1 OPWDD Guidance Documents with Payment Standards This guidance docume nt contains payment st andards, with all payment standards shad ed in grey. Any re quirement in this guidance document which is not shaded in grey is a program standard or an explanation, illu mination or illus tration to aid g the documents. Please note that there may auditors in interpretin be instances where materials may be partially shaded in a sentence, paragraph or beneath a header. It is OPWDD’s intent that only those words that are shaded shall be considered part of a payment standard and any other words with in a sentence or paragraph or below a header that ar e not shaded should be construed to be a program standard or an explanatio n, illumination or illustration to aid auditors in interp reting the document.
2 ADMINISTRATIVE MEMORANDUM - #2006-01 _ TO: ized to Provide Group Day Habilitation Executive Directors of Agencies Author Services Executive Directors of Agencies Author ized to Provide Medicaid Service Coordination DDSO Directors FROM: Helene DeSanto, Executive Deputy Commissioner and Interim Director, Quality Assurance Gary Lind, Director Policy, Planning and Individualized Initiatives James F. Moran, Deputy Commissioner Administration and Revenue Support SUBJECT: GROUP DAY HABILITATION SERVICE DOCUMENTATION REQUIREMENTS DATE: January 1, 2006 Suggested Distribution : Group Day Habilitation Program/Service Staff Quality/Compliance Staff Billing Department Staff rvice Coordinator Supervisors MSC Service Coordinators and Se Purpose : This is to review the Group Day Habilitation servi ce documentation requirements that support a provider’s claim for reimbursement. These service documentati on criteria apply to Group Da y Habilitation services rendered to Home and Community Ba d individuals as well as to non- sed Services (HCBS) waiver-enrolle waiver enrolled individuals effective January 1, 2 006. Requirements set forth in this Administrative Memorandum supersede Administra tive Memorandum 2003-04 and fiscal audit service documentation , The Home and Community Based Services requirements addressed in The Ke y to Individualized Services Waiver (OMRDD, 1997). Quality service standards in The Key remain the same.
3 ADMINISTRATIVE MEMORANDUM #2006-01 Documentation Requirements Group Day Habilitation Service January 1, 2006 : Background 18 NYCRR, Section 504.3(a) states th at by enrolling in the Medicaid program, “the provider agrees...to maintain contemporaneous records prepare and to receive payment under the demonstrating its right to medical assistance program and to keep for a period of six years from the date the care, services or supplies were furnished, all records necessary to disclose the nature an d extent of services furnished and all information regarding claims for payment submitted by, or on behalf of, the provider and to furnish such records and information, upon request, to...the Secr etary of the United States Department of Health and Human Services, the De aud Control and the New York State puty Attorney General for Medicaid Fr Department of Health.” (emphasis a dded) It should be noted that there are other entities with rights to audit Medicaid waiver claims as well, including OMRDD. The regulatory basis for HCBS Wa iver Group Day Habilitation is in 14 NYCRR section 635-10.4 (b)(2) and 635-10.5 (c) Group Day Habilitation Services: Effective January 1, 2006, for billing purposes, Da y Habilitation will be categorized as Group Day Habilitation, Supplemental Group Day Habilitatio n, Individual Day Habilitation or Supplemental tion conform to the existing service . All four forms of Day Habilita Individual Day Habilitation services definitions in 14 NYCRR section 635-10.4 (b)(2). tion requirements for Group Day Habilitation and This memorandum describes the service documenta Supplemental Group Day Habilitation. Group Day Habili tation services are servic es that are generally provided to two or more consumers, although one-to -one services may also be provided. Group Day Habilitation services are provided on weekdays with a service start time prior to 3:00 p.m. Supplemental that are delivered anytime on Satu rday or Sunday, or on weekdays Group Day Habilitation are services of 3:00p.m. or later with a service start time Supplemental services billed separately to Medica id or OMRDD are designed for consumers who live at home, in Supportive IRAs, in Supportive CRs or Family Care Homes. Supplemental Group Day Habilitation services may not be separately billed to Medicaid or OMRDD for consumers who live in residences with 24-hour sta CRs). It is the responsibility of a ffing (e.g., Supervised IRAs or Supervised residence with 24-hour staffing to provide residential habilitation se rvices on weekday evenings and weekends. Billing Standard: Payment for Group Day Habilitation and Supplem ental Group Day Habilitation requires for each consumer served, prior authorization from the DD SO/NYCRO. Service provi ders which have been authorized to provide Supplemental Group Day Habilita tion must correctly categor ize their services as bilitation” based on these time parameters and “Supplemental Group Day Habilitation” vs. “Group Day Ha must use the appropriate billing rate code for each. 2
