Personal Care Services

EPSDT

Louisiana Healthcare Connections provides Early and Periodic Screening, Diagnosis and Treatment (EPSDT) for its members who are younger than 21 years. Personal Care Services (PSC) are defined as medically necessary services pertaining to a member’s EPSDT-eligible physical requirements when physical limitations due to illness or injury necessitate assistance with eating, bathing, dressing, personal hygiene, bladder or bowel requirements, and preventing institutionalization as well as enabling the member to be treated on an outpatient basis rather than an inpatient basis and to the extent PCS provided on an outpatient basis are projected to be more cost effective than PCS provided on an inpatient basis.

Overview

PCS are provided in-home for members with chronic or stable conditions and within the following parameters:

  1. Must be included in an approved EPSDT–PCS Plan of Care completed by the provider, approved by the physician and accompanied by a physician’s prescription and Form 90.
  2. Must meet medical necessity criteria equivalent to Intermediate Care Facility 1 (ICF-1) level of care and member must be impaired in at least two daily living tasks.
  3. Must include and support the performance of direct care services and not provided solely through oversight or supervision. In addition, EPSDT–PCS are not to be provided to meet child care needs nor as a parental substitute in the absence of the parent. EPSDT–PCS are not allowed for the purpose of providing respite care for the primary care giver.
  4. Must maintain or increase the functional capacity of the member.
  5. Must be provided by a qualified individual who is not part of the member’s family or household.
  6. Must be unable to be provided by other resources.
  7. Must have Prior Authorization for periods of six (6) months at a time.

Included Services

Basic Personal Care

Care related to a member’s physical requirements for activities of daily living and as required for the health and maintenance of the member only. Examples of basic personal care include:

  • Assisting a member with eating, bathing, dressing, personal hygiene or toileting.
  • Assisting a member to and from a bed, wheelchair, walker or chair.
  • Performing housekeeping chores such as meal preparation, bed making, dusting and vacuuming/cleaning of the area occupied by the member.
  • Accompanying a member to medical appointments. NOTE: Transporting a member to medical appointments is not allowed under EPSDT–PCS.

Excluded Services

The following services are not appropriate EPSDT–PCS and are not reimbursable:

  • Insertion and sterile irrigation of catheters. NOTE: Changing of a catheter bag is allowed.
  • Irrigation of any body cavities requiring a sterile procedure.
  • Application of a dressing involving prescription medication and aseptic techniques, including care of mild, moderate or severe skin problems.
  • Administration of injections of fluid into veins, muscles or skin.
  • Administration of medicine (as opposed to assisting with self-administered medication for an EPSDT-eligible older than 18 years).
  • Cleaning of floor and furniture in an area not solely occupied by the recipient.
    Example: Cleaning entire living area if the recipient occupies only one room or an area shared with other household members.
  • Laundry not incidental to the care of the recipient.
    Example: laundering of clothing and bedding for the entire household as opposed to laundering of the recipient’s clothing or bedding.
  • Shopping for groceries or household items other than items required specifically for the health and maintenance of the recipient and not for items used by the rest of the household.
  • Skilled nursing services as defined in the state Nurse Practices Act, including medical observation, recording of vital signs, teaching of diet and/or administration of medications/injections or other delegated nursing tasks.
  • Teaching a family member or friend how to care for a recipient who requires frequent changes of clothing or linens due to total or partial incontinence for which no bowel or bladder training program for the recipient is possible.
  • Specialized nursing procedures such as:
    • Insertion of nasogastric feeding tube
    • In-dwelling catheter
    • Tracheotomy care
    • Colostomy care
    • Ileostomy care
    • Venipuncture
    • Injections
  • Rehabilitative services such as those administered by a physical therapist.
  • Teaching a family member or friend techniques for providing specific care.
  • Palliative skin care with medicated creams and ointments and/or required routine changes of surgical dressings and/or dressing changes due to chronic conditions.
  • Teaching of signs and symptoms of disease process, diet and medications of any new or exacerbated disease process.
  • Specialized aide procedures such as:
    • Rehabilitation of the recipient (exercises or performance of simple procedures as an extension of physical therapy services).
    • Measuring/recording recipient’s vital signs (temperature, pulse, respiration and/or blood pressure, etc.), intake/output of fluids.
    • Collection of specimens.
    • Special procedures such as non-sterile dressings, special skin care (non-medicated), decubitus ulcers, cast care, assisting with ostomy care, assisting with catheter care, testing urine for sugar and acetone, breathing exercises, weight measurement or enemas.
  • Home IV therapy.
  • Custodial care or provision of only instrumental activities of daily living tasks or provision of only one activity of daily living task.
  • Occupational therapy.
  • Speech pathology services.
  • Audiology services.
  • Respiratory therapy.
  • Personal comfort items.
  • Durable medical equipment.
  • Administration of Oxygen.
  • Orthotic appliances or prosthetic devices.
  • Drugs provided through the Louisiana Medicaid pharmacy program.
  • Laboratory services.
  • Social work visits.

