T.  PERSONAL CARE SERVICES

Personal Care Services (PCS) is a benefit of the Medicaid Children’s Services - Comprehensive Care Program (Medicaid Children’s Services CCP) for Texas Medicaid clients under the age of 21 years, who are not an inpatient or a resident of a hospital, in a nursing facility or intermediate care facility for the mentally retarded, or in an institution for mental disease.  PCS are support services provided to clients who meet the definition of medical necessity and require assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), and health related functions because of a physical, cognitive, or behavioral limitation related to a client’s disability or chronic health condition. PCS are provided by someone other than the minor client’s legal or foster parent/guardian or the client’s spouse.

T1. What are personal cares services (PCS)?

The descriptions for the personal care services codes are:

Procedure Code

Service

T-1019-U5

PCS in the school, each 15 minutes, individual

T-1019-U5-UD

PCS in the school, each 15 minutes, group

T-1019-U6

PCS on the bus, each student one-way trip, individual

T-1019-U6-UD

PCS on the bus, each student one-way trip, group

PCS include a range of human assistance provided to persons with disabilities and chronic conditions which enables them to accomplish age-appropriate tasks that they would normally do for themselves if they did not have a disability or chronic condition. An individual may be physically capable of performing activities of daily living (ADLs) and instrumental activities of daily living (IADLs), but may have limitations in performing these activities because of a functional, cognitive and/or behavioral impairment. Assistance may be in the form of “hands-on assistance” (actually performing a personal care task for a person) or “cueing” the person so that the person performs the task by him/her self. Such assistance most often relates to performance of ADLs and IADLs. ADLs include eating, bathing, dressing, toileting (including diapering), transferring, and maintaining continence.  ADLs may also include assistance with mobility services (i.e., the ability to move between locations in the individual's environment).

IADLs capture more complex life activities and include personal hygiene, light housework, essential household chores, laundry, meal planning and preparation, transportation, grocery shopping, communication by telephone or other media, medication management, managing finances, getting around and participating in the community, and limited exercises to increase range of motion and flexibility.  These are not an all inclusive list of ADLs and IADLs.

Skilled nursing services that may only be performed or delegated by a registered nurse (RN) or advanced practice nurse (APN) are not considered personal care services.  Delegated nursing services are services that are delegated to an individual whom the RN or APN has trained to perform the delegated nursing task. These delegated services must be billed under Nursing Services.

Personal care services are supports that may be provided through:

  • Total or partial physical assistance
  • Prompting or cueing the student to complete the task
  • Redirection, monitoring, and observation that are medically necessary and an integral part of completing a personal care service.

Note:  Monitoring and observation means watching for outward visible signs that are likely to occur and for which there is an appropriate personal care intervention. This could include such activities as monitoring a child for seizures or potentially dangerous behaviors.

PCS may be required because a cognitive impairment prevents an individual from knowing when or how to carry out the task. For example, an individual may not be able to dress without instruction on how to do so or reminders of what to do and when.  In such cases, PCS may include “cuing” or monitoring to ensure that the individual performs the task properly.

PCS may include observation/monitoring and redirection/intervention for:

  • behavior that interferes with completion of ADL or IADL, such as withdrawal or unusual and repetitive habits;
  • behavior that is socially offensive;
  • behavior that will, or has the potential to, cause injury to the student and/or others; and
  • behavior that will, or has the potential to, cause damage to property.

When is it personal care service?

YES:

  • Personal Care
    • goal not to teach or habilitate, but complete the activity
    • level of assistance is greater than typical child of same age
    • need for assistance is related to disability/condition that affects function

NO:

  • Nursing
    • treat
    • assess
    • educate
    • medication administration
  • Therapy
    • rehab/habilitation
  • Age appropriate activity

DOCUMENTATION IN THE INDIVIDUALIZED EDUCATION PLAN (IEP)

Indication of placement in a self-contained setting [i.e., Life Skills classroom, Preschool Programs for Children with Disabilities (PPCD), etc.] is not sufficient IEP documentation to support Medicaid reimbursement for PCS.

