Revision 22-2; Effective Oct. 1, 2022

General Guidelines for Direct Service Agencies (DSAs)

The DSA is responsible for complying with these guidelines and instructions when completing functional assessments and reassessments for all individuals served by the DSA, according to the Community Living Assistance and Support Services (CLASS) program requirements:

Form 8578, Intellectual Disability/Related Condition (ID/RC) Assessment, and Instructions

List of ICD-10 Approved Diagnostic Codes for Persons with Related Conditions (use for assessments with effective dates on or after Oct. 1, 2022):
Approved Diagnostic Codes for Persons with Related Conditions (PDF)

Guidelines for completing the Inventory for Client and Agency Planning (ICAP)/Scales of Independent Behavior – Revised (SIB-R):
Guidelines for Completing the ICAP/SIB-R Adaptive Behavior Scale (PDF)

Form 8662, Related Conditions Eligibility Screening Instrument (RCESI), and Instructions

All of these resources can be found on the HHS website: https://hhs.texas.gov/

The ID/RC Assessment is the document that contains all of the information required to determine an individual’s initial and continuing eligibility for the CLASS program. The ID/RC summarizes demographic, diagnostic and functional information about the individual.

The tools used to determine functional ability are the RCESI and the Adaptive Behavior Level (ABL) assessment tool. The DSA may select from among four ABL tools for use in the CLASS program: the ICAP, the SIB-R, the Vineland Adaptive Behavior Scales and the American Association of Intellectual and Developmental Disabilities (AAIDD) Adaptive Behavior Scales. The ICAP and SIB-R must be administered by the DSA registered nurse (RN) according to the guidelines noted above. The other two assessments are done by the appropriate professional, usually a licensed psychologist, as identified in the guidelines for the use of these tools. It is up to the DSA to choose the tool used to complete the functional assessments of individuals served by the DSA. The ICAP and the SIB-R must be purchased and licensed through Riverside Publishing (https://www.hmhco.com/classroom-solutions/assessment (link is external)).

The ID/RC, the RCESI, the ABL assessment tool, and the nursing assessment using the CLASS/DBMD Nursing Assessment form must be completed at the time of enrollment (the CLASS/DBMD Nursing Assessment form is not a required part of the ID/RC packet). The DSA RN must conduct these assessments (with the exception of the Vineland or the AAIDD, as stated above). At the time of the annual re-enrollment, these assessments are repeated, with the exception of the ABL assessment tool, which is required only every five years, or if a situation changes. These documents are completed by an RN because the RN has the professional ability to assess the clinical status of the individual and is required to comply with the contractual obligations of the provider, in addition to following the rules of conduct outlined by the Texas Board of Nurses. All corrections to the above referenced documents must also be made by an RN.

All ID/RC packets must include, at a minimum, Form 8578, Form 8662 and the summary (scoring program) of the ABL assessment results.

Initial Eligibility

ID/RC Purpose Code 2 – Initial application; denote this in field 13 on Form 8578.

The DSA must provide the individual’s physician with a list of the Approved Diagnostic Codes for Persons with Related Conditions (see the link above). From this list, the physician will be asked to identify the diagnosis and associated diagnostic code that is primarily responsible for the individual’s disability. If the individual does not have a diagnosis of a related condition, as identified in the Approved Diagnostic Codes for Persons with Related Conditions, the physician must still indicate a diagnosis for the individual and International Classification of Diseases (ICD) code. The physician must complete the section on Page 3 of the ID/RC to testify to the validity of the information in fields 19 – 27 of the form. The physician must be a licensed MD or DO. The DSA is not required to obtain the physician’s signature in handwritten format; the DSA must comply with applicable Home and Community Support Services Agency (HCSSA) requirements related to the receipt of physician orders, as outlined in 40 Texas Administrative Code, Chapter 97, Subchapter C.

The DSA RN must administer the RCESI and the ABL assessment tool, if an ICAP or SIB-R.

