Based on State Plan Amendment (SPA) 15-021, the Local Educational Agency (LEA) Medi-Cal Billing Option Program (BOP) is adding new procedure codes and modifiers associated with new services and practitioner types. In addition, LEA is updating reimbursement rates and modifying the rate reimbursement methodology for Targeted Case Management (TCM).
Removal of Service Limitations for Non-IEP/IFSP Students
The limit of 24 services per state fiscal year is discontinued for students whose care is not provided pursuant to an Individualized Education Plan (IEP) or Individualized Family Services Plan (IFSP). SPA 15-021 allows covered services to be provided to students as long as treatment services are pursuant to an Individualized Health Support Plan (IHSP) or other care plan, including but not limited to a 504 Plan, nursing plan or health services plan. Care plan requirements are detailed in the Part 2, LEA provider manual section, Local Educational Agency (LEA) Individualized Plans.
Allowable Services Expanded
The following chart details the newly reimbursable LEA services and their corresponding procedure codes. The chart indicates the locator keys of the Part 2, LEA provider manual sections where policy for the new services is located.
||For Information See Provider Manual Section:
|Group physical therapy and group occupational therapy treatment services
||CPT® code 97150
||loc ed serv occu, loc ed serv phy
|Nutritional counseling services
||HCPCS code S9470
||loc ed serv nutri
|Orientation and mobility assessment
||HCPCS code T1023
||loc ed serv orient
|Orientation and mobility treatment services
||CPT code 97533
||loc ed serv orient
|Respiratory therapy assessment
||CPT code 94618
||loc ed serv respir
|Respiratory therapy treatment services
||HCPCS code G0237
||loc ed serv respir
|School health aide services – Assistance with activities of daily living (ADLs)
||CPT code 97535
||loc ed serv nurs
Qualified Rendering Practitioners Expanded
SPA 15-021 adds several new qualified rendering practitioners for LEA services. Practitioners who render the services should be identified on the claim with the following modifiers:
||Modifier Required on Claim
|Associate marriage and family therapists
|Licensed respiratory care practitioners
|Occupational therapy assistants
|Orientation and mobility specialists
|Physical therapist assistants
|Physician assistants (PAs)
|Registered associate clinical social workers
|Speech-language pathology assistants
Provider Manual Updates
The LEA Provider Manual is updated with SPA-related policies. Three new LEA individual-services sections are added:
- Local Educational Agency (LEA) Service: Nutrition
- Local Education Agency (LEA) Service: Orientation and Mobility
- Local Educational Agency (LEA) Service: Respiratory Care
Reimbursement and Billing
The Local Educational Agency (LEA) Billing Codes and Reimbursement Rates manual section includes the state fiscal year 2020 – 2021 maximum allowable interim reimbursement rates, procedure codes and required modifiers necessary to claim for the new SPA 15-021 services/practitioners. Providers should also refer to the provider manual section containing policy for each individual service (for example, nutrition) for details about service limitations, allowable units of service and authorization requirements.
Medi-Cal interim reimbursement rates are determined by applying the Federal Medical Assistance Percentage (FMAP) to the maximum allowable rate, or the rate billed by the LEA, whichever is less, per federal financial participation regulations. The current FMAP is 56.2 percent.
Retroactive Claim Submission
SPA 15-021 has an effective date of July 1, 2015; however, at this time the Department of Health Care Services (DHCS) instructs LEAs not to submit claims for services rendered prior to July 1, 2020. In a forthcoming Policy and Procedure Letter (PPL), DHCS will provide instructions for services rendered July 1, 2015 through June 30, 2020.
Current Claim Submission
As of the date of this publication, LEAs may begin submitting claims for the new SPA 15-021-related services and practitioner types for dates of service on or after July 1, 2020.
State Plan Amendment 16-001: Eligible TCM Population Expanded
Subsequent to the approval of SPA 15-021, DHCS received approval for SPA 16-001, which expands the population of students eligible to receive TCM services beyond those students with an IEP/IFSP. Under SPA 16-001, LEAs may receive reimbursement for general education students who have TCM services identified in an IHSP or other care plan. Additional information about the expanded student population is available in the Part 2, Local Educational Agency (LEA) Service: Targeted Case Management manual section.
If an LEA intends to bill for TCM services through the LEA Program, DHCS will require a TCM certification form for Random Moment Time Survey (RMTS) participants (known as Time Survey Participants, or TSPs) that provide and bill for TCM services under the LEA Medi-Cal Billing Option Program.
The Local Educational Agency Medi-Cal Billing Option Program (LEA BOP) Targeted Case Management (TCM) Certification Statement (DHCS 9137) can be found on the DHCS website (www.dhcs.ca.gov) on the Local Educational Agency Medi-Cal Billing Option Program page. On the “Program Information” web page, providers should click “School Based Claiming Random Moment Time Survey” and then “TCM Certification Form.”
The TCM certification must be completed annually, and updated on a quarterly basis, as part of the RMTS process.
Targeted Case Management services will be processed according to a new rate methodology. LEAs will no longer be reimbursed a low, medium or high rate for TCM claims. All TCM services will be reimbursed at the same rate for all qualified rendering practitioners, in 15-minute increments. TCM claims are billed using HCPCS code T1017.
TCM Qualified Practitioners
The following qualified practitioners are now eligible to bill for TCM services:
- Registered credentialed school nurses (TD)
- Licensed registered nurses (TD)
- Certified public health nurses (TD)
- Certified nurse practitioners (TD)
- Licensed clinical social workers (AJ)
- Credentialed school social workers (AJ)
- Registered associate clinical social workers (HM)
- Licensed psychologists (AH)
- Licensed educational psychologists (AH)
- Credentialed school psychologists (AH)
- Licensed marriage and family therapists (no modifier)
- Associate marriage and family therapists (HL)
- Credentialed school counselors (no modifier)
- Licensed vocational nurses (TE)
- Program specialists (HO)
- Licensed speech-language pathologists (GN) – New per SPA 16-001
- Credentialed speech-language pathologists (GN) – New per SPA 16-001
- Licensed occupational therapists (GO) – New per SPA 16-001
- Licensed physical therapists (GP) – New per SPA 16-001
Physician Assistant Reimbursable Services
The following CPT procedure codes are reimbursable for Physician Assistants (PAs), as approved in SPA 15-021: 92551, 92552, 96150, 96151, 96156, 96158, 96159, 96164, 96165, 99173, 99401 and S9470. Policy related to billing by physician assistants is in the Part 2, Local Educational Agency (LEA) Service: Physician Billable Procedures manual section.
|Local Educational Agency
||loc ed (1–5); loc ed a prov (1–15); loc ed bil (1–10, 12–16); loc ed bil cd (1–47); loc ed bil ex (1–13); loc ed elig (1–3); loc ed indiv (1–4); loc ed rend (1–17); loc ed serv hear (5–8); loc ed serv nurs (1–15); loc ed serv nutri (1–7); loc ed serv occu (1–8); loc ed serv orient (1–6); loc ed serv phy (1–8); loc ed serv physician (1–10); loc ed serv psych (1–13); loc ed serv respir (1–8); loc ed serv spe (4, 16); loc ed serv targ (1–8); loc ed serv vis (1–5); modif app (6, 7, 11, 12, 22, 25)
AIDS Waiver Program
Audiology and Hearing Aids
Chronic Dialysis Clinics
Clinics and Hospitals
Durable Medical Equipment
Home Health Agencies/Home and Community-Based Services
Orthotics and Prosthetics
|modif app (6, 7, 11, 12, 22, 25)