Service Record – School Based Nursing Services
Medicaid Number
Last Name
First Name
00000000001
Doe
Jane
WVEIS #
Diagnosis Code
Date of Birth
590000001
F44.5 Conversion disorder
with seizures or convulsion
Beginning Date
Ending Date
County
01-01-1900
Procedure
Unit
059
9-01-2015
9-01-2015
T1001 SE
1
School
Beginning Date
Ending Date
Procedure
Units
201
9-01-2015
9-31-2015
T1000 SE
21
Provider Number
Beginning Date
Ending Date
Procedure
Units
Melanie Smith
9-22-2015
9-22-2015
92950
1
School Based Nursing Services: Written physician’s orders with diagnosis and specialized care
required. Must be identified on Service Plan (Care plan may be attached).
Code
Procedure
Service Unit
T1001 SE
T1000 SE
Nursing Assessment/Evaluation.
School based/independent nursing services – licensed. Regarding the
specialized healthcare procedures summarized below
92950
T1017 SE
Manual Resuscitator
Targeted Case Management (If an appropriate Targeted Case
Management service has been provided, complete the Targeted Case
Management Form).
2 events per calendar year
15 minutes units. Each procedure is
a maximum of 10 units per
instructional day.
10 events per calendar year
15 minutes per 1 unit
Authorized Individual Nursing Services/Treatments:
Anaphylactic Reaction Evaluation
(T1001 SE) (2 Events/Calendar Year)
Seizure Management (T1001 SE)
(2 Events/Calendar Year)
Manual Resuscitator (92950)
(10/Calendar Year)
The following procedures use T1000 SE code: Each of the following procedures can be billed, with a
maximum of 10 units for each procedure per instructional day, (1 Unit = 15 minutes)
Long Term Medication Administration
Ostomy Care: Emptying/Changing of
Ostomy Pouch
Emergency Medication Administration
Enteral Feeding (tube feeding)
Inhalation Therapy by Machine
Anaphylactic Reaction Individual
Catheterization: Clean-Self-Sterile
Measurement of Blood Sugar with a
Glucometer
Oral Suctioning
Postural Drainage and Percussion
Oxygen Administration
Date
Start
Time
1
11:00
2
11:00
3
11:00
4
11:00
End
Time
11:15
11:15
11:15
11:15
Date
Start
Time
16
11:00
17
11:00
18
11:00
19
11:00
End
Time
11:15
11:15
11:15
11:15
5
20
6
21
7
Subcutaneous Insulin by Injection
Tracheostomy Care
Peak Flow Meter
8
11:00
9
11:00
10
11:00
11
11:00
12
11:00
11:15
11:15
11:15
11:15
11:15
22
11:00
23
11:00
24
11:00
25
11:00
26
11:00
11:15
11:15
11:15
11:15
11:15
_____________________________________
Signature/Credentials
WVDE – BMS – SBHS – Appendix A
Mechanical Ventilator
Subcutaneous Insulin Infusion Pump/Bolus
27
13
14
15
11:00
11:15
28
29
11:00
30
11:00
11:15
11:15
9-30-2015
Date
Effective Date: August 1, 2015
31