Nursing Visit Guide

Provider Type(s) for Which These Instructions Apply	Program(s) for Which These Instructions Apply
Assisted Living Providers Home Care Providers Case Management Providers Private Duty Nursing Providers	All Programs

This guide is designed to help users determine the appropriate code to use for nursing visits on ADvantage Waiver, Medically Fragile Waiver, Living Choice, and State Plan Personal Care (SPPC), while also highlighting key compliance considerations.

Table of Contents

1. Quick Rules
2. Waiver Visit Code Table
3. State Plan Personal Care (SPPC) Visit Code Table
4. Skilled Nursing Services (G0299 / G0300)
5. Home Care Transfers for G0299/G0300
6. Assisted Living
7. Additional Information
8. Example Visit Schedules

1. Quick Rules 

• RN must perform all Interdisciplinary Team (IDT) and supervisory assessment visits. 
• All IDT and supervisory visits must be billed under T1002.  
• Home Care Providers shall follow instructions for “Request for Additional HC T1002 Units” to submit a request for additional T1002 Units when the number of units requested exceeds the Units Allowed Per Visit listed on the Waiver Visit Code Table.
• When the Nurse Evaluation is saved in a status of ‘Complete,’ a tickler will automatically be sent to the Case Manager listed on the Division tab of the Member record. This tickler serves as the official notification to the Case Manager that the Nurse Evaluation has been completed; a separate case note is not required.

2. Waiver Visit Code Table 

ADvantage Waiver, Medically Fragile Waiver, and Living Choice 

Type of Visit	Code	RN vs LPN	Units Allowed Per Visit	Comments
New Member Initial Assessment (IDT)	Use T1002 OR for MFW Transitional Visits use T1002:U3.	RN Only	7 per visit standard. Up to 8 with appropriate documentation.	MSU will notify the CM if transitional CM units needs to be used for the new MFW Member.
Transfer Member Initial Assessment (IDT)	T1002	RN Only	5 per visit standard. Up to 8 with appropriate documentation.
Annual Reassessment (IDT)	T1002	RN Only	5 per visit standard. Up to 8 with appropriate documentation.
6-Month Supervisory Assessment	T1002	RN Only	5 per visit standard. Up to 8 with appropriate documentation.	Required every 6 months for all Members. *6 months is counted from previous 6-month supervisory assessment visit. **If the Member is receiving T1019 services the PCA is required to be present annually during the supervisory visit. If the Member is receiving T1019:TF the ASR is required to be present every 6-months during the supervisory visit.
General Health Evaluation of ASR Member (Traditional Home Care Member)	G0299 or G0300	RN or LPN	Up to 5 per visit.	Required every 3 months for all Members with ASR (T1019:TF) authorized on their plan. *3 months is counted from previous 3-month General Health Evaluation of ASR Member visit. Monitors the Member to ensure ASR services are meeting Member needs and is NOT a supervisory visit of the ASR. When completed during the 6-month supervisory assessment or Annual Reassessment, the General Health Evaluation for an ASR Member is billed under T1002.
General Health Evaluation of APSA Member (CDPASS / Self-Direction Member)	G0299 or G0300	RN or LPN	Up to 5 per visit.	Required every 3 months for all Members with APSA (S5125:TF) authorized on their plan. *3 months is counted from previous 3-month General Health Evaluation of APSA Member visit. Monitors the Member to ensure APSA services are meeting Member needs and is NOT a supervisory visit of the APSA. When completed during the 6-month supervisory assessment or Annual Reassessment, the General Health Evaluation for an ASR Member is billed under T1002.
Skilled Nursing Visit	G0299 or G0300	RN or LPN	Up to 5 units per visit	See section 4 for additional information regarding tasks allowed under Skilled Nursing AND section 5 for information regarding authorization start dates.  Medical Order is required for this service.
EM – Level of Function Assessment / Verification of Service Delivery	T1002	RN Only	Up to 5 units per visit.   10 units authorized: 5 each for Level of Function and Verification of Service Delivery.	A Nurse Evaluation Document is not required. The Nurse will complete the appropriate Level of Function / Verification Document.
Participation in Safety Agreement / Negotiated Risk IDT	T1002	RN Only	5 per visit standard. Up to 8 with appropriate documentation.	Required when not completed at the time of the initial or reassessment IDT. This additional IDT must be held to review and complete the documentation with the Member.
Private Duty Nursing (MFW or LC Only)	T1000	RN or LPN	Per the Plan of Care	Medical Order is required for this service.
Expanded State Plan Nursing (ADvantage Only)	G0299:TF / G0300:TF	RN or LPN	Up to 5 units per visit	Authorization only considered if the Member does not have Medicare AND TXIX has issued a denial.  Medical Order is required for this service.  See section 6 for information regarding “Medicaid TXIX Skilled Nursing Benefits”.
Assessment or IDT due to Significant Change in Condition	T1002	RN Only	5 per visit standard. Up to 8 with appropriate documentation.

