumer’s clinical record indicating what the crisis response plan is.

• Final product is individualized to the consumer and not a “standard” protocol (i.e. contact on-call worker, go to local hospital).

IEP/Service Plan Evaluation:• The case manager continually evaluates the appropriateness of the

member's Individualized Education/Service Plan and makes appropriate modifications, establish new linkages, or engage in other dispositions as necessary.

• Purpose for SPE would not be “routine review”, based upon client need and medical necessity.

• “Why” is a review of the plan needed prior to the next 90-day treatment plan review meeting.

• Routine reviews occur under treatment planning codes. 19

Components OF TCM (cont.)

Monitoring and Follow up:•The Case Manager ensures appropriate quality, quantity and effectiveness of service in accordance with the IEP/Service Plan. •The Case Manager may only utilize and bill for this component when one of the above stated components have been utilized and determined to be a valid TCM activity. •Monitoring and Follow-up cannot be the only TCM activity provided within the student’s record.•The amount of time spent to “monitor/follow-up” a TCM service shall not exceed the amount of time spent rendering the valid activity.

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Components OF TCM (cont.)

TCM Documentation RequirementsEach progress note must contain the following:

Be dated and signed by the case manager along with a listing of the case manager’s credentials, (e.g. BA,MA).

Link back to the student’s current IEP and/or other services that may be needed by the student.

Include the purpose (why the activity is being performed) and content (what activity was performed) of the activity as well as the outcome (the end result of the activity performed) achieved.

Include a description of the type of contact provided (e.g., face-to-face, correspondence, telephone contacts).

Include the TCM component of the valid activity provided; (i.e., assessment, service planning, linkage/referral, advocacy, crisis response planning, service plan evaluation and monitoring/follow-up)—this can be a check box.

List the place where the activity occurred. “Other” is not a specific location( i.e. school or home)

List the actual time spent providing each activity by listing the start – and - stop time. (rounding to the nearest 15 minutes not allowed). 21

Additional Information

• A new Bureau for Medical Services School Based Health Services Manual will be developed in 2014-2015. Department of Education will be involved in the rewrite process.

• Retrospective reviews will be completed in the future no set date at this time.

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Questions

For more information contact:Cynthia Parsons, Program Manager

Bureau for Medical Services350 Capitol Street, Room 251

Charleston, WV 25301 Phone: 304-356-4936

E-mail: Cynthia.A.Parsons@wv.gov

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