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���Nursing Services �How to document medical services on a Clinical Service Note in SNAP?��2-16-2023��

Deitrich Drayton

Student Services Compliance Administrator

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Agenda

• Purpose of the Training
• Medicaid Nursing Services
• Access to the Medicaid Webportal
• Access to the Medicaid Webportal
• Medicaid Eligibility
• Nurses Services in Schools
• Medical Forms
• Consent Forms
• Medical Orders
• Individual Health Plan
• Clinical Service Note
• Staff Credentials
• Record Maintenance
• Quality Assurance
• Resources

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Purpose of the Medicaid Nursing Training

• Provide training to promote a greater understanding of the Nursing policies and procedures for the nursing program.

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• This training provides a brief overview of policy requirements specific to Nursing Services.

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• Schools are responsible for ensuring that nursing procedures are followed according to SCDE, DHEC, SCLLR guidelines, and the Nurse Practice ACT.

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Note: This is not a comprehensive nursing training session.

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Nursing Services for Children Under 21 Year

Nursing services for children under 21 years are those specialized health care services including:

• nursing assessment and nursing diagnosis,
• direct care and treatment,
• administration of medication and treatment as authorized and prescribed by a physician or dentist and/or other licensed/authorized healthcare provider,
• nurse management, and
• health counseling and emergency care.

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An RN as allowed under state licensure and regulation must perform acts of nursing diagnosis or prescription of therapeutic or corrective measures. The need for services must be appropriately documented in an IEP, IFSP, IHP, or ITP or clinical service notes, when appropriate.

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Nursing Services Provided in Schools

School-based health centers (SBHCs) provide a variety of health services beyond the first aid treatment provided by a school nurse;

• Administration of immunizations to children in accordance with state immunization law,
• Medication assessment, monitoring, and/or administration,
• Interventions related to the IEP, IFSP, IHP, or ITP, and
• Nursing procedures required for specialized health care including, but not limited to, feeding, catheterization, respiratory care, ostomies, medical support systems, collecting, and/or performance of tests, other nursing procedures, and development of health care and emergency protocols.

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Medicaid – DHHS Web Portal Instructions

Each school will be given a user ID and a temporary password to access the DHHS webportal.

You may access the South Carolina Medicaid Web-Based Claims Submission Tool at: https://portal.scmedicaid.com.

You will be able to check the student’s eligibility, claim status, and remittance advice.

Use the Username which is your ID number and password that was given to you to access the portal to log in to the system. You cannot change your Username. If you have problems with your username, notify the Medicaid district office.

All programs will use the same ID number and password.

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Medicaid – DHHS Password Rules

Once you have accessed the webportal, you must change the password. You will be responsible for keeping this password. If it is lost, you must contact the Medicaid district office to reset the password.

Below are the password rules:

• The new password must be at least 8 characters
• First character must be an upper-case letter
• Must contain a lower-case letter
• Must contain a digit
• Must contain a special character i.e. [",'!@#$%^&*().+_-{}|\></?:;](
• Cannot contain your User ID. (e.g., if your ID is “Fred,” then Fred#007” is not allowed)
• Make sure you write down the password and save the password and username to the computer system.

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Medicaid -Web Portal Log-In Screen

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Instructions:

• Put in your User number and password. Click log in. The system will direct you to change your temporary password to a new password. You may have to re-enter the password to enter the application.

Medicaid – Access Web Portal

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• Once you are in the system the next screen is the web portal.
• See “Select One” and click the drop-down symbol (v) – select South Carolina public charter school and click – Select

This will allow you to review the categories of services.

• Click the Eligibility button to check the student’s Medicaid eligibility and insurance. You can check an individual student or multiple students. You can check the claims remittance of the student by clicking the Report button. This will allow you to see the claims that were billed according to the student’s Medicaid number. It is not categorized by the school’s name.

The Eligibility screen provides the student’s identifying information and insurance information.

