ODP Billing Process for Respite Services

ODP Announcement 19-147 serves to clarify the billing process of respite services in a non-residential setting. Respite services are direct services that are provided to supervise and support participants living in private homes on a short-term basis for planned or emergency situations, giving the person(s) normally providing care a period of relief that may be scheduled or due to an emergency. This communication does not apply to services in the Adult Autism Waiver or any services offered by the Bureau of Supports for Autism and Special Populations (BSASP).

The correct procedure code to use for these services depends on the Needs Level of the individual and the site where the respite is provided.

Respite services could be provided as a service at a residential site or in the community under a site enrolled as a Provider Type 51 specialty 513. Services can be provided under this specialty combination in settings such as:

• A residential site such as a private licensed home in Pennsylvania under the 6400, 6500, 3800, 5310 licensure requirements;
• An unlicensed residential Life Sharing home in Pennsylvania;
• A participant’s private home or an unlicensed private home located in Pennsylvania, Virginia, Washington, DC or a state contiguous to Pennsylvania;
• Other private homes, hotels, or rentals during temporary travel in accordance to ODP’s travel policy;
• Camp settings that meet applicable state or local codes; or
• Community settings that maintain the participant’s schedule of activities.

A new billing option has been created for respite services provided in respite-only homes under the 52 / 513 combination:

• The site would be a respite only home.
• The site would be licensed under the 55 Pa Code Chapter 6400 and the Approved Program Capacity approved prior to enrollment.
• This would not be the same as a residential home licensed under the 55 Pa Code Chapter 6400 providing residential services being billed as a site enrolled under the Provider Type 52 specialty 521. You would not enroll the specialty 513 in combination with a specialty 521 at a PT 52 site.
• The site could also be providing Exceptional Day Respite at a licensed intermediate care facility for individuals with ID (55 Pa Code Chapter 6600) that are owned and operated by private agencies or a Licensed Nursing Home (28 Pa Code Chapters 201, 203, 205, 207, 209 and 211).

When a participant has a Needs Group 3 or 4 that indicates medical or behavioral needs, and the participant is unable to locate a respite provider to render services in a community setting, they may be approved for Exceptional Day Respite. A variance may be requested for Respite services in licensed intermediate care facilities for individuals with an intellectual disability (55 Pa. Code Chapter 6600) that are owned and operated by private agencies, Licensed Nursing Homes (28 Pa. Code Chapters 201, 203, 205, 207, 209 and 211).

And Licensed Community Homes (55 Pa. Code Chapter 6400) located in Pennsylvania within the home’s approved program capacity of 5 to 8 may be requested for approval from the regional office.

For more detailed information, including charts with the appropriate billing codes, please refer to the ODP Announcement.