3. State Plan Personal Care (SPPC) Visit Code Table 

Type of Visit	Code	RN vs LPN	Units Allowed	Comments
New Member Initial Assessment	T1001	RN Only	T1001 is a per visit code and does not require prior authorization. 5 visits allowed per rolling 12-month period.
Transfer Member Initial Assessment	T1001	RN Only	T1001 is a per visit code and does not require prior authorization. 5 visits allowed per rolling 12-month period.
Annual Reassessment	T1001	RN Only	T1001 is a per visit code and does not require prior authorization. 5 visits allowed per rolling 12-month period.
6-Month Supervisory Assessment	T1001	RN Only	T1001 is a per visit code and does not require prior authorization. 5 visits allowed per rolling 12-month period.
Assessment due to Request for Change in Units	T1001	RN Only	T1001 is a per visit code and does not require prior authorization. 5 visits allowed per rolling 12-month period.

4. Skilled Nursing Services (G0299 / G0300) 

The following tasks may be completed under skilled nursing services. This list also includes the eligibility requirements for each task. 

ADvantage Waiver 

• Filling insulin syringes for a visually impaired diabetic who can self-inject the medication but cannot fill his own syringe. Includes monitoring the Member’s continued ability to self-administer insulin. 
• Setting up oral medications in divided daily compartments for a Member who self-administers prescribed medications but needs assistance and monitoring due to disorientation/confusion, visual deficit, limited mobility, or other limitations. 
• Monitoring a Member’s skin condition when at risk of skin breakdown due to immobility or incontinence, or when the Member has a chronic impairment of skin integrity requiring maintenance care and assessment. 
• Conducting general health evaluations. 
• Providing nail care for a Member with diabetes, circulatory, neurological, vision, cognitive, or mobility deficits. 
• On-the-job training and competency testing for Advanced Supportive/Restorative Assistants. Note: Training is to be done by RN’s.  

Additional Skilled Nursing Services

For ADvantage Members, skilled tasks not otherwise listed may be considered under G0299:TF/G0300:TF when the applicable requirements below are met.

• Medicaid-Only Members:
  • If the task is a skilled task covered by SoonerCare/Title XIX (TXIX), the Member should receive the task through a Medicaid Home Health Agency.
  • The first 36 visits may be provided without prior authorization. Visit 37 and beyond require prior authorization from OHCA.
  • If the Member has used all 36 visits and a denial is received for the 37th visit, the TXIX denial may be submitted along with the physician’s order for consideration of the task under ADvantage.
  • If the task is not considered a skilled task covered by TXIX, but the task is required to be performed by a nurse and is custodial in nature, documentation from a Medicaid Home Health Agency stating that the task does not meet TXIX service criteria may be submitted along with the physician’s order for consideration of the task under ADvantage.
• Medicare Members:
  • If the task is a skilled task covered by Medicare, the member should receive the task through a Medicare Home Health Agency.
  • If the task is not considered a skilled task covered by Medicare, but the task is required to be performed by a nurse and is custodial in nature, documentation from a Medicare Home Health Agency stating that the task does not meet Medicare service criteria may be submitted along with the physician’s order for consideration of the task under ADvantage.

Obtaining Required Documentation:

• The Case Manager should obtain the required documentation from a Medicare or Medicaid Home Health Agency, as applicable.

Medically Fragile Waiver 

• Filling a one-week supply of insulin syringes for a blind diabetic who can self-inject but cannot fill his own syringe. Includes monitoring the patient’s continued ability to self-administer insulin. 
• Setting up oral medications in divided daily compartments for a Member who self-administers but needs assistance and monitoring due to a minimal level of disorientation or confusion. 
• Monitoring a Member’s skin condition when at risk of skin breakdown due to immobility or incontinence, or when the Member has a chronic stage II decubitus requiring maintenance care and monitoring. 
• Conducting general health evaluations. 
• Providing nail care for the diabetic Member or Member with circulatory or neurological deficiency. 
• On-site visit to each Member for whom Personal Care or Advanced Supportive/Restorative Care is authorized to evaluate the Member’s condition. A visit report is made to the case manager. Frequency is determined by the individual service plan and occurs no less often than every 6 months. 
• Member-specific training and competency testing for Advanced Supportive/Restorative Assistants. Note: Training is to be done by RN’s.  5. Authorization Start Dates (G0299/G0300) 
• Start Date for request on plan 1 OR 1^st authorization for the service code regardless of plan year: 
• Date that the Medicaid Services Unit (MSU) creates the authorization 
• Start Date for plan 2 (and forward) if code was authorized on prior plan: 
• If the order contains the plan year dates, the start date will be the first day of the plan. 
• If the order does not contain the plan year dates, the physician’s signature date will be used, or the plan start date will be used if the signature date is prior to the plan start date. 