Personal care services can be provided on a continuing basis or on episodic occasions.  Personal care services are provided on a one-on-one basis or group setting.

One-on-One

PCS delivered on a one-on-one basis to one student: (1) all day or (2) at various times throughout the day.  Examples of sufficient IEP documentation are indicated below.  Documentation of medical necessity is required for PCS. That documentation should include, at a minimum, the diagnosis or diagnoses resulting in the need for PCS and any history of chronic conditions supporting the need for PCS.  If the child is receiving one-on-one personal care services, the aide providing the one-on-one personal care services cannot be billed as a group service to other children in the school or on the bus.

Example of documentation in the IEP

Sufficient documentation

  • Assistance is required for one-on-one PCS for “Johnny”. PCS needs include observation and redirection of self-injurious behavior. PCS is required throughout the school day and during transportation to and from school on the bus. Johnny has bipolar disorder and gets angry, frustrated very easily. He often displays his anger and frustration

Insufficient documentation

  • Assistance is required for one-on-one PCS for “Sue”. Sue has cerebral palsy.

One on One PSC Periodically throughout the day

The need for a student to receive one-on-one PCS periodically throughout the day must be documented in the IEP with examples provided. The documentation needs to address of the following items or provide the requested documentation: 

(1)    Is the service provided on a one-on-one basis or group or both;

(2)    Examples of PCS;

(3)    When/where are the PCS needed; and

(4)    Reason(s) for PCS, such as medical necessity, etc.

 

Example of documentation in the IEP

Sufficient documentation

  • PCS assistance is required for “Timmy” periodically throughout the day on a one-on-one basis. Timmy has mental retardation and needs periodic PCS to assist him in moving from class to class. Without PCS assistance, Timmy would wander off.

Insufficient documentation

  • PCS assistance is required for “Jane” periodically throughout the day on a one-on-one basis because she has visual impairment.

Group PCS

Group PCS are defined as when a staff person or a team of staff members work directly with more than one student (for example, in a self-contained classroom). REMINDER: Indication of placement in a self-contained setting [i.e., Life Skills classroom, Preschool Programs for Children with Disabilities (PPCD), etc.] is not sufficient IEP documentation to support Medicaid reimbursement for PCS.

The need for students to receive group PCS must be documented in the IEP with examples provided. The documentation needs to answer the following questions or provide the requested documentation: (1) Examples of PCS; (2) when are/where are the services needed; and (3) the reason(s) for PCS, such as medical necessity, etc.

Example of documentation in the IEP

Sufficient documentation

  • Group PCS assistance is required for “Janice” throughout the day. Janice has ADHD. She has difficulty staying on task and is very impulsive. She requires constant cueing, prompting, and redirection.

Insufficient documentation

  • Group PCS assistance is required for “Janice” throughout the day because she has ADHD.

Group PCS with intermittent one-on-one PCS

 

Students receiving group PCS may also require intermittent one-on-one PCS

Example of documentation in the IEP for group PCS with intermittent one-on- one PCS

Sufficient documentation

  • Sue is in a self-contained classroom and needs group PCS throughout the day. In addition, Sue needs individual assistance with ADLs, including eating, toileting, mobility, and transfers because she is unable to transfer herself to the toilet and during transportation to and from school on the bus. Sue has cerebral palsy and cannot navigate her chair, feed or toilet herself.

Insufficient documentation

  • Bobby needs group and one-on-one PCS throughout the day. Bobby is wheelchair bound.

 

DOCUMENTATION OF SERVICES PROVIDED

One on One

In order to bill for PCS, all individual PCS must be documented by including in the service log the start time and stop time for each personal care service task/episode throughout the day, with minutes accumulated for the day for all personal care services delivered in an individual setting and converted to units, with checkboxes for the various types of personal care services delivered.  Personal care services delivered on a one-on-one basis for one student for an entire day must have included in the service log the start time and stop time for the entire day.  Service log for PCS must include the signature of the individual that provided the PCS. In cases where more than one person provided PCS throughout the day, only one person needs to sign the service log.  If there are times in the day when the student receives services other than personal care services (e.g., speech therapy, nursing services, and non-SHARS services) and are not accompanied by a PCS attendant, those minutes should be subtracted to arrive at the net personal care services minutes for the day.  No session notes are required.