An initial application will not have Individual Plan of Care (IPC) begin or end dates identified on the ID/RC. When the ID/RC is authorized by DADS, a begin date will be assigned, based on the date the packet was received by DADS. After all assessments are completed, the RN completes the ID/RC form, signs and dates the form, and forwards it to the physician for his review and sign-off. When returned by the physician, the ID/RC packet is then mailed to DADS for review.

Instructions for the ID/RC form require the program provider that transmits Form 8578 to maintain the original Form 8578 and all other original forms in the individual’s record.

Continuing Eligibility

ID/RC Purpose Code 3 – Reassessments

Continuing eligibility must be determined at least annually. As with the initial assessment, the DSA RN is required to complete an ID/RC, an RCESI (this must be completed every year) and an ABL assessment (ICAP/SIB-R) if the current one is greater than five years old, or is no longer valid. If the ABL tool is the Vineland or the AAIDD, the DSA will arrange to have this done. If the individual’s situation has not changed since the last submission, a copy of the summary of results (the scoring program) of the current ABL assessment is included in the packet.

The RN will record the IPC begin and end dates. For a reassessment, the ID/RC packet must not be submitted more than 120 calendar days prior to the individual’s IPC begin date. The packet must be submitted no less than 60 calendar days prior to the expiration of the current IPC.

If an ID/RC is reviewed by DADS and is authorized before the IPC begin date, the ID/RC will be approved with the IPC begin date.

If the ID/RC is not received by DADS with complete and accurate information in order to be authorized before the individual’s IPC begin date, the ID/RC will be authorized with the DADS receipt date.

When an ID/RC is approved after the IPC begin date, a Purpose Code E will be required to cover the gap between the individual’s original IPC begin date and the authorized, later date on the Purpose Code 3.

ID/RC Purpose Code E – Required to cover a lapse in eligibility

A Purpose Code E must be completed by the DSA RN to cover the period from the individual’s IPC begin date to the day before the Purpose Code 3 was authorized by DADS. A Purpose Code E is required to document the individual’s continuous program eligibility.

The DSA must:

• prepare a Purpose Code E if the ID/RC packet with the Purpose Code 3 is not submitted in sufficient time to arrive at DADS by the individual’s IPC begin date;
• date the completion of the Purpose Code E as the date that it is actually prepared;
• ensure the Purpose Code E is a separate document (it cannot be a copy of the Purpose Code 3 and it must match the Purpose Code 3 exactly, except for the completion dates);
• ensure that if a Purpose Code E is submitted separately from the Purpose Code 3, to include a copy of the authorized Purpose Code 3 in the packet and indicate on the Purpose Code E the exact end date for the Purpose Code E (copies of the RCESI and ABL assessment tool are not required with submission of a Purpose Code E to DADS as long as these documents are submitted with a DADS authorized Purpose Code 3); and
• ensure the IPC begin date for a Purpose Code E is the same as the original IPC begin date.

A Purpose Code E does not require a physician’s signature, even if one is requested for the Purpose Code 3.

Note: In situations that require submission of a Purpose Code E, there can be no break in service provision to the individual.

Form 8578, Intellectual Disability/Related Condition Assessment

Form fields that do not apply – The following fields should always be blank for CLASS:

• 6 — Component Code;
• 7 — Case No;
• 73 — CARE ID;
• 18 — LON;
• 29 — IQ;
• 68 — IQ Instrument; and
• Page 2 of the ID/RC.

DADS does not issue remands for these fields. Staff are not required to insert "NA" in these fields as NA is understood.

Dates on Form 8578

• Completion dates for the ID/RC must be on or after the RCESI dates and the date of completion of the ABL assessment, unless it was necessary to conduct a new assessment;
• Date in field 12 on or before the date in field 58;
• Date in field 58 on or before the physician’s date on Page 3;
• If preparing a Purpose Code E, document the date that the form was completed; and
• If re-typing a form in response to a remand from DADS, document the date that the form was re-typed in field 58, or explain that the form was re-typed in the provider comments section.