4 ADMINISTRATIVE MEMORANDUM #2006-01 Documentation Requirements Group Day Habilitation Service January 1, 2006 Group Day Habilitation and Supplemental Group Day Habilita as either a Full Unit tion services are billed or a Half Unit. A Full Unit may be billed when st aff deliver and document at least two individualized ices to a consumer during the program day, and the program day face-to-face Group Day Habilitation serv Unit of Group Day Habilitation or Supplemental Group duration is four to six hours in duration. A Half Day Habilitation may be billed when staff deliver a nd document at least one individualized face-to-face Group Day Habilitation service to a consumer during th e program day, and the program day duration is at least two hours. is For both Group Day Habilitation and S upplemental Group Day Habilitation the program day duration tation services to the face-to-face Group Day Habili defined as the length of time the provider delivers person. Time spent in the followi ng activities cannot be counted to ward the program day duration: • Time the consumer spends being transported to the first Group Day Habilitation activity of the day and time being transported home or to the next activity after the c onclusion of Group Day Habilitation services. ice (e.g., a clinic service) and the time being • Time the consumer spends at a separate serv transported to and from the separate service. Note: The provision of Medicaid Service Coordination (MSC) le regarding “backing out” time is the only exception to the ru at another Medicaid service from the Day Habilitation program day. Time the consumer spends with his/her MSC Service Coordinator can be counted towa rd the Group Day Habilitation or Supplemental Group Day Habilitation program day as long bilitation service location. Also, as the visit occurs at a Day Ha the consumer’s time at the ISP review conducted by the MSC Service Coordinator may count toward the Day Habilitation program day duration as long as the Day Habilitation staff accompany the consumer to the meeting. • Mealtime. Day Habilitation services delivered during mealtimes, while at a clinic or during travel specified above, cannot be used to meet the billing requirements for a Full or Half Unit. While services provided at these times are important to service quality, they cannot be used to fulfill the billing requirement of two services for a Full Unit or one service for a Half Unit. Service Documentation: Medicaid rules require that service documentation be contemporaneous with the service provision . Required service documentation elements are: 1. Consumer’s name and Medicaid number (CIN). Note that the CIN need not be included in daily documentation; rather, it can appear in the consumer’s Group Day Habilitation Plan. 3
5 ADMINISTRATIVE MEMORANDUM #2006-01 Documentation Requirements Group Day Habilitation Service January 1, 2006 2. Identification of category of waiver service provided. Although the waiver service is identified as “Group Day Habilitation” or “Supplemental Group Day Habilitation” fo r billing and service lized Service Plan (IS documentation purposes, the consumer’s Individua P) should identify the category of waiver service as “Day Habilitation.” 3. quired minimum number of face-to-face services provided by A daily description of the re staff . Face-to-face services are individualized services based on the person’s Group Day Habilitation Plan, e.g., the staff person documents that he/she “taught the person how to count change up to one dollar.” The number of face-to -face services required to support billing depends e above section titled “Billing Standards.” on the unit billed and is described in th 4. Documentation that the minimum service duration requirement was met. by • For Group Day Habilitation, the provider may document the program day duration indicating the service start time and service stop time. Alterna tively, the provider may elect to document the program day duration with a daily affirmation, stating that the minimum duration was met in either a narrative note or checklist format, e.g., “ I attest that a 4-hour program day was provided today to John Smith. Sally Jones, Group Day Habilitation Worker, January 12, .” Note that where a provider does not doc ument service start and service stop time, an 2006 outside reviewer may require other document ation that supports th e service duration, for example, a bus log that demonstrates the consum er was at a Group Day Habilitation site for at least 4 hours. • For Supplemental Group Day Habilitation, the provider must docum ent the service start time and the service stop time. In addition to documenting the program day dura tion, when a consumer attends another service during the Group Day Habilitation or Supplementa l Group Day Habilitation program day, such as a clinic service or doc tor’s appointment, the provider must document the “clock” time of the consumer’s departure from the Group Day Habilitation program and the time the consumer returned. 5. For example, the staff person documents that “after The consumer’s response to the service. er was able to count the change several practice sessions the consum he received after purchasing a magazine.” Note that at a minimum, the cons umer response must be documented in a monthly summary note, although a provider may choose to in clude the consumer response more frequently, e.g. daily. The date the service was provided. 6. 7. The primary service location , e.g., “Maple Avenue Group Day Habilitation” or “without walls,” if services are provided at changing locations in the community and there is no primary service location. 4