Group

In order to bill for group PCS, PCS may be documented by indicating the various types of personal care services delivered.  In addition, group PCS must document the start time and stop time for each day.  If there are times in the day when the student receives services other than personal care services (e.g., speech therapy, nursing services, and non-SHARS services), those minutes should be subtracted to arrive at the net personal care services minutes for the day. No session notes are required.

Group and One-on-One

Students receiving group PCS may also require intermittent one-on-one PCS throughout the day.

For example: a student may need one-on-one assistance with toileting. Group PCS documentation must show stop time when documentation for one-on-one PCS assistance starts. Group PCS assistance start time will be documented when one-on-one PCS assistance ends.

Due to the additional paperwork required, districts may choose not to seek reimbursement for episodes of one-on-one PCS time and may bill all of the student’s PCS under the group PCS code.  If there are times in the day when the student receives services other than personal care services (e.g., speech therapy, nursing services, and non-SHARS services), those minutes should be subtracted to arrive at the net personal care services minutes for the day. No session notes are required.

T2. If a student needs constant monitoring all day, even during instructional time, is the entire day billable as personal care services?

The IEP should clearly justify the need for constant supervision or monitoring and any other PCS (such as toileting, feeding, etc.) required during the school day.  The documentation justifying the medical necessity of PCS needs to answer the following questions or provide the requested documentation:

(1)  examples of PCS;

(2)  when/where are the personal care services are needed;

(3)  reason(s) for PCS (such as medical necessity, etc.); and

(4)  why can’t the student perform the age appropriate task?

T3. Can personal care services be billed under nursing services?

No, personal care services are not skilled nursing tasks. 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.

See also response to O5.

T4. What is required for documenting services for PCS?

PCS documentation:

1) Must capture the minutes of the service with start and stop times,

2) Must have notation of specific type of PCS required,

3) Must identify type of PCS (one-on-one or group),

4) If PCS is provided throughout the day, the accumulation of all the PCS minutes for the day must be totaled and converted to units of service, and

5) Must include the signature of the individual that provided the PCS. (In group settings, each caregiver does not have to provide      documentation for each child. Rather one caregiver can document for 2 or 3 students while another caregiver documents on the other 2 or 3 students.

T5. May we bill SHARS for a student that is severe and profound to have a staff person accompany him to the job site or vocation training to provide job coaching and provide monitoring to the student while on the job? Is it billable and how must it be listed in the ARD/IEP?

If a staff person, of the school district, accompanies the student to a job site or vocational training (during school hours), PCS can be billed when the need for PCS at the job site or vocational training (during school hours) is documented in the IEP. The IEP documentation justifying the medical necessity of PCS needs to answer the following questions or provide the requested documentation:

(1) examples of PCS;

(2) when/where are the personal care services are needed;

(3) reason(s) for PCS (such as medical necessity, etc.); and

(4) why can’t the student perform the age appropriate task?

In addition, required PCS documentation of the service(s) provided is outlined in T4.

See also information and examples in T1.

T6. How do you bill for a full-time childhood special education setting (Early Childhood Intervention – ECI) as it relates to PCS? This setting consists of 3-5 students who have any assistants in the classroom to assist them in most everything they do. Most are severe. Would this be a group PCS?

ECI is a separate Medicaid program and is not billable under SHARS.

T7. We have a student in PPCD (Preschool Program for Children with Disabilities) who requires PCS but does not require one-on-one PCS. This student is in the classroom from 8 am to 2 pm or 6 hours/360 minutes. The IEP deducts 60 minutes a day for lunch, etc., showing only 300 minutes. Can the hour for lunch, etc. be included in the group PCS claim? The student must still be fed, changed, cared for during this hour.

