Use this form for new codes. Be sure to revise the form as appropriate. 154/159

Item No.

PROGRAM: MPC Services EFF. DATE: 09/01/01

35 SERVICE NAME: MPC RN Delegation

36 SERVICE CODE: 4560

SERVICE DESCRIPTION: Payment to a registered nurse or an agency employing registered nurses for Nurse Delegation services as provided to a MPC client residing in an adult family home. The nurse or agency is under contract with Aging and Disability Services Administration (AASA) as provided under RCW 18.79.260 and RCW 18.88A.210-230. This includes initial nursing assessment, reassessment, teaching or supervising a nursing assistant and related travel time and collateral contacts.

17/26 RECIPIENT STATUS: CHILD ADULT

PRIMARY X

SERVICE X

32/33 MAXIMUM LENGTH OF SERVICE: 3 Months

37 REASON:

CODE TITLE

A Oral/Topical Medication Admin.

B Eye/Ear/Nose Drops Administration

C Blood Sugar Checks (Glucometer)

D Oxygen Administration

E Non-sterile Dressings

F Other

38 OBJECTIVE: None

PAYMENT DATA:

Payment Type: Invoice SOURCE OF FUNDS (Item 31): None 39‑41 Unit of Service: Each (EA)

41 Rate: 7.96

42 Maximum No. of Units: 20

ADDITIONAL DATA:

1. THE MAXIMUM NUMBER OF UNITS THAT CAN BE APPROVED IN A

12 MONTH PERIOD IS 52 (1 unit = 15 minutes; 52 units = 13 hours).

2. Service allocation: 52 units equals 13 hours. This service requires an initial

evaluation/teaching visit which may take 4 hours but subsequent visits may

occur only every other month, and may last only 1 hour each. If 20 units

are authorized for each of the first 3 months, the yearly maximum will be

exceeded in the first 3 months of service. In a usual case, authorize 16

units (4 hours) the first month, then 10 units (2.5 hours) every month

thereafter, unless the RN Delegator indicates subsequent visits require

more time.

3. “Each” on the Unit of Service means 15 minute increments per one unit.

Four units per hour.

4. To exceed the 52 unit maximum in a 12 month period approval must be

received from the Nurse Delegation Program Manager.

5. This service will not prorate for partial month’s service. This

service can not be adjusted retroactively.

6. This service code is used for Nurse Delegation services provided only in an

adult family home setting.

7. Services may include the initial client visit, teaching or supervision of

nursing assistant, reassessment of client and related travel time and

collateral contacts.

8. Collateral contacts may include time spent on telephone calls to health care

provider, pharmacist, family members, case managers, etc.

9. Reason Codes reflect possible reasons the client may need nurse

delegation and are not all inclusive. Other tasks may be delegated at the

discretion of the registered nurse delegator.

10. In no instances may the following tasks be delegated:

A) Administration of medications by injection

B) Sterile procedures, including dressings

C) Maintenance of a central intravenous line.

11. Leave items 12-16 blank. Invoices and warrants go to the provider.

12. The department will send a 1099 wage statement to providers paid $600.00

or more in the year.