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Medicaid – Eligibility Screen- Web Portal

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You can check the student’s eligibility start date and types of insurance. You will be able to view other identification information. If the student’s page has an alert, you will be able to notify the parent or contact the district office for support. This information will alert you to whether the student is eligible for Medicaid services. Please review the student’s status at least twice a year and make a copy of the eligibility report and keep a copy on file. If you have any questions or concerns, contact Dee Drayton at ddrayton@sccharter.org

Note: If the student has other health insurance carriers, make sure to receive a copy of the other insurance information from the parent. Medicaid is the payer of last resort. The parent does not have to pay a co-payment or a deductible, but Medicaid will require that we send a bill to the insurance company. The insurance company will pay a portion of the bill and Medicaid will pay the additional cost. The parent nor the school pays any money for services.

Medicaid Eligibility Update

• The Department of Health and Human Services (DHHS) sent out a Medicaid Notice on February 13, 2023, to notify Medicaid members that DHHS will start reviewing Medicaid eligibility in April. The COVID-19 Federal Public Health Emergency (PHE) end date will be May 11, 2023. Medicaid members will be notified to update their information with DHHS. This project may take up to a year to complete. Schools may remind Medicaid members to update their address, phone number, and email address online at apply.scdhhs.gov.
• Also, the General Medicaid consent can be placed in the student’s registration packet for the next academic year and the school will have the Medicaid information.
• Schools may also access the Medicaid webportal to check the student’s Medicaid eligibility before school starts next academic year. Reminder, a copy should be scanned or placed in the student’s file. If the school needs a copy of the Medicaid card, please request it.

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Example of the Medicaid Edibility Form

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Nursing Services Provided in Schools

School-based health centers (SBHCs) provide a variety of health services beyond the first aid treatment provided by a school nurse;

• Administration of immunizations to children in accordance with state immunization law,
• Medication assessment, monitoring, and/or administration,
• Interventions related to the IEP, IFSP, IHP, or ITP, and
• Nursing procedures required for specialized health care including, but not limited to, feeding, catheterization, respiratory care, ostomies, medical support systems, collecting, and/or performance of tests, other nursing procedures, and development of health care and emergency protocols.

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Medical Documentation for Nurses

Nursing documents must be completed annually, and for new students entering school.

• Consent and Permission to Provide Medication or Medical Services
• General Medicaid Consent (for Medicaid students)
• Permission to Provide Medication (IDEA requirement)
• Medical Orders (For all students with a medical prescription)
• Medical Assessment (For students with a medical prescription – nurse evaluation)
• Individualize Education Plan (IEP), Individual Health Plan (IHP), or Individual Treatment Plan (ITP) – (For students with a medical prescription)
• Clinical Service Notes (CSN) (Documentation for all students receiving medical care)
• Staff Credentials – (For all Nursing staff providing medical care)
• Storage and Retention of Records – (For medical records – FERPA and HIPAA regulations)

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Medicaid Consent Form and Annual Notification Form

Consent Form

A Release of Information form must be signed by the child’s parent or guardian to authorize the release of any medical information necessary to process Medicaid claims and request payment of government benefits on behalf of the child. (The consent form must be completed for ALL Medicaid Services.)

Annual Notification Form

The Annual notification form documents that the parent has been informed of their Medicaid rights.

• Must be signed annually, given to the parent, and a copy placed in the student’s file.

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Copy of the Medicaid Consent Form

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Medical Orders

A medical order is a written order by an authorized licensed prescriber for medication, treatment, or procedure; may also be referred to as a treatment order, medication permission form, or prescription.

Medical orders must be:

• given for prescriptions,
• written for treatments, and
• written medical procedures.

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Prescribers of Medical Orders

A medical order for prescriptions or treatment must be prescribed by one of the following:

• Medical Doctor (M.D.),
• Doctor of Osteopathy (D.O.),
• Dentist (D.M.D., D.D.S),
• Advanced Practice Registered Nurse (APRN) or Nurse Practitioner (NP), and
• Physician Assistant (PA).

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What must be included in the Medical Order?

The documentation must include:

• student name,
• date,
• addresses the frequency and duration of the order (i.e., 1 x PRN, or 1 TID)
• reason for the medical orders, and
• description of services to be rendered.
• signed by the prescribing provider, and
• parent must sign.

