Collaboration with the participant, his/her family, and his/her team in order to develop positive interventions to address specific presenting issues; and Completion of required paperwork related to data collection, progress reporting, and development of annual planning material. T2025 Nursing – Registered Nurse (RN), Licensed Practical Nurse (LPN) Each service note must include and end time; and Nurse signature (Esignature is allowed), license type – Registered Nurse (RN) or Licensed Practical Nurse (LPN) Nurse, and title. A service note must be included for each continuous span of 15 minute units that describes what activities the nurse performed in relationship to the nursing care plan. Based upon the diagnosis of the participant, the nurse should document activities around assessment, intervention, response, and any planned next steps. Progress Notes must Include progress (or lack of) toward authorized plan outcomes and actions documented in the ISP; Include action planned/taken to address lack of progress, if applicable; and Must be completed at least monthly in any calendar month the service is provided. Speech and Language Therapy Each service note must include Start and end time; and Therapist signature (Esignature is allowed), license type, and title. The service note should describe what the therapist did in relation to the orders of the participant’s licensed physician, or an evaluation and recommendation as specified in the approved waivers (PT and OT–Prescription by a physician; Speech and Language--Evaluation and recommendation by an American Speech-Language-Hearing Association (ASHA) certified and state licensed speech-language pathologist or physician; and recommendation by a licensed psychologist or psychiatrist; and Orientation, Mobility, and Vision--Evaluation and recommendation by a trained mobility specialist/instructor or a physician.) Progress Notes must Include progress (or lack of) toward authorized plan outcomes and actions documented in the ISP; Include action planned/taken to address lack of progress, if applicable; and Must be completed at least monthly in any calendar month the service is provided. Occupational Therapy (OT) Physical Therapy (PT) Behavior Therapy - Individual Therapy Orientation, Mobility, and Vision Therapy
W7291 W7293 Family Living 1-Individual Home Adult (Licensed under 55 Pa. Code Chapter 6500)-TD (service provided by a RN) and TE (service provided by a LPN). Family Living 2-Individual Home Adult (Licensed under 55 Pa. Code Chapter 6500)-TD each billed day – this may be an attendance roster, a progress note, a MAR, etc. An affirmative confirmation that documents the person was present rather than assumes the person was present is essential. The provider must retain time sheets (including ESignatures or electronic time sheets) that demonstrate the staffing ratio specified in the ISP. Exceptions include Therapeutic Leave which requires start and end times on the day of absence and return, and Medical Leave which requires admission and discharge date from medical center. In addition: License Type – RN or LPN, Title A service note must be included for each one day unit that describes what the nurse did to address any health/medical interventions performed by the nurse. Based upon the diagnosis of the participant, the nurse should document activities around assessment, intervention, Specialist must use a monthly progress note to determine Whether the service is being provided as specified in the ISP; Whether the service is meeting the participant’s assessed needs and preferences; Whether is progress toward ISP specified outcomes and actions; and When there is an identified lack of progress, how the lack of progress will be addressed. Progress notes must document substantive issues that impact the participant’s Health; Safety; Preferences; Priorities; and Routine. Documentation needed upon occurrence as required by Pa. code, including, for example but not limited to reportable events.
response, and any planned next steps. W7037 W7039 W7078 W7080 W7082 Community Residential Rehabilitation--Unlicensed 1, 2 Individual Family Living Home Residential Habilitation-- Unlicensed 1, 2, 3 Individual Home Same as above: Documentation that indicates a contact with the participant is required to confirm presence for each billed day – this may be an attendance roster, a progress note, a MAR, etc. An affirmative confirmation that documents the person was present rather than assumes the person was present is essential. The provider must retain staff time sheets (including ESignatures or electronic time sheets) that demonstrate the staffing ratio specified in the ISP. Exceptions include Therapeutic which requires start and end times on the day of absence and return, and Medical Leave which requires admission and discharge date from medical center. Progress Notes In accordance with 55 PA Code, Chapter 51.16, the Provider must use a monthly progress note to determine Whether the service is being provided as specified in the ISP; Whether the service is meeting the participant’s assessed and preferences; Whether is progress toward ISP specified outcomes and actions; and When there is an identified lack of progress, how the lack of progress will be addressed Progress notes must document substantive issues that impact the participant’s Health; Safety; Preferences; Priorities; and Routine. Documentation needed upon occurrence as required by Pa. code, including, for example but not limited to reportable events. W7070 W7084 W7086 Supplemental Habilitation 1:1, 2:1 Additional Individual Staffing 1:1, 2:1 15 minutes In addition to residential habilitation billing documentation requirements, service must include Start and end times for supplemental/additional staff; and Progress Notes The progress note completed for Residential Habilitation should address progress in Supplemental Habilitation.
