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Billing & Payment

2009 Guideline Revision Training

Billing and Payment Unit StaffMisti J. Ackermann, Manager

Department of Aging and Disability Services

HCS Billing Guidelines

• You can find the newest version (October 2009) of the Billing Guidelines on the DADS website:http://www.dads.state.tx.us/handbooks/hcsbg/

• You can find the newest version (October 2009) of the Frequently Asked Questions (FAQ) on the DADS website:

http://www.dads.state.tx.us/providers/HCS/faqs/HCSBillingGuidelinesQA.pdf

General Requirements

§3.03 Activity Not Billable:• Travel time• Writing documentation

Except in Nursing & Specialized Therapies • Reviewing records

Except in Nursing & Specialized Therapies

• Drafting ISP’s • Staff Training/Conferences• Processing service claims

3-3


§3.04 Qualified Service Provider• An adult (over 18)• A staff member or contractor of the program provider• Paid by the program provider• Not be disqualified by this section to provide the particular

service (sub)component being claimed• Meet the minimum provider qualifications (Part 4)• Not have been convicted of an offense listed under §250.006 of

the Texas Health and Safety Code• Not be designated in either the Employee Misconduct Registry

or the Nurse Aid Registry maintained by DADS as having abused, neglected, or exploited a person or misappropriated a person’s property.

3-4, 3-5 & 3-6


Required Content for Written Documentation

• Written narrative: (CMM, Specialized Therapies*, NU*, RSS, SL, SHL, RE and SE) written and signed by the person providing the service

*See next slide for revisions

3-12

Nursing and Specialized Therapies (exceptions)

• The Nursing service allows the review of medical documents. It is also allowable to write one annual treatment plan per IPC year.

• The Specialized Therapies service allows the review of documents related to the providers specified field. It is also allowable to write one annual report per IPC year.

• Neither Nursing nor Specialized Therapies are allowed to bill for the review of service delivery narratives or summaries


Required Content for Written Documentation

• Written narrative or written summary: (FC and DH) written and signed by the person providing the service

3-13


• Information that identifies the individual• A detailed, unique description of activities

performed by the service provider• Justification for the length of the service event• A general, unique description (daily service)• Evidence of billable activity• Description of the location• Signature/title of service provider• Description of any unusual incident or progress

toward a service goal

A written narrative must include:

3-13


A written summary (weekly note) must include:• Information that identifies the individual• A general, unique description of activities

performed during the calendar week• Signature/title of service provider• Being made within a reasonable time after

the week being documented

3-14


Unacceptable Content for Documentation:• Ditto marks• References to other narratives or

summaries using words or symbols• Non-specific statements• Repeated statements, photocopies,

otherwise identical narratives or summaries

• Preprinted schedules, check-off sheets, or “fill-in-the-blank” type forms

Unacceptable as Billing Documentation:• Data collection sheets• Medication logs

3-14 & 3-15

Specific Requirements

Overview of HCS Billing Guidelines

§4.01 Specific Requirements

Case Management Billable ActivityInteracting face-to-face with the individual to:• Identify HCS and non-HCS Program services

the individual may need• Coordinate the provision of service

components to the individual• Monitor the effectiveness of service

components the individual is receiving and the individual’s progress toward achieving the service outcomes described in the individual’s service plan

4.01-1

Not Billable as Case Management:• Travel time• Written documentation• Reviewing records• Drafting ISP’s or PDP’s• Staff Training/Conferences• Processing service claims• Anything not listed as billable

4.01-1


Case Management Monthly Unit of Service

A program provider may include only one unit of service per calendar month on a service claim for case management except when an individual is transferring from one program provider to another (§4.01G). In the case of a transfer the service provider’s combined increments must not exceed one unit.