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Student Emergency and Health Information Form

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Detailed Student Medical, Health, and History Consent Form

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Page 2 of the Student Medical, Health, and History Form

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Medication and Treatment Permission Form

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�Authorization for Non-Prescription Over-the-Counter Medication at School

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Nursing Assessments - Documentation

Nursing Assessments must include:

• medical health problems,
• list medications,
• list treatments,
• write medical procedures taken by the nurse, and
• child development issues observed by the nurse/child’s response to treatment.

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Treatment Plan Development

If a medical order or prescription indicate a Medicaid school-based nursing service is medically necessary, the development of an IEP, IFSP, ITP, or IHP, must be indicated on the IEP, IFSP, ITP, or IHP.

When a medical order or prescription is not provided, the nursing services are not required to be documented in a treatment plan. The services must be documented in a clinical service note.

An IHP is a plan of care designed specifically for an individual student to provide for meeting the health monitoring and care of the student during the school day or at school-sponsored functions, Section 59-63-80(B) stipulates that students with special health care needs must have an IHP.

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Medical Criteria to Develop a Treatment Plan

Students with special health care needs are defined as students with health conditions requiring treatments, medical procedures, medications, and/or monitoring that must be performed by school personnel and meet one or more of the criteria below.

(a) are complicated and/or lengthy,

(b) require several contacts with the nurse or health assistant during the school day,

(c) are needed to prevent death or disability on an emergent basis,

(d) are needed for students who have medically fragile health conditions, and/or

(e) are prescribed for treatment, medical procedures, medications, and/or monitoring at school.

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Additionally, students who have been granted permission to self-medicate and/or self-monitor in accordance with the school district’s policy are also considered to have special healthcare needs an IHP or ITP must be established in order for a student to be allowed to self-medicate and/or self-monitor.

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Treatment Plan Components

The treatment plan must include the following components:

• Individualization – the student’s name must be used throughout the treatment plan
• Specific problems to be addressed – Specify the Medical care the child will receive according to the medical order in the Assessment section and list the diagnoses of the medical condition
• Goals of treatment - nursing interventions – Nurses’ goals on how to care for the medical condition
• Types of interventions to be utilized – list types of intervention to be used in caring for the student’s medical condition
• Planned frequency of service delivery and duration – frequency of the medication or medical service – example: 2 x a day
• Criteria for achievement – list in the nursing goals or student goals what the student should learn or accomplish in understanding or caring for the medical condition
• Beneficiary’s strengths and weaknesses – list in the student’s goals
• Signature, date signed, and title of the nurse. Must be completed.

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Copy of the IHP/ITP – Front Page

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Copy of the IHP/ITP – Last Page

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Purpose of the Clinical Service Note (CSN)

• When a treatment plan is not developed, the nursing encounter must be documented in a clinical service note.
• The purpose of these notes is to record the nature of the Student’s treatment by capturing the services provided.
• The clinical service note must summarize the student’s participation in treatment. (Explain how the student reacted to treatment.)
• The nursing encounter may be documented electronically or handwritten. (The district has contracted with two nursing platforms to utilize their software for documenting and billing for services.
• Both nursing platforms upload student Medicaid data from PowerSchool. (It is important to input Medicaid data into PowerSchool and to check the data often.)

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CSN Requirements

Clinical Service Notes must include a narrative summary of each treatment encounter and must justify the number of units billed.

Clinical Service Note requirements:

• Provide a pertinent clinical description of the activities that took place during the medical encounter (diagnoses code),
• Student’s level of participation/response to treatment as it reflect the student’s behavior/response during the medical encounter,
• Reflect the delivery of a specific billable service as identified in the physician’s order (Procedure code and description of the service rendered),
• Document the services rendered corresponding to the billing
• Date of service, Type of service rendered, and number of units billed,
• Individualized and student-specific with the student’s response to treatment
• Start and stop times of the medical encounter, and
• Date signature and professional title of the provider delivering the service.

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SNAP Instructions�setting up the Student Health Records

• Login and click Student
• Go to the Home screen | Insurance
• Enter the student’s primary address
• Next – Click the Insurance box
• In the Insurance window, enter the student’s Medicaid number in the Medicaid # field
• Click the Checkmark if they have “Parental authorization to bill”
• Click Ok this will close the insurance window
• Click the green OK button and this will save the information.

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Add the ICD10 codes (Diagnose code of the student’s health. When the note has been completed, SNAP documents are uploaded into the CGM system for billing.