Note: The order is good for 1 year from the date of the physician’s signature.  If G0299 or G0300 is already authorized for the plan year, the additional units will be added to the existing authorized planned service line, and a comment note will be entered detailing the added units. A duplicate authorization will not be created. 

5. Home Care Transfers for G0299/G0300

When transferring a Member to a new Home Care provider for existing Skilled Nursing services (G0299/G0300) requiring a physician’s order:

• Existing Skilled Nursing services will not be ended until the new home care provider has obtained an order for Skilled Nursing.
  • It is the responsibility of the new Home Care provider to obtain the physician’s order for Skilled Nursing services.
  • Neither the existing Home Care provider nor the Case Manager may obtain the physician’s order for the new Home Care agency.
• The outgoing provider should continue to provide services to the Member to ensure there is no break in service.
• Once the new provider has submitted the physician’s order:
  • The new provider will be authorized to begin providing services on Monday following the date of processing by MSU. The existing provider authorizations will end the Sunday before.
  •  This process will help to avoid any break or overlap in service.
• If the Home Care provider selected by the Member does not have staff to provide needed G0299/G0300 skilled nursing services, an alternate provider may be selected.
  • In other words, the Home Care provider and the Skilled Nursing provider do not have to be the same agency except for supervision of Personal Care/ASR Assistants.

6. Assisted Living

Services provided in an Assisted Living setting are authorized and billed differently from traditional home care services. Instead of billing individual service codes, Assisted Living services are authorized and reimbursed using a daily rate. Separate nursing service codes are not billed for Members residing in Assisted Living.

The Assisted Living RN is responsible for completing the following assessments and visits for Members residing in Assisted Living:

• New Member Initial Assessment (IDT)
• Annual Reassessment (IDT)
• Six-Month Supervisory Assessment
• Assessment or IDT due to a Significant Change in Condition

7. Additional Information

SoonerCare (Medicaid) TXIX Skilled Nursing Benefits

SoonerCare (Medicaid)-only Members can obtain skilled nursing services, such as wound care and blood draws, under their TXIX benefit.

• Up to 36 visits per calendar year may be provided without prior authorization.
• Visit 37 and beyond requires prior authorization submitted to OHCA.
• Code 551 is used for TXIX skilled nursing visits.
• Refer to OHCA Guidelines: Additional Home Health Visit(s).

Significant Change in Condition During the Plan Year

If the Member has a significant change in condition during the plan year and the Case Manager identifies that the personal care allotment tool/personal care worksheet will have task or frequency changes that increase the T1019, T1019:TF, S5125, or S5125:TF weekly units, the following actions are required:

• The CM must update the UCAT and personal care allotment tool/personal care worksheet, as appropriate.
• The CM must notify the Home Care RN, by phone and/or Harmony Case Note, regarding all plan changes related to the service codes listed above.
• If there is an increase of 16 units or more per week for any of the services listed above, a Nurse Evaluation must be completed by the Home Care RN before the CM submits the change request to MSU.

Note: A decrease in units during the plan year does not require a Nurse evaluation, but the Case Manager must communicate the change with the Home Care Agency, as required with any service change.

New Request for Skilled Nursing, Personal Care or Advanced Supportive/Restorative Services

If a new request for Skilled Nursing services (G0299/G0300), Personal Care services (T1019/S5125), or Advanced Supportive/Restorative services (T1019:TF/S5125:TF) is made during the plan year, the Home Care (HC) Registered Nurse (RN) must complete a Nurse Evaluation before the Case Manager (CM) submits the change request to the Medicaid Services Unit (MSU).

The Nurse Evaluation must include documentation of the Member’s current condition and sufficient clinical information to support the Member’s eligibility for Skilled Nursing services under the waiver. If the request includes the addition of Personal Care or Advanced Supportive/Restorative services, the Nurse Evaluation must also include clinical justification supporting the Member’s need for those services.

Maximum Units Per Day

Per policy, a maximum of eight (8) units per day of nursing may be billed for assessment/evaluation and/or service plan development. These units include assessment and IDT visits and are not considered Skilled Nursing Visits. Assessment and IDT visits must be claimed and billed under T1002.