4.01-2


• Poor Quality Narrative• Vague about type of meeting (face-to-face,

telephone, etc.)• Billing on the first day of the month instead of

actual date service was provided• Billing while individual is in Hospital• Billing for meeting with sleeping individual• Not signing individual out of day habilitation

when activities are interrupted• No Progress Note

§4.01 Common Errors


Specialized Therapies• Audiology services• Dietary services• Occupational therapy services• Physical therapy services• Behavioral Support services• Social work services• Speech and language pathology services

4.02-1

Specialized Therapies Billable Activity• Interacting face-to-face or by telephone with an

individual to conduct assessments or provide services within the scope of the service provider’s practice

• Interacting face-to-face or by telephone with a person, except a service provider of nursing, case management, or specialized therapies, regarding a specialized therapies subcomponent provided to an individual

4.02-1


Specialized Therapies Billable Activity• Participating in an IDT meeting• Training a service provider of residential assistance,

day habilitation, respite or supported employment, or a person other than a service provider who is involved in serving the individual, regarding how treatment that is within the scope of practice of the service provider of specialized therapies will be provided, including training to document the provision of treatment

4.02-1


Specialized Therapies Billable Activity• Writing an annual treatment plan within the scope of

your license.• Reviewing data for the purpose of improving training a

service provider of residential assistance, day habilitation, respite or supported employment, or a person other than a service provider who is involved in serving the individual, regarding how treatment that is within the scope of practice of the service provider of specialized therapies will be provided, including training to document the provision of treatment for an individual.

4.02-1


Not Billable as Counseling and Therapies • Travel time• Writing progress notes or reports other

than an annual plan• Reviewing records except documentation of

your plan or to improve care• Drafting ISP’s • Staff Training/Conferences• Processing service claims

4.02-2


Examples of Activity Not Billable• Writing how treatment will be provided• Reviewing a service record• Providing services outside the service providers

scope• Scheduling an appointment• Transporting an individual• Traveling to or waiting to provide a

subcomponent• Training or interacting about general topics, not

specific to the individual

4.02-2


Specialized Therapies Written Documentation

• Must meet the general requirements outlined in §3.08

• Include the exact begin and end time for the service event by the service provider making the written narrative

• Include a written narrative of the service event• Must include a written justification in the

individual’s ISP for any activity performed by multiple service providers at the same time for the same individual

4.02-3


• No begin and/or end times• No location of service provided• Duplicated progress notes• Reviewing service records

(narrative/summary)• Family paying for rate differential• Using location codes as only documentation of

location• No Progress Note



Day Habilitation Billable ActivityInteracting face-to-face with an individual to

assist the individual in achieving goals to:

• Acquire, retain or improve self-help skills, socialization skills or adaptive skills that are necessary for the individual to successfully reside, integrate and participate in the community

4.03-1

DH billable activity :• Reinforce a skill taught in school, specialized

therapies• Develop opportunities for employment in the

community• Transport an individual between day habilitation sites• Assist an individual with personal care activities• Participate in IDT meetings

4.03-1


Day Habilitation may not be provided in the individual’s residence unless there is adequate justification in the individual’s service plan of a severe medical condition or serious behavioral issues.

4.03-1


Not Billable as Day Habilitation

• Travel time (except from one Day Habilitation site to another)

• Written documentation• Reviewing records• Drafting ISP’s • Staff Training/Conferences• Processing service claims• Assisting an individual for the sole purpose

of meeting vocational goals

4.03-1 & 4.03-2


May not submit DH service claim for:• An individual who refuses to participate • An individual who is sleeping• Assisting an individual in achieving goals

not documented in their ISP• More than five units of service in a

calendar week• More than 260 units of service per IPC year• Day habilitation that is funded by another

source other than HCS

4.03-2


Day Habilitation Unit of Service HCS

• A unit of service for Day Habilitation is one day• One-half unit of service may be billed if service is

provided for two consecutive hours in one calendar day• Three-quarters unit of service may be billed if service is

provided for at least three and one-half hours (with at least two consecutive hours) in one calendar day

• One unit may be billed if at least five hours are provided on one consecutive day-two of the five hours must be consecutive

4.03-3


Day Habilitation Unit of Service TxHmL

• A unit of service for Day Habilitation is one day• One-quarter unit of service may be billed if one hour and

fifteen mins. of service is provided.• One-half unit of service may be billed if service is provided for

two consecutive hours and 30 mins.in one calendar day• Three-quarters unit of service may be billed if service is

provided for at least three and 45 mins. (with at least two consecutive hours) in one calendar day

• One unit may be billed if at least five hours are provided on one consecutive day and two of the five hours must be consecutive

4.03-3


DH Written Documentation must:• Meet the requirements in §3.08• Include a description of the DH site• Include daily exact start and end times documented

by the person present at the site at those times• Include a written narrative or written summary• Include a description of the individual’s ISP goals

and outcomes

4.03-3 & 4.03-4


• Individual sleeping• Not signing individual out of Day Habilitation for other

services provided (CMM, NU, SHL, etc.)• No description of service provided (details about

interactions, activities, behaviors, successes, refusals, etc.)