Authorization Protocols (Initial and Subsequent)

PCS authorizations will be approved for a maximum of 180 days (6 months) at a time. A unit of PCS is 15 minutes of direct service to the member. Time spent for travel, lunch, breaks or administrative activities such as completing reports or paperwork shall not be included. The following documentation is required for Prior Authorization (PA) or reauthorization of PCS.

  1. Physician’s referral for PCS. Services must be prescribed initially and subsequently every 180 days (6 months) or when changes in the Plan of Care occur.
    • The prescription does not have to specify the number of hours being requested but must specify PCS and not a Personal Care Attendant (PCA).
    • The physician signature must be original or electronic, not rubber stamped.
    • Signatures by nurse practitioners and registered nurses on referrals are not accepted.
  2. Plan of Care prepared by the PCA agency with physician approval. NO SERVICES may be initiated or changed prior to approval by Louisiana Healthcare Connections.
    • Plan of Care must be completed in its entirety and include the tasks to be provided, frequency and duration of those tasks as well as total number of hours per day and week needed to perform the tasks.
  3. EPSDT–PCS Form 90
    • Completed by the attending physician within the last 90 days
    • To include documentation that recipient requires/would require institutional level of care equal to an Intermediate Care Facility 1,
    • Must document that a face-to-face assessment was made.
  4. EPSDT–PCS Social Assessment Form
    • Specifies the personal care activities which the parent or other caregiver is providing and requires assistance with,
    • States the reason parent cannot provide the assistance.
  5. EPSDT–PCS Daily Schedule Form
    Guidelines for these services are outlined in the Louisiana Medicaid Personal Care Services Manual as referenced below.

Authorizations are not transferable between agencies. PCS recipients have the right to change providers at any time. However, the current agency must notify Louisiana Healthcare Connections of a recipient’s discharge and the new agency must obtain their own PA using the standard PA process.

Hours approved cannot be “saved” for another week or “banked” for future use. EPSDT–PCS are not subject to service limits. The units of service approved shall be based on the physical requirements of the recipient and medical necessity for the covered services in the program as delineated in the physician’s assessment documented on EPSDT-PCS Form 90.

The rules governing EPSDT–PCS care are outlined in the State Provider Manual and may be accessed at the following link: http://www.lamedicaid.com/provweb1/Providermanuals/manuals/PCS/pcs.pdf.

  • The clinical decision process begins when a request for PA of services is received by Louisiana Healthcare Connections.
  • Upon verification of receipt of required documentation, the standard PA process is followed.
  • To support the utilization review decision-making process, clinical information relevant to the case—along with the rationale used to make the clinical decision—is documented consistently and accurately.

REQUIRED FORMS

Coding Implications

The following code(s) are for informational purposes only. Inclusion or exclusion of any code(s) does not guarantee coverage.

Procedure Code(s) Description

T1019-EP EPSDT – Personal Care Services