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2012 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2. Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.8 Personal Care Services (PCS) (CCP) : 2.8.2 Services, Benefits, and Limitations

PCS is a benefit of CCP for Texas Medicaid clients who are birth through 20 years of age and who are not inpatients or residents of a hospital, in a nursing facility or intermediate care facility for persons with intellectual disabilities (ICF-MR), or in an institution for mental disease. PCS will be denied when billed on the same date of service as an inpatient stay service. The provider may appeal the denied claim with documentation supporting that PCS was performed while the client was not in a hospital setting. PCS are support services provided to clients who meet the definition of medical necessity and require assistance with the performance of activities of daily living (ADLs), instrumental activities of daily living (IADLs), and health-related functions due to a physical, cognitive, or behavioral limitation related to a client’s disability or chronic health condition. PCS are provided by someone other than the legal responsible adult of the client who is a minor child or the legal spouse of the client.
A responsible adult is an individual who is an adult, as defined by the Texas Family Code, and who has agreed to accept the responsibility for providing food, shelter, clothing, education, nurturing, and supervision for the client. Responsible adults include, but are not limited to, biological parents, adoptive parents, foster parents, guardians, court-appointed managing conservators, and other family members by birth or marriage.
PCS are those services that assist eligible clients in performing ADLs, IADLs, and other health-related functions. The scope of ADLs, IADLs, and health-related functions includes a range of activities that healthy, nondisabled adults can perform for themselves. Typically, developing children gradually and sequentially acquire the ability to perform these ADLs, IADLs, and health-related functions for themselves. If a typically developing child of the same chronological age could not safely and independently perform an ADL, IADL, or health-related function without adult supervision, then the client’s responsible adult ensures that the client’s needs for the ADLs, IADLs, and health-related functions are met.
PCS include direct intervention (assisting the client in performing a task) or indirect intervention (cueing or redirecting the client to perform a task). ADLs, IADLs, and health-related functions include, but are not limited to, the following:
Application/maintenance of prosthetics and orthotics
Reporting as to the client’s condition, including changes to the client’s condition or needs and completing appropriate records
Skin care — maintenance of the hygienic state of the client’s skin under optimal conditions of cleanliness and comfort
* Medical transportation includes the coordination of transportation to medical appointments and accompaniment to appointments. PCS does not include the payment for transportation or transportation vehicles since these services are available through the MTP.
Exercise and range of motion are not available through PCS, but are services that could be provided through physical therapy, private duty nursing, or home health skilled nursing.
PCS do not include the following:
ADLs, IADLs, or health-related functions that a typically developing child of the same chronological age could not safely and independently perform without adult supervision.
Services that provide direct intervention when the client has the physical, behavioral, and cognitive abilities to perform an ADL, IADL, or health-related function without adult supervision.
PCS is considered for reimbursement when providers use procedure code T1019 in conjunction with the appropriate modifier listed in the table below. PCS provided by a home health agency or PAS-only provider, including PCS being provided under the SRO defined in 40 TAC Part 1, Chapter 41, must be billed in 15‑minute increments. PCS provided by a consumer-directed services agency (CDSA) under the consumer directed services (CDS) option defined in 40 TAC Part 1, Chapter 41, must submit the attendant fee in 15‑minute increments. CDSAs must bill the administration fee once per calendar month per client for any month in which the client receives PCS under the CDS option and regardless of the number of PCS units of service the client receives under the CDS option during the month. PCS claims are considered for reimbursement only when TMHP has issued a valid PAN to a PCS provider.

Texas Medicaid & Healthcare Partnership
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