The answer is no, because you specifically state those 60 minutes are not in the student’s IEP. If it is not in the IEP, the service cannot be a SHARS reimbursable service. However, it would be appropriate for the PCS attendant to perform those duties and get reimbursed through SHARS, if the IEP was changed and effective with the date of change forward, you would be able to bill for the PCS.

T8. Who is qualified to provide PCS?

PCS must be provided by a qualified provider who is 18 years or older and has been trained to provide the personal care services required by the client, e.g., bus monitor/aide on the bus, special education teacher and special education teacher's aide.

T9. Can a paraprofessional provide PCS when they interpret to 2 hearing impaired students in a classroom for mainstream students?

Yes, the paraprofessional would meet the definition of a PCS provider.

T10. If a student has speech therapy in the life skills classroom because the student can become combative and the therapist wants the teacher’s aide to be readily available to assist with the student, should the speech therapist’s time be backed out of the total time for PCS?

Yes. When the speech therapist begins therapy in the life skills classroom, the group PCS should be documented with a stop time and the speech therapist’s time should be should be documented with start and stop time for the period of the therapy session.  Because the teacher’s aide is simply present in the classroom during the speech therapy, no PCS is being performed and cannot be billed. However, if the teacher’s aide is actually required to provide PCS during the same time the speech therapist is providing speech therapy (and documented in the IEP justifying the medical necessity of PCS during speech therapy time), then the PCS could be billed as individual PCS and documented with start and stop time.

T11. Can we bill SHARS for special transportation and PCS, including PCS on the bus, if the IEP does not list special transportation, but does indicate transportation aid on the personal care attendant schedule of services?

If the medical necessity for the PCS is documented in the IEP (to include PCS on the bus), the PCS on the specialized transportation vehicle (PCS on the bus) can be billed to SHARS. The specialized transportation (bus ride) cannot be billed to SHARS because there is no medical necessity for the specialized transportation documented in the IEP.  In order to bill SHARS for specialized transportation, the IEP would have to list that the child requires a specific adaptation(s) on a bus/vehicle and why the specific adaptation(s) were needed.

 T12. For personnel who have multiple duties, PCS Aide and Bus Driver, would the district claim total compensation and benefits to include both positions under “direct medical” expense?

PCS Aide is a direct medical services provider that would be reported in Step 3 of the SHARS cost report. A bus driver is a transportation employee that would be reported in Step 4 of the cost report. In this scenario, you do not report total compensation and benefits under direct medical expenses. Instead, allocate the total cost of the employee between the two positions held. The ratios within the cost report will then reduce the employee’s costs accordingly.

T13. Can a life skills teacher or aide who provides adaptive P.E. (physical education) be billed under PCS?

Yes, if the PCS service provider assists in providing the adaptive need.  For example, the PCS attendant assists with PT, OT, or range of motion.  This PCS must be documented in the IEP (as outlined in T1, T2, and T5 - justifying the medical necessity of PCS) and the service must be documented as outlined in T4.

T14. Can we bill for low-functioning children under PCS if they receive help with sorting, numbers, coloring, puzzles, calendars, etc.? If these life skills students’ goals and objectives are tied to these types of activities, which in some cases may seem academic in nature, are they considered a PCS?

In order to bill for low-functioning children under PCS, the school must look at the purpose of the PCS – if the PCS assistance is to help with range of motion, then yes, that is billable to SHARS PCS. If the PCS assistance is to meet academic goals, then no, that is not billable to SHARS PCS.  Another question to ask is – are the tasks ones that are age-appropriate for the student?  If so, why can the student not perform those tasks?  If the reason the student cannot perform the age- appropriate task is because of the student’s physical, cognitive or behavioral disability(ies) that cause the student to be unable to perform these tasks, then yes, that is billable to SHARS PCS. In determining if a SHARS PCS service is billable, it is helpful to know what ADLs and IADLs are associated with these tasks.

T15. We have two students that arrive early and are met by their aide at the bus stop. When do we start billing PCS for SHARS?