Note: Eight (8) units represents the maximum allowable amount and is not the standard expectation. It should be used rarely and is not anticipated for the majority of cases. On average, most Nurse visits should utilize five (5) units. If additional units are needed, the Home Care Provider may submit the request following the process in the Harmony Library for “Request for Additional HC (T1002) Units.”

Unit Billing and Time Requirements

Nursing services are prior authorized by the Medicaid Services Unit (MSU) and billed per fifteen (15) minute unit of service. Units are billed according to the amount of time it takes to complete the activity and not for a set number of units to complete specific documents or tasks.

Per policy 317:35-17-22, providers do not bill for services performed for less than eight (8) minutes:

• Less than eight (8) minutes cannot be rounded up and does not constitute a billable fifteen (15) minute unit.
• Eight (8) to fifteen (15) minutes is rounded up and does constitute a billable fifteen (15) minute unit.
• Evidence of paid claims not supported by documentation of service provision is referred to the Oklahoma Health Care Authority (OHCA) Program Integrity Unit for follow-up investigation.

Billing Guidelines

• Nursing visits must be completed in person and in the Member’s home.
• Billing for services provided outside of an in-person visit is limited to obtaining Physician Orders, care coordination, post-visit documentation, and mobile Assessment updates. Units used and billed for these services must be less than the units billed for the corresponding in-person visit.
• If more than one provider is delivering services in the home, each provider is required to complete supervisory visits for the services they are authorized to provide. Example: if two private duty nursing (PDN) providers are authorized to provide T1000 services and those services are delivered by an LPN, both PDN providers are required to complete the applicable supervisory visits.
• If multiple visit types are completed during the same visit, such as a 6-month supervisory assessment and a General Health Evaluation for an ASR Member, the visit should be billed under T1002. If a skilled task, such as filling insulin syringes or setting up oral medications, is also performed during that visit, the time spent on the skilled task should be billed under G0299, while the remaining visit time should be billed under T1002.
• Personal Care cannot be authorized for a date prior to the initial Nurse eval completed by the provider delivering the personal care services.

8. Example Visit Schedules 

New Member:

Has Personal Care (T1019/S5125)

Has ASR/APSA (T1019:TF/S5125:TF)

Does not have Skilled Nursing (G0299/G0300) OR Private Duty Nursing (T1000) provided by an LPN

Visit Type	Frequency	Code Used
New Member Initial Assessment (IDT)	Complete within first 10 business days of receiving new case.	T1002
General Health Evaluation of ASR/APSA Member	Complete every 3 months (counted from initial IDT visit), may be completed in conjunction with other Nurse visits.	G0299 or G0300
6-Month Supervisory Assessment	Complete every 6 months (counted from initial IDT visit)	T1002
Annual Reassessment (IDT)	Complete 30-60 days prior to service plan end date.	T1002

Initial Units authorized would include 17 units for T1002 and 10 units for G0299 and G0300. Additional Units may be requested by the Home Care Provider, as appropriate.

Existing Member:

Has Personal Care (T1019/S5125)

Has ASR/APSA (T1019:TF/S5125:TF)

Does not have Skilled Nursing (G0299/G0300) OR Private Duty Nursing (T1000) provided by an LPN

Visit Type	Frequency	Code Used
General Health Evaluation of ASR/APSA Member	Complete every 3 months (counted from previous General Health Evaluation visit), may be completed in conjunction with other Nurse visits.	G0299 or G0300
6-Month Supervisory Assessment	Complete every 6 months (counted from previous 6-month supervisory assessment)	T1002
Annual Reassessment (IDT)	Complete 30-60 days prior to service plan end date.	T1002

Initial Units authorized would include 10 units for T1002 and 10 units for G0299 and G0300. Additional Units may be requested by the Home Care Provider, as appropriate.

---

New Member:

Has Personal Care (T1019/S5125)

Has Skilled Nursing (G0299/G0300) OR Private Duty Nursing (T1000) provided by an LPN

Does not have ASR/APSA (T1019:TF/S5125:TF)

                  OR

New Member:

Has Skilled Nursing (G0299/G0300) OR Private Duty Nursing (T1000) provided by an LPN

Does not have Personal Care (T1019/S5125)

Does not have ASR/APSA (T1019:TF/S5125:TF)

Visit Type	Frequency	Code Used
New Member Initial Assessment (IDT)	Complete within first 10 business days of receiving new case.	T1002
6-Month Supervisory Assessment	Complete every 6 months (counted from Initial IDT visit)	T1002
Annual Reassessment (IDT)	Complete 30-60 days prior to service plan end date.	T1002

Initial Units authorized would include 17 Units for T1002. Additional Units may be requested by the Home Care Provider, as appropriate.