Signature of the person providing the service (eSignature is allowed). A service note must be included for each continuous span of 15 minute units that describes how the service performed relates to the reason the service was authorized. Respite Code Service Unit Required Information for Record Billing Other Required Documentation W7247 W7251 W7252 W7255 W7256 W7258 W7264 W7266 W8000 W8001 W8002 W8003 Respite--In Home and out of Home Unlicensed– Basic; Levels 1, 2, 3; Participant Directed Services (PDS); U4; and Enhanced Respite--Unlicensed Out of home Basic; Level 1 and 2; PDS;U2; Level 2 Enhanced Support and PDS; and U4 PDS. One day Documentation must include start and end time(s) in a 24 hour period (accommodate multiple in and out to calculate more than 16 hour requirement); and Signature of person providing the service (eSignature is allowed), degree/title, and title for enhanced service levels only. The provider must retain staff time sheets (including eSignatures or electronic time sheets) that demonstrate the staffing ratio specified in the ISP. Service Note A service note must be included for each continuous span of 15 minute units (or each day unit) that document caregiver relief. Notes should be written No monthly progress note is required. For each consecutive block of units, documentation is required for substantive issues that impact the participant’s Health; Safety; Preferences; Priorities; and Routine. Documentation needed upon occurrence as required by Pa. Respite--In Home and out of home unlicensed– Basic; levels 1, 2, and 3; PDS; U4; and Enhanced 15 minutes
of the person providing the service (eSignature is allowed); and the documentation must indicate how staffing ratios authorized in the ISP have been met; and licensed and approved program capacity is not exceeded. In addition: There is a process to request approval in an emergency situation to provide respite beyond program capacity. Confirmation of ODP approval for these situations must be maintained. Day Habilitation Code Service Unit Required Information for Claim Record Billing Other Required Documentation W7060 W7061 W7068 Home and Community Habilitation Unlicensed Basic; Levels 1, 2, 3, and 4; PDS; U4 ; and Enhanced Support. 15 minutes Documentation must include start and end time(s); signature of person providing the service (eSignature is allowed); and degree/license and title for enhanced service levels only. 1:1 staffing ratios require time sheets with start and end times for the 1:1 staff. The provider must retain staff time sheets (including eSignatures or electronic time sheets) that demonstrate the staffing ratio specified in the ISP. A service note must be included for each continuous span of 15 minute to describe service activities. Notes must be maintained for Progress Notes In accordance with 55 PA Code, Chapter 51.16, a monthly progress note is used to determine Whether the service is being provided as specified in the ISP; Whether the service is meeting the participant’s assessed needs and preferences; Whether there is progress toward ISP specified outcomes and actions; and When there is an identified lack of progress, how the lack of progress will be addressed.
W7035 W7072 W7073 W7075 W7076 Licensed Day Habilitation (2380) Base; Levels 1, 2, 3, and 4; Enhanced Support An attendance roster with participant start and end time(s) is required to include accommodation of multiple in and out times. The provider must retain time sheets (including eSignatures or electronic time sheets) that demonstrate that staffing ratio and, where applicable, enhanced staffing, authorized in the ISP and billed has been provided. Progress Notes In accordance with 55 Pa. Code, Chapter 51.16(d) and 55 Pa. Code, Chapter 2380.33, the Program Specialist must use a monthly progress note to determine Whether the service is being provided as specified in the ISP; Whether the service is meeting the participant’s assessed and preferences; Whether there is progress toward ISP specified outcomes and actions; and When is an identified lack of progress, how the lack of progress will be addressed. Documentation is required for substantive issues that impact the participant’s: Health; Safety; Preferences; Priorities; and Routine. Documentation needed upon occurrence as required by Pa. code, including, for example but not limited to reportable events. Licensed Day Habilitation (Licensed under 55 Pa. Code Chapter 2380 - Level 3 Same as above: An attendance roster with participant start and end time(s) is required to include accommodation of multiple in and out times. Same as above: Progress Notes In accordance with 55 PA Code, Chapter 51.16(d) and 55 PA Code, Chapter
Code Service Unit Required Information for Claim Record Billing Other Required Documentation W7237 W7239 W7241 W7245 Transitional Work Services Base; Levels 1, 2, and 3 15 minutes An attendance roster with participant start and end time(s) to include accommodation of multiple in and out times. 1:1 staffing ratios require time sheets with start and end times for the 1:1 staff The provider must retain staff time sheets (including eSignatures or electronic time sheets) that demonstrate the staffing ratio specified in the ISP. Progress Notes In accordance with 55 Pa. Code, Chapter 51.13, a monthly progress note is used to determine Whether the service is being provided as specified in the ISP; Whether the service is meeting the participant’s assessed and preferences; Whether there is progress toward ISP specified outcomes and actions; and When is an identified lack of progress, how the lack of progress will be addressed. Documentation is required for substantive issues that impact the participant’s: Health; Safety; Preferences; Priorities; and Routine. Documentation needed upon occurrence as required by Pa. code, including, for example but not limited to reportable events W7235 Supported Employment and PDS and U4 PDS Documentation must include and end time(s) and signature of person Progress Notes
Supports for Participant Direction Code Service Unit Required Information for Claim Record Billing Requirement Other Required Documentation Supports Broker Services 15 minutes Documentation must include start and end time(s) and signature of person providing the service (eSignature is allowed). A service note must be included for each continuous span of 15 minute units to describe service activities. The requirement can be achieved by using a checklist to indicate the assistance provided to the participant, which may include Explaining and providing support in completing employer-or managing employer related paperwork; Participating in Financial Management Services (FMS) orientation and necessary trainings and interactions with the FMS provider; Developing effective recruiting and hiring techniques; Determining pay rates for workers; Providing or arranging for worker training; Developing worker schedules; Developing, implementing and modifying a back-up plan for services, staffing for emergencies and/or worker absences; Scheduling paid and unpaid supports; Developing effective management and supervision techniques such as conflict resolution; Developing proper procedures for termination of workers in the VF/EA FMS option or communication with the AWC Progress Progress notes should include a detailed summary of Current and outstanding issues; Content/impact of services being billed; Progress (or lack thereof) toward outcomes and actions; and Required follow up. The note shall be at least monthly in any calendar month the service is provided.