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Effective for dates of service on or after October 1, 2021, School Health and Related Services (SHARS) benefits will change for Texas Medicaid.
Overview of Benefit Changes
Major changes to this medical benefit include the following:
- New billable procedure codes for audiology evaluation and management services
- Clarification for Occupational Therapy (OT), Physical Therapy (PT), Speech Therapy (ST), and Audiology Services
- New documentation requirements for all SHARS services
- New documentation requirements for special transportation
A new School Health and Related Services (SHARS) Handbook will also be created for the Texas Medicaid Provider Procedures Manual.
Providers may refer to the following articles for information about additional changes that will be effective October 1, 2021:
- “SHARS – Updates to Interim Claiming and Cost Reporting Requirements for SHARS PT, OT, ST, and Audiology Services," which was published on this website August 13, 2021.
- "SHARS Updates to Audiology Services Under Section 504 Plan," which was published on this website August 13, 2021.
The following information about provider referrals for Audiology Services will be added:
- A referral from a physician or another eligible referring provider is required for Audiology Services. The referral must be signed and dated within three calendar years before the initiation of services and must be updated a minimum of once every three calendar years.
- Audiologists whose evaluations serve as the referral must be enrolled in Medicaid as individual practitioners and must use their individual National Provider Identifier (NPI) for claim submission.
- The school district must maintain the referral in the client’s record.
New SHARS Audiology Procedure Codes
The following procedure codes will be a benefit for SHARS providers when services are provided in the office, home, or other location (e.g., school) setting:
|Procedure Code||Therapist||Student Plan|
|92553 with modifier TM||Licensed audiologist||Individualized Education Program (IEP)|
|92553 with modifier U4||Licensed audiologist||Section 504|
|92556 with modifier TM||Licensed audiologist||IEP|
|92556 with modifier U4||Licensed audiologist||Section 504|
|92557 with modifier TM||Licensed audiologist||IEP|
|92557 with modifier U4||Licensed audiologist||Section 504|
|92592 with modifier TM||Licensed audiologist||IEP|
|92592 with modifier U4||Licensed audiologist||Section 504|
|92593 with modifier TM||Licensed audiologist||IEP|
|92593 with modifier U4||Licensed audiologist||Section 504|
|92621 with modifier TM||Licensed audiologist||IEP|
|92621 with modifier U4||Licensed audiologist||Section 504|
Note: Services provided to students under the Section 504 plan are pending Centers for Medicare & Medicaid Services (CMS) approval.
Audiometry procedure codes 92553 and 92556 are each limited to one per day, any provider. These services include testing of both ears. Audiologists must use modifier 52 to indicate reduced services if a test is applied to only one ear.
Hearing aid check (one ear) procedure code 92592 will be denied if submitted for the same date of service as hearing aid check (two ears) procedure code 92593.
The maximum billable time for audiology evaluation (each additional 15 minutes) procedure code 92621 is one hour.
Audiology Procedure Code Updates
Procedure code 92620 must be submitted with modifier TM for services provided to clients with an IEP, or with modifier U4 for services provided to clients with a Section 504 plan. The maximum billable time for audiology evaluation procedure code 92620 is one hour. Procedure code 92620 will be limited to one per day, any provider.
An audiology evaluation (procedure codes 92620 and 92621) will be denied if submitted for the same date of service as audiology therapy (procedure codes 92507 and 92508).
PT, OT, and ST Therapy
The following information about care coordination for PT, OT, and ST services will be added:
- Care coordination between SHARS PT, OT, and ST providers and non-SHARS PT, OT, and ST providers is strongly encouraged to reduce or avoid duplication of services.
- Care coordination requires parental consent and must be carried out in a manner that complies with privacy and confidentiality requirements in accordance with state and federal law and regulations including Health Insurance Portability and Accountability Act (HIPAA) and Family Educational Rights and Privacy Act (FERPA).
Physical and Occupational Therapy
The following information about prescriptions for PT and OT services will be added:
- A prescription from a physician or other eligible prescribing provider is required for PT and OT services. The prescription must be signed and dated within three calendar years before the initiation of services and must be updated a minimum of once every three calendar years.
- A prescription is defined as a written order for services from the ordering physician or other eligible prescribing provider.
- PT and OT services may be reimbursed up to (but not to exceed) the amount designated in the prescription.
- The Local Education Agency (LEA) must maintain the prescription in the client’s record.
The following information about provider referrals for ST services will be added:
- A referral from a physician or other eligible referring provider is required for ST services. The referral must be signed and dated within three calendar years before the initiation of services and must be updated a minimum of once every three calendar years.
