FAQs - Medicaid
The FAQ below provides clarification on the requirements for Medicaid Reimbursement for certain nursing services provided to students with disabilities.
- Documentation
- ICD Codes
- Individualized Health Plan (IHP) | Individualized Health Care Plan (IHCP)
- Reimbursement
Documentation
Q: What information must be included in a (Medicaid reimbursable) session note?
A:
- Student’s name
- Specific type of service provided
- Whether the service was provided individually or in a group
- The setting in which the service was rendered (school, clinic, other)
- Date and time the service was rendered (length of session)
- Brief description of the student’s progress made by receiving the service during the session
- Name, title, signature, and credentials of the person furnishing the service and signature/credentials of supervising clinician as appropriate
Q: What must be specified on the student's IEP (Individualized Education Plan)?
A: The phrase "Skilled Nursing Services," "Intermittent Nursing Services," etc. must be listed on the IEP (e.g. Medical Alerts, Related Services, or other Support Services).
Q: Must the specific nursing service or medication be detailed on the IEP?
A: No. The IEP must recommend intermittent nursing services. The actual procedure need not be detailed in order to maintain the confidentiality of the student’s treatment plan and medical records maintained by the school. You should not indicate the name of the medication on the IEP.
Q: Where should protocols, checklists, etc., be kept?
A: In the office of the school nurse who is providing the nursing services indicated on the IEP.
Q: How do substitutes sign the MAR?
A: A sub will need the NPI # in order to sign for any med given etc. Another nurse CANNOT sign for a med someone else gave.
ICD Codes
Q: What are ICD Codes?
A: ICD-10 stands for the International Statistical Classification of Diseases and Related Health Problems, 10th Revision. CMS is switched from ICD-9 to ICD-10 as part of the implementation of the Health Insurance Portability and Accountability Act on 10/1/15. ICD codes are more specific, more clinically accurate, and more logically organized and run to a maximum of 7 characters compared with 5 for the old codes. ICD-10 http://www.cms.gov/Medicare/Coding/ICD10/downloads/ICD-10MythsandFacts.pdf
Q: When must ICD numbers be included in Medicaid claims for SSHSP services?
A: Medicaid claims for SSHSP services must include a valid International Classification of Diseases (ICD) diagnosis code that indicates why the service was provided. The provider is responsible to know the ICD codes that apply to their disciplines and including the ICD-10 code on all written orders and written referrals for SSHSP evaluations and services. If the ICD-10 code is not included in the order, the school district should go back to the ordering provider to obtain it. Support can be obtained from http://www.oms.nysed.gov/medicaid/contacts/
Individualized Health Plan (IHP) | Individualized Health Care Plan (IHCP)
Q: What is an IHP or IHCP?
A: An IHCP is a plan of medical care for a child with health needs. It is not required by law, but is customarily used in nursing practice and is recommended for all students with special health care needs. Schools are eligible to receive Medicaid reimbursement for skilled nursing services for Medicaid eligible students only if an IHCP is part of a student’s cumulative health record and such services are included in the student’s IEP.
Q: Who should create and implement an IHCP?
A: The Registered School Nurse is responsible for the development and implementation of the IHCP.
Q: What medical documents must be on file with the IEP?
A: No documentation is to be kept with the IEP; doing so could violate confidentiality requirements.
Q: What medical documentation should be kept on file with the IHCP?
A:
- Health history/Health notes (there is no requirement for the number of notes).
- Medication log.
- Doctor's orders: orders are required when the student enters school for the first time each school year and when there are any significant changes in the student’s condition or procedure.
- Written protocols for each procedure required for the student
Q: Who maintains the IHCP and Data Sheets?
A: The nurse who provides the services to the individual student is the one who maintains the IHCP and data sheets –s/he has the necessary information for the completion of the forms.
Q: Who writes the IHCP for students in BOCES classes?
A: The Registered Nurse who cares for the student writes the IHCP. When must RNs and LPNs obtain an NPI (National Provider Identifier) number?
Effective January 1, 2012, school supportive health service claims submitted to Medicaid for reimbursement must contain both the billing provider’s NPI and the attending provider’s NPI. LPN's do not need an NPI number. They will bill using the NPI number of the RN under whose direction they practice.
Reimbursement
Q: What is required in order for Medicaid to reimburse for skilled nursing services?
A: A written order signed and dated by a NYS licensed and registered Physician, Nurse Practitioner, or Physician Assistant acting within the scope of their practice.
- The written order is required prior to the initiation of services, and new orders are required when there are any significant changes in the student’s condition.
- The need for skilled nursing must be documented in the IEP.
- The RN should develop an IHCP for the student also.
- The attending and billing providers NPI number must be included on the claim
- The ICD code must be included on the claim
Q: Are mandated health services (e.g. height, weight, screening), Medicaid reimbursable?
A: Routine, mandated health care services are NOT reimbursed except as they apply to the special education-related conditions specified on the IHCP. The IEP must specifically say "nursing services;" the guidelines would be followed (e.g., monitoring height and weight for a student with an eating disorder) and the service could be billed.
Q: May a school district bill for dispensing medications?
A: Yes, if the need to dispense the medication is indicated on the IEP ("nursing service", "nursing services as needed" or "intermittent nursing service") and only if the medication is dispensed by an RN (or LPN if within the scope of the Nurse Practice Act).
Q: May a school district bill for emergency first aid?
A: No. You may only bill for skilled nursing services that are required for a student with a disability to benefit from special education. Do not bill for routine first aid.
Page Updated 5/29/25