Medicaid Billing Module
Targeted Case Management
(TCM) Billing Form
Changes
• Targeted Case Management (TCM) can
only be billed for students getting billable
services based upon medical necessity.
• An SLD student who doesn’t have speech,
OT, PT, Nursing, psychotherapy, behavior
intervention would not be eligible for TCM
• Can be billed by multiple providers, but
should be coordinated by one person.
Targeted Case Management
• TCM is capped as five units per
instructional day.
• TCM can be billed on days the student is
absent.
Demographics
• Complete the sections with attention to the
following:
• Diagnosis code should not be based on an
educational disability such as Learning
Disability. Example would be an LD
student with speech as a related service,
use the speech diagnosis code.
Approved Activity List
• Has been re-organized into four major
categories.
• A – Needs Assessment and
Reassessment
• B – Development/Revision of Service Plan
• C – Referral and Related Services
• D – Monitoring and Follow-up
Assessment Activities
• Assess/Reassess student
• Assessed the student's ability to interact and
socialize with peers in the general setting
• Assessed the student's
modifications/accommodations
• Assessed/Reviewed student's assessment and
discipline data
• Assessed current progress notes/therapy logs
• Conducted an assessment of the student's
needs in regards to hygiene and independence
Assessment Activities Continued
• Conducted a student behavioral assessment for
behavioral health concerns.
• Conducted review of student's progress with
Medicaid covered services
• Gathered and analyzed behavioral data on
student's target behaviors included in the behavior
intervention plan
• Gathered information from the student's records
and from Medicaid service providers
• Reviewed documentation from outside agencies
such as physicians, psychologists, audiologists
Development of Service Plan
Activities
• Conducted revision of plan
• Develop a "draft" Service Plan that
incorporated strengths and
weaknesses along with
modifications/accommodations
• Developed a home communication plan
based on medical needs (behavior)
Referral and Related Service
Activities
• Advocated with outside non-school therapy
provider
• Advocated for the student with administration
• Assisted family with application for outside
supports
• Consulted/met with County or School
Administrator
• Consulted/met with Occupational Therapist
• Consulted with outside medical provider
Referral and Related Service
Activities
•
•
•
•
Consulted/met with Parent/Guardian
Consulted/met with Personal Care Aide
Consulted/met with Physical Therapist
Consulted/met with Psychologist or
other Mental Health Provider
• Consulted/met with School Counselor
• Consulted/met with Nurse
Referral and Related Service
Activities
• Consulted/met with Speech Therapist
• Consulted/met with Teacher (General or
Special Ed) teachers
• Reviewed the student's Behavior Intervention
Plan and Crisis Response procedures with
school staff
• Arrange/assess for the student to have
calming strategies included in the student's
behavior intervention plan and sensory diet.
Referral and Related Service
Activities
• Consult with crisis team
• Provided Intervention by implementing
CPI techniques in response to crisis
• Provided intervention according to
behavior intervention plan (described
below)
• Worked with crisis team
Monitoring and Follow-Up Activities
• Monitored behavioral health needs through the
development of progress notes that are sent
home to parents
• Followed up on the student's behavior
referrals towards meeting goals
• Followed up on the student's Medicaid related
services
• Followed up on the student's previous
involvement in an incident as part of follow up
activities when CPI is used
TCM Purposes
• Access travel to Medicaid covered services in
community
• Assistance for related therapies
• Assist the student in accessing medical
services
• Assure student receives appropriate action as
medically necessary
• Complete correspondence with agency outside
of school to participate in developing plan.
• Complete at-risk referral.
TCM Purposes
• Coordinate and provide a continuity of services.
• Determine an appropriate Behavior Intervention
Plan as it relates to medically necessary services.
• Assess if target behaviors are being generalized in
the home environment
• Assess if target behavior skills are being
generalized in the school environment.
• Assess if target communication skills are being
generalized in the school environment
• Assess if target communication skills are being
generalized in the home environment.
TCM Purposes
• Assess the student's communication skills in all
settings.
• Develop a Behavior Intervention Plan as medically
necessary
• Develop a Behavior Intervention Plan and Crisis
Response procedures
• Assess the response to the crisis
• Assess/reassess progress and generalization of
Medicaid related services
• Monitor and follow up that adequate Crisis
Response procedures are followed.
TCM Purposes
• Facilitate communication with parents of
progress with student Medicaid related
services
• Advocate behavioral intervention.
• Advocate counseling services.
• Advocate nursing services.
• Advocate psychological services.
TCM Purposes
• Advocate speech services.
• Advocate needed support to access general
education, cafeteria, bathroom and auditorium
• Recommend behavior interventionist to assist
student in developing coping skills for behavioral
issues
• Review of Functional Behavior Assessment results
• Related to the student's medical services/needs
necessary for the development of a Health Care
Plan.
Individual Service Note
• For each entry add an individual service note.
• Include the student name to personalize the
note. Example: Met with Jane’s classroom
teacher to determine how she is generalizing
speech in classroom setting
• This is a brief description of what was done.
Documentation
• For each service list:
– Date of service
– Type of contact (1. Face to Face, 2.
Correspondence, 3. Telephone Contact)
– TCM Activity Type
– Start Time
– Stop Time
– Total Minutes
Documentation
• Choose an activity from the drop down list
• Choose a purpose from the drop down list
• Write a personalized brief note of what
occurred
• Sign and list credentials
• Date signature
Accumulation of Minutes
• A TCM unit can be obtaining by adding
minutes across multiple days.
• Minutes must be from the same month.
• Minutes do not have to be on consecutive
instructional days.
• If doing multiple day unit list the date of
service as the day the 15th minute was
provided.
Accumulation of Minutes
• If accumulating minutes on a regular
schedule for the exact same type of activity
such as 2:50-2:55 for “Provided intervention
according to behavior intervention plan” you
may use one entry and document the three
dates involved in the unit.
• If the accumulating minutes are for different
activities the minutes for partial units would
need documented on a separate section of
the form.
Terry Riley – Coordinator
Office of Special Education
tjriley@k12.wv.us
304-957-9833 ext 53223
WVDE Medicaid Website:
http://wvde.state.wv.us/osp/medicaid.html