- A referral is defined as a written document requesting evaluation for services (such as ST or Audiology) from the referring physician or other eligible referring provider.
- Speech therapists whose evaluations serve as the referral must be enrolled in Medicaid as individual practitioners and must use their individual NPI for claim submission.
- The school district must maintain the referral in the client’s record.
The following information about co-treatment for PT, OT, and ST services will be added:
- Co-treatment is defined as two different therapy disciplines performing therapy on the same client at the same time by a licensed therapist.
- PT, OT, or ST services that are prescribed in the student's IEP may be reimbursed when delivered as co-treatment.
- Providers should document in the session notes the reason for co-treatment. Multi-disciplinary team evaluations performed collaboratively with any combination of PT, OT, or ST, and psychology may be billed by each provider when performed during overlapping time periods.
- Co-treatment is defined as two different therapy disciplines performing therapy on the same client at the same time by a licensed therapist and rendered in accordance with the Executive Council of Physical Therapy and Occupational Therapy Examiners and State Board of Examiners for Speech-Language Pathology and Audiology.
The following information about re-evaluation requirements for SHARS services will be added:
- Individuals with Disabilities in Education Act (IDEA) requires that a student receiving SHARS services must have a re-evaluation every three years, which requires current information, unless the parent and the LEA agree that a re-evaluation is unnecessary (IDEA §1414 (a)(2)(B)). The need for a re-evaluation should be determined by the student’s ARD (Admission, Review, and Dismissal Committee) or 504 plan committee.
- A physician’s prescription or referral is not required specifically for a re-evaluation, provided the prescription or referral for services has occurred in the previous 3 years.
The following documentation requirements will be added:
Documentation of services should be generated at the time of service, or shortly thereafter, to maintain an accurate medical record. Documentation of services must occur within 1 week (7 days) of the time the service is rendered.
The following service log documentation is required for all SHARS services (including audiology evaluation and management services covered under Section 504 plans):
- Student’s name
- Student’s date of birth
- Student’s Medicaid identification number on every page of the chart/record/note
- Date of service, including the following for each date of service:
- Billable start and stop time
- Total billable minutes
- Student observation
- Procedure code(s)
- Activity performed; documentation of service provided must support the services billed
- The SHARS provider’s printed name, title, and original handwritten signature or electronic signature
Service providers are expected to perform and document evaluations in accordance with discipline-specific standards of practice and retain records in the student’s file.
Session notes are required for therapy (audiology, OT, PT, ST, and counseling), and must include all elements of a service log in addition to the following:
- Student’s progress towards goals (if applicable)
- Note whether the service was provided individually or in a group
- The related IEP objective
Note: Any e-signature technologies that are used must comply with all federal and state statutes and administrative rules.
The following requirements for special transportation trip logs will be added:
Trip logs must be maintained daily to record one-way specialized transportation trips. This documentation must include the number of one-way trips per day and the time for each trip (can be indicated using AM/PM). At a minimum, trip logs should also include the following:
- Name of the LEA
- Route name or number
- Bus driver’s name
- Bus aid or bus monitor aid name (if applicable) and initials for each one-way trip
- Date of service and day of the week
- If a service is not provided on a school day, Monday-Friday, mark the student as absent
- Copy of the school district’s calendar (to be submitted once during the annual desk review)
- Indication if a bus aid or monitor was needed
- Schools may only bill for a bus aid/monitor if this service is prescribed in the child’s IEP
- If personal care services are provided on the bus, documentation of the type of personal care service (type of activity and group/individual) that was performed must be included
- Student’s full name, and Medicaid number
- If the Medicaid number is not in the log, a separate ledger detailing student name, date of birth, and Medicaid status and number must be provided
- Dated signature of the bus driver and bus aid/monitor (if applicable)
- Dated signatures should be captured after all trips have been documented
Reminder: LEAs must adhere to all HIPAA and FERPA guidelines when documenting and submitting special transportation logs.
The following additional documents must be collected and maintained by the LEA:
- Written agreements (contracts) for contracted service providers
- Copies of signed Certification of Funds (COF) letters and supporting documentation, including quarterly COF reports
- E-signature authorization forms, if applicable
Refer to: The current Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, subsection 3.4.1, “Record Retention,” for a list of additional documents that must be collected and maintained.
New Provider Manual Handbook
The current Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, section 3, “School Health and Related Services (SHARS),” will be replaced by the Texas Medicaid Provider Procedures Manual, School Health and Related Services (SHARS) Handbook.
For more information, call the TMHP Contact Center at 800-925-9126.