If the service is documented in the IEP (including justifying the medical necessity of PCS), the school can begin billing PCS when the aides meet the child at the bus stop. The same applies for after school.

T16. If a life skills student has IEP goals/objectives that outline the Special Olympics/bowling and summer camp activities during the summer months and is transported on a special education bus to the bowling alley for this activity because there are no facilities on campus to support the goals/objectives. Can we bill for the service and for transportation to the off campus sites?

Yes, if the specialized transportation needs are included in the IEP. The IEP must document the medical necessity for specialized transportation, as well as, document the medical necessity for the personal care service and why and how the activities meet the IEP goals/objectives for the life skills student. The IEP must also document what services/activities are ADL, PCS, etc.

T17. If a nurse changes the diaper for a child receiving personal care services during a life skills class, is this billed under nursing services?

In order to bill SHARS for nursing services, it must be documented in the IEP. Billing the diaper change as a nursing service would depend on whether the diaper changing required the special skills of a nurse, e.g. a child with Spina Bifida requiring the application of a salve – in this case of a child with Spina Bifida, yes, the diaper change could be billed under nursing services.  If the nurse only changed the diaper because the child felt comfortable with the school health professional in this case, no, the diaper change could not be billed under nursing services.

T18. How can the determination be made whether the service should be billed under personal care service or billed under nursing services?

Personal care services are not skilled nursing tasks.  PCS must be billed as PCS and nursing services (skilled nursing tasks) must be 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.

See also responses to O5 and T3.

T18. How can the determination be made whether the service should be billed under personal care service or billed under nursing services?

 

Personal care services are not skilled nursing tasks. PCS must be billed as PCS and nursing services (skilled nursing tasks) must be 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.

See also responses to Questions O5 and T3.

T19. Is music therapy an allowable SHARS service under PCS?

Generally therapies are not considered PCS. If the district determines that music therapy does in fact fall under PCS, you will need to maintain proper documentation to support the services, including the medical necessity and all other PCS documentation requirements as they may be requested in an audit.

T20. For the Community-based instruction/Vocational training we feel that some activities fall under housekeeping or money management chores, but some activities do not, i.e. teaching a student how to react in their environment as they transition from one class to another or from classroom to lunchroom, from school to work program, etc. Can guidance be provided for Personal Care services definitions and explanations that include Community-based instruction/Vocational training?

In order to bill for PCS services for activities that occur in the Community-based instruction/Vocational training, the activities must meet the criteria of support services provided to clients who meet the definition of medical necessity and require assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), and health related functions because of a physical, cognitive, or behavioral limitation related to a client’s disability or chronic health condition.

See also response and examples listed the response to Question T1.

T21. If the Visual Impairment Specialist(s) is working with a student to assist them in adapting in the classroom using various methods and devices in order to complete assignments, would this type of service be considered a "Personal Care" service by Medicaid definitions & therefore be billable, or at the least "not deducted" from the rest of a student's personal care day?

The Vision Impairment provider can review the visually-impaired student’s classroom documents and/or the PCS provider’s notation of specific type of PCS provided to be sure that she agrees that the VI specialist is providing PCS in that she is assisting the student with the performance of Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) because the student is not able to perform the age appropriate tasks due to his/her disabilities.  Services provided by Orientation & Mobility Specialists often meet the definition of PCS for visually- impaired students.

See also response and examples listed in T1.

T22. We have special education students whose IEPs prescribe redirection services. The teacher and/or teacher’s assistant go to the classrooms and/or bring them to the behavior room to talk to them in order to redirect their inappropriate behavior. Different methods are used to help the student deescalate their behavior. Is this an allowable cost under PCS?

In this instance, the services are not billable because they are not medically necessary. Personal care services include a wide range of human assistance services provided to persons with disabilities and chronic conditions which enables them to accomplish age-appropriate tasks that they would normally do for themselves if they did not have a disability or chronic condition. Services must be documented in the student’s IEP and that documentation supporting the medical necessity for those services is required. Oftentimes, PCS assistance is prescribed in the IEPs to meet academic goals.