To enter the ICD10 code:

• Single-click on the word Select in the ICD-10 code column, the ICD-10 library will display.
• In the Filter field at the top type the name of the student’s condition or if you have been given their diagnosis code by their doctor click the diagnosis from the drop-down box.
• Expand each category until you get to the item with the green arrow.
• Single-click on that item and click OK.
• Click OK to save and close the student’s health record.

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SNAP – Optional Services

• Immunizations can be logged for each student.
• Hearing and vision screening can be logged.
• The student’s medical orders.
• The student’s health conditions.
• The IHP can be documented using the SNAP template.
• Print the student’s health record.

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• If you need information about the optional services, contact the Medicaid Administrator.

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Clinical Service �Note – Daily Note Handwritten

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�CSN – Administration of Routine�Medication Monthly Report

Nursing Clinical Service Notes - Daily Administration of Medication – Monthly Report

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Medication Pill Count Sheet – Example

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The Medicaid Process for Billing

The Medicaid process:

• Medicaid Consent form must be signed.
• Medical Orders signed by the doctor and parent must be signed.
• IHP must be completed and signed, (if a medical is needed).
• Clinical service notes must be completed for each medical encounter that is rendered by the nurse.
• For Medical procedures lasting under 15 minutes use procedure code T1003 for LPNs. This code can be billed to Medicaid 24 times a day. The medical encounter needs to last at least five to seven minutes to justify medical necessity.
• For Medical procedures lasting under 15 minutes use procedure code T1002 for RNs. This code can be billed to Medicaid 24 times a day
• For Medical procedures lasting more than 15 minutes use procedure code T1015 TE for LPNs. This code can be billed to Medicaid 4 times a day.
• For Medical procedures lasting more than 15 minutes use procedure code T1015 TD for RNs. This code can be billed to Medicaid 4 times a day
• For Medical administration (giving a medication) use procedure code T1502 for both the RN and LPN. This code can be billed to Medicaid 4 times a day.
• Make sure that you document the time in and time out for each medical encounter.
• Each medical encounter needs to be at least 5 minutes apart. If it is an emergency, the medical encounter will be documented as one service.

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Nursing Procedure Codes

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�Nursing Supervision - Updates

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• Nursing Supervision requirements
• An LPN must be supervised at all times by an RN.
• RN must be physically present or accessible by phone/pager.
• RN must be readily available (i.e., physically accessible to the individual being supervised within a certain response time based upon the medical history and condition of the beneficiary and competency of personnel).

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• On October 21, SCDE and DHHS sent an email to update the nursing supervision. Medicaid will not require the RN to co-sign the LPN’s clinical service notes.

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Supervision (Cont.)

• The RN supervisor will provide the initial assessment of the child’s condition as appropriate and establish a plan of care based on the child’s medical condition in accordance with state licensure and regulation.
• If the LPN receives additional information regarding the child’s health condition after the initial assessment, the LPN will consult with the RN.
• Supervision by the RN of the LPN must be performed at a minimum of every 60 days via direct observation or review of clinical service notes. It is best practice to have written or electronic documentation of the RN’s supervision of the LPN. Nurses billing Medicaid must show proof of supervision.
• Note: The supervision log must be submitted at the beginning and end of the academic year to the district office according to the Medicaid contract. If you need a template notify the Medicaid district office.

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Staff Credential Verification Process

• Schools are required to check the credentials of all licensed staff through SCLLR to verify their license, which may exclude them from providing services. A copy of the nurse’s license must be submitted to the district office. An updated copy must be kept on file.
• Schools using a software company must notify the district office of any staff changes.
• A copy of the South Carolina nurse license can be found at the South Carolina Labor and Licensing Regulatory Authority at https://llr.sc.gov.
• Medicaid nurses must check the OIG’s office twice a year and keep a copy on file. The OIG link is located at Search the Exclusions Database | Office of Inspector General (hhs.gov).