• Daily narrative used for weekly summary• No habilitation occurring in the day habilitation center• Duplicated Progress notes*• Using location codes as only documentation of



Revised Nursing Services

• 4.04 Registered Nurse• 4.041 Licensed Vocational Nurse• 4.042 Specialized Registered Nursing

All RN services provided to person with tracheotomy or dependent on ventilator

• 4.043 Specialized Vocational Nursing All LVN services provided to person with

tracheotomy or dependent on ventilator

Nursing Billable Activity

• Interacting face-to-face or by telephone with an individual to provide professional or vocational nursing for which there is a documented or immediate medical necessity

• Preparing or administering medication or treatment ordered by a physician, podiatrist or dentist

• Assisting or observing self-administration of medication

• Assessing an individual’s health status

4.04-1

Nursing Specific Requirements

Nursing Billable Activity

• Interacting face-to-face or by telephone with a person (other than a service provider of nursing, case management, or specialized therapies) regarding the health status of an individual

• Instructing, verifying the competency of, or supervising an unlicensed person in the performance of a task delegated in accordance with the rules of the Board of Nurse Examiners

• Participating in an IDT meeting• Writing an ITP for an individual

4.04-1


Examples of Non-Billable Activities:• Activities that do not constitute the practice of nursing

(transportation, waiting to perform billable activities)• Making appointments• Instructing on general topics• Preparing a treatment or medication for administration

if not face-to-face• Storing, counting, refilling, reordering or delivering

medications• Reviewing documentation except labs,Dr. orders or

medical documentation

4.04-2


Nursing Rule of Thumb:

If it does not require a nursing license to perform a task, it is not billable.


Nursing Unit of Service• 15 Minute of Service

A service claim cannot be made for a fraction of a unit of service

• Accumulation of Service TimesCan be accumulated for nursing provided to one individual on a single calendar day*

4.04-3


Nursing Unit of Service- Accumulation

• Accumulation of Service TimesCan accumulate between multiple nursing events

(LVN & RN) in same calendar day• Provider must use the lower contracted rate when

accumulating multiple nursing service events

4.04-3



Nursing Written Documentation• Must meet the requirements in §3.08• Include a written narrative of the service event• Include the exact start and end time of the service

event documented by the person making the written narrative

• Include a description if the medical necessity for the activity performed during the service event

• For any activity simultaneously performed by more than one service provider, include a written justification in the individual’s ISP for the use of more than one service provider

4.04-4

Common Nursing Errors

• Billing for reviewing progress notes.• No medical necessity on vitals taken weekly, monthly, or

quarterly• No medical necessity shown when residential staff calls

nurse to administer over the counter medication to individual

• No medical necessity for follow-up phone call• Billing for services without Face-to-Face or Telephone

contact• Providing any activity not requiring a nursing license• Poor justification in PDP/ISP for nursing services• Using location codes as only documentation of location• One note used for multiple service events• No Progress Note

Supported Home Living (SHL)


§4.05 Residential Assistance

4.05-3

§4.05 Specific Requirements - SHL

Supported Home Living Billable Activity

Interacting face-to-face with the individual:• to assist with activities of daily living• to assist with ambulation and mobility• to reinforce specialized therapy subcomponents• to assist with administration of medication or tasks

delegated by an RN• to conduct habilitation activities• to secure transportation for the individual• to supervise the individual’s safety and security

4.05-3

Supported Home Living Billable Activity

• Interacting face-to-face or by telephone with an individual or an involved person regarding an incident that directly affects the individual’s health or safety

• Performing one of the following activities that does not involve interacting face-to-face with an individual: shopping for the individual, planning or preparing meals for the individual, housekeeping for the individual, procuring or preparing the individual’s medication or securing transportation for the individual.

• Participating in an IDT meeting

4.05-4


Supported Home Living claims may not be submitted for:

• An individual whose IPC does not have a residential location of “own home/family home”

• Transporting an individual from one DH or SE site to another

• A minor being home schooled during normal school hours or a minor that leaves school before age 18

4.05-5


Supported Home Living Written Documentation• Must meet requirements of §3.08• Includes a written narrative of the service event• Includes exact begin and end time of the service event

documented by the service provider making the written narrative• If not face-to-face, justification must be in the individual’s ISP.

