Medical evaluation is the
recording of chief complaints; present illness; family history; past medical
history; personal history; social history; a system review; a complete physical
evaluation; the ordering of appropriate diagnostic tests and procedures; and a
recommended plan of treatment.
To claim for
medical reimbursement, providers must abide by the following:
·
A
school physical scheduled in accordance with Section 903 of the Education Law
may be billed as a medical evaluation under the Medicaid billing code 5310 for
a student suspected of having a disability if the medical examination was used
in the IEP process.
·
The
medical evaluation must have been provided by a NYS licensed and registered
physician, nurse practitioner (according to the Nurse Practice Act) or a
registered physician assistant under the supervision of a NYS licensed
physician.
·
Medical
evaluations must be signed and dated by a NYS licensed and registered
physician, licensed nurse practitioner (according to the Nurse Practice Act) or
a registered physician assistant under the supervision of a NYS licensed
physician.
·
School
districts/§4201 schools/counties must incur a cost for the evaluation in order
to claim Medicaid.
·
The
evaluation must be part of the IEP process.
The
licensure/certification credentials of the professionals should be kept on
file.
Codes and Fees:
|
SSHSP (NYC) Fee |
5301 |
$ 160 |
|
SSHSP (Rest of
State) Fee |
5301 |
$ 130 |
|
PSHSP Individual
& Center based (NYC) Fee |
5310 |
$ 190 |
|
PSHSP Individual
& Center based (Rest of State) Fee |
5310 |
$ 155 |
NOTE: SCHOOL DISTRICTS MAY NO
LONGER CLAIM A MEDICAL EVALUATION FOR A PHYSICIAN'S, NURSE PRACTITIONER’S OR A
REGISTERED PHYSICIAN’S ASSISTANT’S SIGN-OFF ON ALL RELATED SERVICES INDICATED
ON THE STUDENT'S IEP.