Alignment Between Diagnosis and ICD Code

For assessments with effective dates prior to Oct. 1, 2015, the list of ICD-9 approved diagnostic codes for persons with related conditions can be found here.

For assessments with effective dates on or after Oct. 1, 2017, the list of ICD-10 approved diagnostic codes for persons with related conditions can be found at:
Approved Diagnostic Codes for Persons with Related Conditions (PDF).

Diagnoses for eligibility consideration by DADS must be a diagnosis included in the approved list. The individual’s diagnosis must be a valid code documented exactly as the diagnosis is denoted in the list. On or after Oct. 1, 2015, ICD-9 codes will no longer be accepted. ICD-10-CM is composed of codes with three, four, five, six or seven characters. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of four, five, six or seven characters to provide greater specificity. A three-character code is to be used only if it is not further subdivided.

An example is H91.9, Unspecified Hearing Loss, which by itself is not a valid code. Examples of valid codes within category H91.9 contain five characters, such as:

H91.90, Unspecified Hearing Loss, Unspecified Ear;
H91.91, Unspecified Hearing Loss, Right Ear;
H91.92, Unspecified Hearing Loss, Left Ear; and
H91.93, Unspecified Hearing Loss, Bilateral.

Notes:

• Additional digits are needed for most 800 codes (850 is the exception).
• The diagnosis has to record what is in the list, through the final digit. Example: 854.01
  854. = intracranial injury of other and unspecified nature; .0 = no mention of open intracranial wound; 1 = (from Page 5 of the list) no loss of consciousness; 854.01 = intracranial injury of other and unspecified nature, no intracranial wound, no loss of consciousness.

List the diagnosis associated with the code in the approved list:

• Text up to the parentheses or semicolon; a specific condition can always be included in parentheses.
• The text in parentheses usually clarifies a diagnosis or contains other diagnoses that are included in the broader diagnosis; it is not necessary to record these unless the text in parentheses applies. Example: 299.0 Autistic disorder; does the individual have just childhood autism, or does he have infantile psychosis or Kanner’s syndrome?
• It is acceptable to abbreviate (PDD, CP; "NOS" for unspecified; "no" for without).

The primary diagnosis is the only diagnosis field that is required in CLASS.

• If secondary or tertiary diagnoses are recorded, they must be documented fully and accurately. Even if the primary diagnosis is an eligible related condition with the correct ICD-9 code, the ID/RC will not be authorized if the additional diagnoses and ICD-9 codes are not accurate.
• If a secondary or tertiary diagnosis is recorded that is not on the list of Approved Diagnostic Codes, the provider must go to the global ICD-9 to obtain the correct code.

The physician attests to the accuracy of these diagnoses and codes. In the event any changes or modifications are required to these fields, the DSA must obtain the physician’s agreement, as indicated by the signature and date on Page 3.

Problematic Fields on Form 8578

Mistakes in documentation in these fields are common:

• Previous Residence (16) – This refers to the individual's previous residence, location or program before being enrolled in the CLASS program. Staff may have to ask the family to help determine this value.
• Recommended LOC (17) – This is usually an ‘8’; put a zero here to indicate that the individual is not eligible for the program; ‘1’ does not apply to the CLASS program.
• Version Code (21, 25, 28) – This is always ‘9’; may change in 2013.
• Score Identified by ABL Instrument (74) – For ICAPs, this will contain the same value as in field 33; for SIB-Rs, this is the score represented by X/90; this does not apply to the other ABL tools.
• Functional Assessment (75) – This is the score from the RCESI and should match what is reported on the assessment. The value will always be between 1 and 6 for those over age 10, and 1 to 4 for those under age 10.

Form 8662, Related Conditions Eligibility Screening Instrument (RCESI)

This assessment measures the functional limitations in the six major areas of life activities. To qualify for CLASS, the individual must have impairments in at least three of the six areas for persons age 10 and over, or three of the four areas for those under age 10 (42 Code of Federal Regulations 45.1010).