The activity must be described in the written narrative• For any activity simultaneously performed, justification must be

included in the individual’s ISP

4.05-9


SHL Transportation Written Documentation • Name of the individual being transported• Day, month and year the transportation was provided• Place of departure and destination for the individual being

transported• Notation of which method was used to calculate transportation

time• Begin and end time for each transportation time

4.05-9 & 4.05-10


SHL Transportation Written Documentation cont’d

• Total minutes of each transportation time• Signature of the service provider• The unit of service for a service claim resulting from

each service time; and• Any service times accumulated to make a unit of service

for a service claim

Attachment F: Supported Home Living Transportation Billing Log Example

4.05-10


§4.05 Common Errors - SHL

• Overlapping times with other services• Transportation method completed incorrectly• Time not divided evenly between two or more individuals

receiving services at the same time• Non-qualified Service Provider (Proof of residence, etc.)• No justification for receiving SHL in DH facility• No begin and/or end times on documentation• No location of services provided on documentation• Duplicated progress note• Using location codes as only documentation of location• No Progress Note• Assisting a person that is volunteering more than 10 hrs a

month.

Foster Care (FC)



4.05-11

Foster Care Requirements of Setting• The program provider may not lease or own the residence• The individual receiving care must have a residence in

which no more than three persons receive: foster/companion care, a non-HCS Program service similar to foster/companion care; and

• If the individual is a minor, the parent or step-parent may not provide this service

4.05-11

§4.05 Specific Requirements - FC

Foster Care Requirements of Setting• The service provider must have the same

residence as the individual; and• Ensure that foster/companion care is

provided to an individual when necessary

4.05-11


Foster Care Unit of Service• Unit of service is one day• May not be for more than one day • May not have a fraction of a unit of service

4.05-14


Foster Care Billable Activity• Assisting the individual with activities of daily

living (bathing, dressing, personal hygiene, eating, meal planning and preparation and housekeeping)

• Assisting the individual with ambulation and mobility

• Reinforcing any specialized therapy subcomponent provided to the individual

• Assisting with the administration of the individual’s medication or to perform a task delegated by an RN

4.05-11 & 4.05-12


Foster Care Billable Activity• Conducting habilitation activities that train the

individual to:Develop or improve skills that allow the

individual to live more independentlyDevelop socially valued behaviors Integrate into community activitiesUse natural supports and typical community

services available to the publicParticipate in leisure activities

4.05-12


Foster Care Written Documentation• Must meet the requirements in §3.08• Must include a description of the

location of the individual’s residence; and

• Include a written narrative of the calendar day or a written summary of the calendar week

4.05-14 & 4.05-15


Foster Care Service Claim for an Individual on a Visit with Family or FriendA program provider may submit a service claim for an individual who is on a visit with a family member or friend away from their residence if the visit is for at least a calendar day. If the visit is for more than 14 consecutive calendar days, the program provider may submit a service claim for only 14 calendar days of the visit.

4.05-15


• Failure to discharge individual while in the hospital

• Weekly summary exceeds seven days• Duplicated progress note• Using location codes as only documentation of


§4.05 Common Errors - FC

Residential Support Services (RSS)



4.05-16

Residential Support Requirements of Setting• The residence must be a Three or Four person residence• The program provider may not have the same residence as

the individual• The service provider must be available to provide

residential support to an individual as needed; and• The service provider must be present and awake in the

residence when the individual is present in the residence

4.05-16

§4.05 Specific Requirements - RSS

Residential Support Service Provider Shifts

• Off Duty Requirement--Must be off duty for at least 8 hours before working another shift

• No Shifts of More than 24 Hours• Must have a change of staff each day• No more than Five Extended Shifts per Month

(Extended Shift: a combined period of time more than 16 hours during a 24 hour period)

4.05-16


Residential Support Billable Activity• Assisting the individual with activities of daily

living (bathing, dressing, personal hygiene, eating, meal planning and preparation and housekeeping)




4.05-17


Residential Support Billable Activity• Conducting habilitation activities that train the




4.05-17


Residential Support Written Documentation• Must meet the requirements in §3.08• Must include a description of the location of the

individual’s residence• Must include at least two written narratives (one by the

service provider who is on duty while the individual is awake and one by the service provider who is on duty while the individual is asleep)

• Must include the begin and end time of the shift worked by the service provider making the written narrative

4.05-20


Service Claim for an Individual on a Visit with Family or Friend Written Documentation Written documentation must include the individual’s name, the dates the individual was visiting the family member or friend, the location of the visit and the date and signature of the service provider.