6 ADMINISTRATIVE MEMORANDUM #2006-01 Documentation Requirements Group Day Habilitation Service January 1, 2006 8. Verification of service provision by the Group Day Habilitation staff person delivering the Initials are permitted if a “key” is provided, which identifies the title, signature and full service. name associated with the staff initials. 9. The signature and title of the Group Day Hab ilitation staff person documenting the service. 10. The date the service was documented. Note that this date must be concurrent with service provision. upporting a provider’s billi ng submittal is either a The acceptable format for the service documentation s narrative note or a checklist/chart with an entry made at the same time each Group Day Habilitation service is delivered and billed. Narrative Note Format If the narrative note format is selected, the doc umentation can be completed in one of two ways: A daily service note describing at least two face- to-face individualized services delivered by Group 1. Day Habilitation staff on each day the provider bills a Full Unit of either Group Day Habilitation or Supplemental Group Day Habilitation. At least one face-to-face individualized service delivered by Group Day Habilitation staff must be documented on each day the provider bills a Half Unit of either Group Day Habilitation or Supplemental Group Day Habilitation. Since the daily note does not include the consumer’s response to the servic e, a monthly summary note is required. This of the individual’s Group Day Habilitation Plan, monthly note must summarize the implementation ices provided and any issues or concerns; OR address the consumer’s response to the serv On each day the provider bills a Full Unit of e ither Group Day Habilitation or Supplemental Group 2. least two face-to-face i ndividualized services Day Habilitation, a daily service note describing at delivered by Day Habilitation staff and the consumer’s response to the service. On each day the provider bills a Half Unit of either Group Day Habilitation or Supplemental Group Day Habilitation, a daily service note describing at least one face-to-f ace individualized service delivered by Group Day Habilitation staff and the consumer’s response to the service delivery. Additionally, at least one of the daily notes h must summarize the implementation of the written during the mont individual’s Group Day Hab ilitation Plan and address any issues or concerns. Checklist / Chart Format For each day service is delivered, a provider ma y elect to document the required face-to-face individualized Group Day Habilitation and Supplem ental Group Day Habilitation service delivered by Group Day Habilitation staff using a ch ecklist or chart. If this form at is selected, a monthly summary note is also required. The monthl y summary note must summarize the implementation of the individual’s Group Day Habilitation Plan; address the consumer’s response to services provided and any issues or concerns. 5
7 ADMINISTRATIVE MEMORANDUM #2006-01 Documentation Requirements Group Day Habilitation Service January 1, 2006 Both the Narrative Note format and the Checklis t/Chart format must include all the Service Documentation elements listed above, including a description of the required minimum number of face-to-face individualized services provided by Day Habilitation staff each day the provider bills either Group Day Habilitation or Supplemental Group Day Habilitation. Other Documentation Requirements: In addition to the service note(s) supporting Group Day Habilitation or Supplemental Group Day Habilitation billing claims, your agency mu st maintain the following documentation: 9 A copy of the consumer’s Individualized Service Pl an (ISP), covering the time period of the claim, developed by the consumer’s Medicaid Service Coor dinator (MSC) or Plan of Care Support Services (PCSS) service coordinator. A entation purposes we distinguish lthough for billing and service docum between the four types of Day Ha bilitation (i.e., Individual Day Hab ilitation, Supplemental Individual Day Habilitation, Group Day Habilitation or Suppl emental Group Day Habilitation), the ISP should identify the category of waiver se rvice as “Day Habilitation.” The ISP, which is the “authorization” for waiver services, must also identify your agency as the provider of the service. Further, the ISP must specify an effective date for Day Habilitation that is on or before the first date of service for which your agency bills Day Habilitation for the consumer . The ISPs should identify the frequency for . day” Group Day Habilitation and Supplem ental Group Day Habilitation as “a 9 The Group Day Habilitation Plan developed by your agency that c onforms to the Habilitation Plan requirements found in ADM 2003-03. For both Group Day Habilitation and Supplemental Group Day Habilitation the Habilitation Plan is entitled “Group Day Habilitation Plan”. The Group Day Habilitation Plan must “cover” the time period of th e Group Day Habilitation service claim. Note that the consumer’s Group Day Habilitation Plan is attach ed to his/her ISP. If a consumer attends both Group and Supplemental Group Day Habilitation Se rvices, you may maintain one Group Day Habilitation Plan. This plan must, ho wever, have a separate section that clearly identifies the supports and a separate section th and services associated with Group Day Habilitation at clearly identifies the supports and services associated with Supplemental Group Day Habilitation. Documentation Retention: All documentation specified above, including the ISP, Group Day Habilitation Plan and service documentation, must be retained for a period of at le ast six years from the date of the service billed . Diagnostic information and other clin ical records are generally maintain ed for a longer period of time and are not the subject of this memorandum. Fiscal Audit: In a fiscal audit a Day Habilitation claim for a samp led consumer will be selected and the auditor will typically ask for the ISP and Group Day Habilitation Pl an in effect for the claim date. The auditor will e service documentation specified above. also require, for the claim dates, th 6
8 ADMINISTRATIVE MEMORANDUM #2006-01 Group Day Habilitation Service Documentation Requirements January 1, 2006 quirements or to request samples of documentation For additional information on the documentation re checklist formats, contact Ms. Carol Metevia, Director of Training and Medicaid Standards at (518) 408-2096, or Mr. Kevin O’De ll, Director of Waiver Mana gement at (518) 474-5647. cc: Provider Associations Kathy Broderick Michele Gatens Carol Metevia Kevin O’Dell David Picker 7