Provider Notice issued 02/06/03

Chapter U 200, Handbook for LEAs Fee-for-Service Program

U-210.6 Nursing Services

U-210.10 School Health Aide

This notice clarifies nursing services listed in Chapter U-200, Handbook for Local Education Agencies. This is not a change in current policy.

Each of the following criteria must be met when claiming a reimbursement for services:

• The service must be either necessary for the development of the student's Individual Education Program/Individual Family Service Plan (IEP/IFSP) or documented in the IEP/IFSP.
• The service must be relevant to the medical and rehabilitative needs of the child.
• The service must be provided through direct service intervention or consultation.

LEA's may claim reimbursement only for services that are listed on the IEP/IFSP or are required in the development of an IEP/IFSP. "General medical services" listed on an IEP/IFSP does not meet the definition of nursing services and may not be used as a basis for claiming reimbursement. Medicaid or Kidcare eligibility of a child is not the only required criterion for a claim to be eligible for reimbursement.

Effective July 1, 2002, School Health Aide services became eligible as a covered service for reimbursement, using the W7123 (T1021) procedure code. School Health Aide services documented in the student's IEP/IFSP must provide assistance with activities of daily living and be necessitated by the student's medical condition.

The addition of section U-210.10 provides the service description, staff qualifications, and claimable services for School Health Aides. Claims made prior to July 1, 2002 for School Health Aide services using inappropriate procedure codes (i.e. nursing or social work) must be adjusted in accordance with Chapter 100, Appendix 6, of the Handbook for Providers of Medical Services.

The following examples provide guidance in proper billing.

Example 1: The child has an IEP listing nursing services as necessary to address a history of respiratory problems. The nurse administers a nebulizer treatment (as ordered by a physician) to the child. This is a covered service eligible for reimbursement.

Example 2: A child has an IEP listing social work services only. The nurse provides Tylenol® to the child for a headache. As this does not meet the requirement of being relevant to the medical and rehabilitative needs as listed on the IEP, this service is not a covered service and may not be claimed.

Example 3: A child has no IEP on file. The nurse provides first aid to the child when he or she chokes during lunch. As this does not meet the requirement as necessary for the development of the student's IEP/IFSP, this service is not a covered service and may not be claimed.

Example 4: A child has an IEP listing nursing services for a history of respiratory problems. The nurse administers a nebulizer treatment (as ordered by a physician) to the child. The nurse provides first aid to the child who is coughing and choking during lunch. As the treatment to the child for coughing and choking meets the requirement of being relevant to the medical and rehabilitative needs as listed on the IEP, this service would be considered a covered service eligible for reimbursement and may be claimed.

If you have any questions concerning this notice, you may contact School-Based Health Services at (217) 524-4976.

A. George Hovanec, Administrator
Division of Medical Programs