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NHTD/TBI Billing Changes Issued

Last week, the Department of Health (DOH) issued eMedNY alerts regarding billing changes for Nursing Home Transition and Diversion (NHTD) and Traumatic Brain Injury (TBI) services. Please note the following changes:

Billing Partial Units:

Currently, Program Manuals for both the NHTD and TBI Medicaid waivers describe billing practices when a waiver service provider cannot complete a full billable unit of service.

"Providers must accumulate billable units until a whole hour is reached before billing for the service"

To accommodate services provided through alternative means during the Public Health Emergency (PHE), effective March 1, 2020, providers may bill using partial units for the following services:

Independent Living Skills Training (ILST) – NHTD Rate code: 9756 | TBI Rate code: 9858

Positive Behavioral Intervention and Supports (PBIS) NHTD Rate code: 9757 | TBI Rate code: 9860

Community Integration Counseling (CIC) NHTD Rate code: 9755 | TBI Rate code: 9861

Home and Community Support Services (HCSS) NHTD Rate code: 9795 | TBI Rate code: 9879, 9880, 9881, 9882

Structured Day Program NHTD Rate code: 9777 | TBI Rate code: 9870

Substance Abuse Program (TBI only) TBI Rate code: 9859

Providers will no longer be required to "accrue" time until one full unit is achieved. Providers should bill using 1/4 units (.25, .50, .75) using no less than a 1/4 (.25) unit. During the PHE, services may be provided through face-to-face or alternative means. All service provision must continue to be documented according to service guidelines. All services provided through alternative means must be documented in the detailed plan explaining the alternative method of service delivery.

DOH anticipates that this billing accommodation will remain in place after the PHE.

Billing of Service Coordination:

Currently, the Program Manuals for both the NHTD and TBI Medicaid waivers require Service Coordination (SC) to be reimbursed in monthly units on the first of the month after service provision. As with all waiver services, SC must be included in the participant's approved service plan and can only be billed after the service is rendered. For reimbursement purposes during the COVID-19 emergency, and as established in the waivers’ Appendix K amendment, the Service Coordinator must have at least one contact with the participant in the month for which the provider bills. Unfortunately, during the COVID-19 epidemic, waiver participants have been lost. Providers offered support throughout the time of their illness. Current billing practices provide that if the waiver participant passes away during the service month, and even if SC services were provided during that month, the provider is unable to bill for services rendered. This is due to the termination of Medicaid coverage effective the date of death. As a result, services could not be billed on the first of the following month.

Due to some changes in the eMedNY edit process, effective March 1, 2020, upon the death of a waiver participant, providers may now bill for ongoing SC (Rate codes 9775/NHTD, 9851/TBI) twice in one month. This would provide for the routine billing on the first of the month for services rendered in the prior month and allow for an additional claim for SC on the date of death. This allows the provider to bill for services provided after the first of the month leading up to the date of the participant’s death. Providers are required to adhere to all eMedNY billing guidelines, and the billing date of service must be before the date of death. All waiver documentation requirements remain in effect.

Providers may bill for these services retroactive to March 1, 2020 but will require a delay reason code of 03. Please note that providers may not bill for Initial SC at any time if an applicant does not reach full waiver eligibility due to death.

All questions regarding these changes may be directed to the waiver mailbox at waivertransition@health.ny.gov.

Contact: Meg Everett, meverett@leadingageny.org, 518-929-9342