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Family Educational Rights and Privacy ACT (FERPA)/Healthcare Insurance Portability and Accountability Act (HIPAA)

• All records must follow the HIPAA/FERPA security measures.
• All clinical records must be secured under lock and key and in locked cabinets.
• Signature logs of people who have accessed health records.
• All providers must grant access to SCPCSD, or its designees for the purpose of reviewing and/or investigating and allow for copying and reproducing documents.
• Each school should have a retention policy. Staff should review the General Records Retention Schedules for School District Records, Subarticle 6 Student Records for additional information. The webpage is located at https://scdah.sc.gov/sites/scdah/files/Documents/Records%20Management%20(RM)/Schedules/genskedskldist.pdf.
• The SC Archives also have staff that will help a school set up a retention schedule.
• Only files must be locked and secure. The regulations state that files must be under two locks. (1^st Front door, and the 2^nd office door)

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�Medicaid Clinical Records and Maintenance

Requirements for Clinical Records and Maintenance

• Each clinical entry must be typed or legibly handwritten in dark ink,
• Clinical records must be arranged logically.
• All clinical entries must be filed in the student’s clinical records.
• Each entry must stand on its own and not include arrows, ditto marks, etc.
• Schools are required to maintain a clinical record on every student that is rendered services.
• Clinical records must be current, meet documentation requirements and, provide a clear descriptive narrative of the services provided.
• It is essential that an internal records review be conducted to ensure that the services are medically necessary and appropriate both in quality and quantity and that services are documented.

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Medicaid Clinical Records

Clinical Records

• As a condition of participation in the Medicaid program, providers are required to maintain and allow appropriate access to clinical records that fully disclose the extent of services provided to the Medicaid beneficiary. The maintenance of adequate records is regarded as essential for the delivery of appropriate services and quality medical care. Providers must be aware that these records are key documents for post-payment review.

The records must follow these criteria:

• Errors must be corrected according to Medicaid policy and procedures (draw a line through the error, initial the error, date the error, and document the correction, if applicable).
• The school must have an abbreviation key available in the student’s file. (List of the most common abbreviations used for each program must be available.)
• The school must have a signature sheet or logbook that identifies the staff’s name, signature, and initials in the student’s file or logbook.

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Medical Documentation- Monitoring

• Each school must set up a system on how to file medical records for the students and staff.
• These records must be accessible for review.
• Before new schools can bill for services, the district office randomly selects files to review and request Medicaid documents. This review ensures the school is prepared and has the appropriate billing documents. Once this process has been completed the district office will notify CGM to onboard new schools and start the billing process.
• If documents are not in compliance with Medicaid policy, training and support will be provided to ensure the Medicaid files follow policy. Training can be provided to each school.
• Schools using SNAP and need training on documentation, there are manuals and online training provided by SNAP. The district office can provide basic training on documenting Medicaid services and billing.

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Quality Assurance and Monitoring

SCDHHS, SCDE, or the SCPCSD will conduct reviews to ensure that schools/providers comply with applicable laws, regulations, and policies.

Other authoritative entities may conduct reviews of LEA-Mental Health /RBHS providers, including the State Auditor’s Office, the South Carolina Attorney General’s Office, the United States Department of Health and Human Services, the Government Accountability Office, and/or their designees.

SCDE will conduct an annual Medicaid Quality Assurance Review on the RBHS Medicaid program. The Medicaid files which include all Medicaid documents and the staff’s credentials must be available.

SCPCSD will conduct random reviews of the program throughout the school year and provide feedback to assist the staff.

Upon request, information must be furnished regarding any claim for payment to SCDHHS.

All providers must grant access to SCDHHS, or its designees for the purpose of reviewing and/or investigating and allow for copying and reproducing documents.

Failure of the provider to comply with this provision may result in the immediate termination of enrollment.

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Resources

• SCDE-OMS Webpage: Medicaid - South Carolina Department of Education - 01/19/2023 4:02 PM (sc.gov)
• SCDHHS: Local Education Agencies Provider Manual - Report (Vertical) (scdhhs.gov)
• SCDHEC Resources: DHEC-liaison-Victoria Ladd, MSN, RN - State School Nurse Consultant Division of Children's Health and Perinatal Services - S.C. Dept. of Health & Environmental Control - Office: (803) 898-2347 - Email: laddvj@dhec.sc.gov

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Contact Information�Deitrich (Dee) Drayton�ddrayton@sccharter.org�(803) 212-5482�

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