4.05-21


• No Shift Changes or change of staff• Day Habilitation is NOT a shift change• More than five extended shifts per month• Gaps in coverage while individual is in residence• Working longer than 24 hour shifts• Failure to discharge individual while in the hospital• Duplicated progress notes• Using location codes as only documentation of location• No Progress Note

§4.05 Common Errors - RSS

Supervised Living (SL)



4.05-22

Supervised Living Requirements of Setting• The residence must be a 3 or 4-person residence

(if 4-per one must be rss)• The service provider must be available to provide

residential support to an individual as needed; and• The service provider must be present in the

residence when the individual is present in the residence

4.05-22

§4.05 Specific Requirements - SL

Supervised Living Billable Activity• Assisting the individual with activities of

daily living (bathing, dressing, personal hygiene, eating, meal planning and preparation and housekeeping)




4.05-22


Supervised Living Billable Activity• Conducting habilitation activities that train the





Supervised Living Written Documentation• Must meet the requirements in §3.08• Must include a description of the location of the

individual’s residence• Must include at least one written narrative made

by the service provider who is on duty while the individual was awake; and

• Must include the begin and end time of the shift worked by the service provider making the written narrative

4.05-25


• Failure to discharge consumer while in the hospital

• Using location codes as only documentation of location

• No Progress Note

§4.05 Common Errors - SL


RespiteTemporary Provision of Assistance-Service provider does not provide foster care, residential support or supervised living to the individual

4.06-1

Respite Billable Activity

• Assisting the individual with activities of daily living


• Reinforcing any specialized therapy provided to the individual


4.06-1 & 4.06-2


Submitting a Service Claim for Respite

Provision of less than 10 hours in one calendar day in any location

ORProvision of 10 or more hours in a location other than the individual’s residence a max. of 10 hrs can be billed per day

ORProvision of 10 or more hours in an individual’s residence up to 96 units daily.

4.06-3 & 4.06-4


Respite Written Documentation• Meet requirements in §3.08• Written narrative• Exact begin/end time• Written justification in ISP for

more than one service provider

4.06-5 & 4.06-6


• Location of service not on documentation• Billing more than 10 hours for respite occurring out of

the individuals home• Individual lives alone without a live-in caregiver• No begin and/or end times • Non Qualified Service Provider (Proof of residence,

etc.)• Duplicated progress note• Using location codes as only documentation of




Supported Employment: Requirements

• Fair Labor Standards Act – must be compensated by the employer as an “employee” under this act

• Must be employed at a site where no more than one employee or 3% of the employees, whichever is greater, has a disability

4.07-1

Supported Employment Billable Activity

• Face to face or by telephone with individual’s supervisor to sustain individual employment

• IDT meetings• Face to face with individual at work

site only

4.07-1


Billing Day Habilitation for SE

Documentation must include name of the individual, exact time worked each day, exact dates worked each week, name, address and phone number of employer and signature of employment supervisor, service provider or case manager. ( not in TxHmL)

4.07-3


Examples of Activities Not Billable under SE• Interacting with individual when not on

duty• Services provided prior to

employment-includes assessments, assisting or arranging interviews, completing applications and transporting

4.07-1 & 4.07-2


Restrictions (SE):• Program provider can’t be employer

unless the program provider has an approved variance from DADS

• An individual receives more than 600 units/150 hrs per IPC year

• Supported employment is available through another source (public school or DARS)

4.07-2 & 4.07-3


Supported Employment Documentation

• Meet requirements set forth in §3.08• Written narrative in §3.08(B)• Service Event in §3.06(A)(1)• Exact Begin and End time• Evidence not available through

school or other funding source

4.07-3


• Training not occurring at the job site• Pre-vocational training• Duplicated progress note• Using location codes as only documentation of



Billing & Payment Contacts

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