O.  NURSING SERVICES

O1. Who can provide the nursing services listed in the IEP?

Nursing services can be provided by a registered nurse (RN or APN), a licensed vocational nurse (LVN), or a licensed practical nurse (LPN). Services delegated by an RN or APN and provided by individuals who have been trained are also billable. Examples of individuals to whom an RN or APN might delegate nursing services include special education teachers and school heath aides.

O2. What are the various services covered under nursing services? How explicitly do nursing services need to be stated in the IEP?

Effective 9-1-06, school health services are now referred to as nursing services. Nursing services are skilled nursing tasks as defined by the Board of Nursing (BON). A district can receive Medicaid reimbursement for any nursing service that is determined by the ARD/IEP committee to be needed in order for a Medicaid- eligible student to fully participate in school. Due to the wide variation in individual needs, it is impossible to develop an all-inclusive list of nursing services. Examples of reimbursable nursing services include, but are not limited to: inhalation therapy, ventilator monitoring, nonroutine medication administration, tracheostomy care, gastrostomy care, ileostomy care, catheterization, tube feeding, suctioning, client training, and assessment of a student’s nursing and personal care services needs. The ARD minutes should include recommendations derived from the RN/APN or physician’s evaluation of the student’s nursing services needs.  Nursing services need to be stated with the same level of detail as is provided for the other related services.  But, due to the type of services, it may be appropriate to add language such as “as needed”. Remember that the actual format of the IEP is a local policy decision. In order to receive reimbursement, the specific nursing services need to be included in the IEP; but, there is no prescribed wording.

O3. How should the administration of medication be billed?

The way administration of a medication should be billed depends upon whether the medication is considered “routine oral medication” or regular nursing service.  That determination should be made by a RN/APN. If the medication is not a routine oral medication, the time spent administering that medication should be accumulated with all the other nursing services for the calendar day and then converted to 15- minute units and billed accordingly.  If the medication is a routine oral medication, please maintain the required service logs billable under the appropriate procedure code (medication administration).

 See also Billing Guidelines on the TEA website (refer to the billing guidelines section).

O4. When a RN is provided by the district for a student who needs one-on-one services, can the district bill for the entire day?

All nursing services provided in accordance with the IEP can be billed under SHARS, whether delivered by RN/APN, LVN, or delegation. If nursing services are needed for the entire day, then an entire day’s worth of services may be billed. Time spent away from the student (e.g., breaks or lunch) must be deducted from that RN’s billable time. If those breaks and lunch are serviced by another RN, then the second RN documents that billable time. According to the Billing Guidelines on the TEA SHARS website, nursing services that exceed recommended limits will be denied. Providers can appeal denials by submitting required documentation. Required documentation includes, but is not limited to, showing medical necessity, physician referral, IEP documentation, service log, and actual time spent delivering the service.

O5. If a student is unable to feed his/her self and the IEP designates that the student must be hand fed, not tube fed, may this service be billed?

A RN/APN must determine whether this service is a skilled nursing service or a personal care service (not a skilled nursing task) before the service can be billed with the appropriate procedure code.

PCS must be billed as PCS and nursing services billed as nursing tasks.  If there is uncertainty whether a task is a personal care service or a nursing service, the SHARS provider should check with their RN or APN who can make that determination.

O6. May a student receive private duty nursing in school?

Yes, private duty nursing is a Medicaid service under the Medicaid Children’s Services CCP program and is primarily available outside the school setting.  Private duty nursing services require prior authorization from TMHP and can be delivered in the student’s residence, the student’s school, or the daycare facility.  If the private duty nursing services meet all of the student’s nursing services needs documented in the IEP, then the district should note in the student’s IEP that the student’s nursing services needs are being met through private duty nursing services.  In this situation, the school district would not bill SHARS for any reimbursement for nursing services. 

Arrangements can be made with the private duty nursing provider such that the school district performs some nursing services required by the IEP and bills SHARS for reimbursement for those specific nursing services, while the private duty nursing provider delivers all other nursing services.

If there are conflicts between the school’s nursing services or the school’s personal care services and the private duty nursing services, schools should contact the HHSC Senior Policy Analyst for SHARS, who will in turn request that Case Management for Children and Pregnant Women (CPW) services be used to resolve differences between the school district, the outside provider, and the parent(s)/guardian(s).

O7. Does an LVN need to be supervised by an RN?

The Texas State Medicaid Plan has no supervisory requirements for Nursing Services to be payable through SHARS. However, the Texas Board of Nursing (BON) does have rules regarding supervision requirements that providers must follow. For more information on supervision requirements mandated by the BON please visit https://www.bon.texas.gov/.