MA Billing

PCA services must be supervised by a qualified professional who is operating within their scope of practice (see examples in each section). These qualified professionals are responsible for ensuring that PCAs are trained on the specific needs of the student—as identified in the IEP and written in the PCA Plan of Care (see the section below on 'Services Documentation' for more information about PCA Plans of Care)—display competency in providing the required services, and understand documentation requirements. In order to qualify as a PCA for the purposes of MA billing, paraprofessionals must pass the DHS Individual PCA Training Course and provide the district with a copy of their certificate of completion. Billable PCA services fall under the three categories described below:

Activities of Daily Living (ADLs)

• Eating: Assisting with hand washing, applying orthotics, transfers, food preparation, and feeding.

• Toileting: Assisting with elimination and diapering, transfers, mobility, positioning, feminine hygiene, use of toileting equipment and supplies, cleansing, skin inspection, adjusting clothing, or re-dressing.

• Grooming: Assisting with personal hygiene, basic hair care, oral care, shaving, applying cosmetics and deodorant, or eyeglass and hearing aid care.

• Dressing: Assisting with choosing, applying, or changing clothes; applying orthotics and prosthetics; or special clothing (TED hose).

• Bathing: Assisting with basic personal hygiene and skin care for bathing or showering. This includes transfers, positioning, assisting with soap, rinsing, drying, skin inspection, and applying lotion or other products.

• Transferring: Assisting with moving from one seat/bed to another, using a lift, pivoting. Includes two person lifts and standing by to assist.

• Mobility: Assisting with ambulation. This includes assisting with using a wheelchair, walker, or cane.

• Positioning: Assisting with positioning, repositioning, or turning for necessary care and comfort. This includes relieving pressure areas, positioning with pillows, wedges, or bolsters whether in a chair, bed, sofa, or wheelchair.

Depending on the specific ADL being supported, school personnel who would be qualified to supervise PCAs in this area include, but are not limited to: PTs, OTs, school nurses, and developmental disabilities specialists (e.g., DCD-licensed teachers). The specific ADLs of positioning, transfers, and toileting can be supervised by a PT or school nurse; however, they cannot be supervised by: speech pathologists, audiologists, school psychologists, social workers, or special education teachers because positioning, transfers, and toileting are not considered to be within the scope of practice of those professions.

Health-Related Tasks

Covered services include health-related tasks that do not require the skill of a nurse, such as:

• Assistance with range of motion and passive exercises to maintain muscle function and strength

• Assistance with self-administered medication (e.g., cueing student to take medication, handing the student medication that has been set-up, opening medication, and ensuring that the student takes medication). PCAs do not dispense or administer medication.

• Intervention for seizures including monitoring and observing while the child is having a seizure. Continuous monitoring for seizures is not covered.

• Tracheostomy suctioning and ventilator care. Clean procedures are covered, but PCAs do not provide sterile procedures.

School personnel who would be qualified to supervise PCAs in this area include school nurses.

Observation, Redirection, or Intervention of a Behavior Episode

There are three categories of behavior that require covered services:

• Level 1 Behaviors: Self-injurious behavior, physical aggression towards others, or destruction of property.

  • Behaviors occur at different frequencies, intensities, and in different situations. For PCA services to be billable, the level 1 behavior must be current, and episodes must occur either daily or on an ongoing basis (e.g., four times a week). To qualify for PCA services in this area, the student's behaviors must occur due to a medical or mental health condition.

  • The school can only bill for time when the PCA is fully engaged, working face-to-face or hands-on with the student during episodes that require the immediate response of another person to prevent injury to self, injury to others, or damage to property. The clock can start when the student begins to demonstrate lower-intensity behaviors that typically escalate into level 1 behaviors if, at that point, the PCA begins to implement specific strategies designed to prevent level 1 behavior. For example, for a student who appears agitated, pushes away from his/her desk, and stands up, if a PCA begins using verbal de-escalation strategies and/or begins moving objects away from the student (to prevent property destruction or other level 1 behaviors), the school could count that time for the purposes of billing.

• Increased vulnerability due to cognitive deficits or socially inappropriate behavior (only for students who receive another PCA service (i.e., ADLs)). For example, for a student who is receiving PCA services for toileting who also has a history of elopement during unstructured activities, PCA services that include observation and redirection of behavior would be billable during passing time, recess, and/or lunch.

• Resisting care and verbal aggression that cause care to take longer than normally expected (while receiving another PCA services (i.e., ADLs)). For example, for a student who is receiving PCA services for eating, PCA services that include observation and redirection of behavior would be billable when the student swears at staff and pushes eating materials off their table.

Examples of non-billable/non-covered services include redirection when students are: not staying on task with the lesson plan, not listening to the teacher, speaking out of turn, making comments out loud, or grabbing for other children’s property.

School personnel who would be qualified to supervise PCAs in this area include, but are not limited to: school social workers, school psychologists, and some special education teachers (e.g., EBD-licensed teachers for Level 1 behaviors and DD/DCD-licensed teachers for the other categories described above).

**For specific information and resources related to documenting PCA services (i.e. time studies), refer to the section further down this page, titled "Service Documentation", under PCA Services, under Logging Services.