Existing Member:

Has Personal Care (T1019/S5125)

Has Skilled Nursing (G0299/G0300) OR Private Duty Nursing (T1000) provided by an LPN

Does not have ASR/APSA (T1019:TF/S5125:TF)

                  OR

Existing Member:

Has Skilled Nursing (G0299/G0300) OR Private Duty Nursing (T1000) provided by an LPN

Does not have Personal Care (T1019/S5125)

Does not have ASR/APSA (T1019:TF/S5125:TF)

Visit Type	Frequency	Code Used
6-Month Supervisory Assessment	Complete every 6 months (counted from previous 6-month supervisory assessment)	T1002
Annual Reassessment (IDT)	Complete 30-60 days prior to service plan end date.	T1002

Initial Plan would receive 10 units for T1002. Additional Units may be requested by the Home Care Provider, as appropriate

---

New Member:

Has Personal Care (T1019/S5125)

Does not have ASR/APSA (T1019:TF/S5125:TF)

Does not have Skilled Nursing (G0299/G0300) OR Private Duty Nursing (T1000) provided by an LPN

                  OR

New Member:

Does not have Skilled Nursing (G0299/G0300) OR Private Duty Nursing (T1000) provided by an LPN

Does not have Personal Care (T1019/S5125)

Does not have ASR/APSA (T1019:TF/S5125:TF)

Visit Type	Frequency	Code Used
New Member Initial Assessment (IDT)	Complete within first 10 business days of receiving new case.	T1002
6-Month Supervisory	Complete every 6 months (counted from Initial IDT visit)	T1002
Annual Reassessment (IDT)	Complete 30-60 days prior to service plan end date.	T1002

Initial Units authorized would include 17 Units for T1002. Additional Units may be requested by the Home Care Provider, as appropriate.

Existing Member:

Has Personal Care (T1019/S5125)

Does not have ASR/APSA (T1019:TF/S5125:TF)

Does not have Skilled Nursing (G0299/G0300) OR Private Duty Nursing (T1000) provided by an LPN

                  OR

Existing Member:

Does not have Skilled Nursing (G0299/G0300) OR Private Duty Nursing (T1000) provided by an LPN

Does not have Personal Care (T1019/S5125)

Does not have ASR/APSA (T1019:TF/S5125:TF)

Visit Type	Frequency	Code Used
6-Month Supervisory Assessment	Complete every 6 months (counted from previous 6-month supervisory assessment)	T1002
Annual Reassessment (IDT)	Complete 30-60 days prior to service plan end date.	T1002

Initial Plan would receive 10 units of T1002. Additional Units may be requested by the Home Care Provider, as appropriate

New Member:

Has Personal Care (T1019/S5125)

Has Skilled Nursing (G0299/G0300) OR Private Duty Nursing (T1000) provided by an LPN

Has ASR/APSA (T1019:TF/S5125:TF)

Visit Type	Frequency	Code Used
New Member Initial Assessment (IDT)	Complete within first 10 business days of receiving new case.	T1002
General Health Evaluation of ASR/APSA Member	Complete every 3 months (counted from Inital IDT visit)	G0299 or G0300, T1002 when completed during the 6-month visit.
6-Month Supervisory Assessment	Complete every 6 months (counted from Initial IDT visit)	T1002
Annual Reassessment (IDT)	Complete 30-60 days prior to service plan end date.	T1002

Initial Units authorized would include 17 Units for T1002 and 10 units for G0299 and G0300. Additional Units may be requested by the Home Care Provider, as appropriate.

Existing Member:

Has Personal Care (T1019/S5125)

Has Skilled Nursing (G0299/G0300) OR Private Duty Nursing (T1000) provided by an LPN

Has ASR/APSA (T1019:TF/S5125:TF)

Visit Type	Frequency	Code Used
General Health Evaluation of ASR/APSA Member	Complete every 3 months (counted from previous General Health Evaluation of ASR/APSA Member)	G0299 or G0300, T1002 when completed during the 6-month visit.
6-Month Supervisory Assessment	Complete every 6 months (counted from previous 6-month supervisory assessment)	T1002
Annual Reassessment (IDT)	Complete 30-60 days prior to service plan end date.	T1002

Initial Plan would receive 10 units of T1002 and 10 units for G0299 and G0300. Additional Units may be requested by the Home Care Provider, as appropriate.