Right of the individual to sign:

• If the individual is an adult with no guardian and is able to respond to the assessment, he may answer for himself and must sign for himself.
• If the individual has a guardian, the guardian must sign Form 8662. In addition to the guardian’s signature, the individual may sign for himself.
• No other person can sign for the individual, even if a guardian. The guardian will usually be represented as the informant. If the individual is his own guardian, but is unable to sign or stamp his name, he should make some kind of mark (using hand-over-hand assistance, if necessary). The nurse can note "John’s mark" and her signature on the form is testimony to his signing. If the individual is unable to make a mark even with hand-over-hand, note the reason on the form in the comment section – this is reserved only for rare circumstances.

Use of Informant — If an informant is needed to assist the individual, regardless of legal status, that informant must always sign the form as the informant. If the individual is his own guardian, he must sign the form in addition to the informant.

Note: If the form is altered after the assessment, for instance to remove the name of an informant, the form must be re-signed and dated by the appropriate person(s) to indicate agreement with the change(s).

Consistency Between Activities, the Summary and the ID/RC

• The Summary in Section 4 (B) 1 must match what is recorded in the individual activities on Pages 1 and 2. The score must match what is on the ID/RC (field 75).
• Note the age of the individual – Activities E and F are not applicable to children under age 10.
• Score between 1 and 6:
  • For an individual age 10 and older, the maximum score is 6
  • For a child under age 10, the maximum score is 4.

Adaptive Behavior Level (ABL) Assessment Tool

ICAP, SIB-R, Vineland, AAIDD:

• Only ICAPs and SIB-Rs are done by DSA RNs.
• ICAP and SIB-R are very similar and guidelines are the same for both.
• The DSA RN does face-to-face with the individual, regardless of age.
• The RN must engage the individual during the time of assessment, even if a minor and even when the RN will make use of an informant to assist in completion of the assessment:
  • RN is the independent, objective observer and assessor of the individual;
  • RN must take into account the information provided by the individual or family (can sometimes be under- or over-estimate of actual abilities);
  • RN observes, may use props, can ask the individual to demonstrate tasks or can generalize from other tasks;
  • RN compiles information from individual/family/attendants/etc., and from the RN’s own observations and knowledge of the individual, to arrive at an independent assessment.
• Booklet – the supporting clinical documentation for the ABL assessment:
  • must be complete, accurate, and done in permanent pen;
  • must match the scoring program; and
  • the original must be kept in the individual’s file.
• The transferring DSA must forward all originals in the individual’s case record; if no originals are available, a receiving DSA may want to conduct a new assessment.

Problem Behaviors

• Not every behavior is a problem; not every problem is serious (per assessment guidelines, that can be found at the following link: Guidelines for Completing the ICAP/SIB-R Adaptive Behavior Scale (PDF).
• Definition of a problem (from the guidelines):
  • Many behaviors, even if listed as examples, may not be problems if they are mild, infrequent or age appropriate.
  • For the purpose of the CLASS assessment, a behavior is not a problem if it does not require the attention or intervention of staff, or if it is not discussed as an issue during the service planning team.
  • Does not include behaviors that are a part of the diagnosis, that are medical problems or for which a behavior plan would not be effective.
• Criteria for severity (from the guidelines):
  • From least (mild) to most severe (critical).
  • Guidelines help the RN to determine the severity of the problem.
  • This section is to assess what behavior is going to present a problem for the service provider; it does not necessarily matter how serious a behavior may be to a parent or other family member if the behavior is not a factor with regard to direct service provision.
• Staff record only one problem behavior in a category and do not record the same behavior in more than one category.
• Staff can record more than one problem in the individual’s record, but must choose only one to report in the assessment document.

The ICAP or SIB-R is an assessment of the individual’s activity in the month directly prior to the time the assessment is conducted:

• If a behavior occurs less than once a month and did not occur during the previous month, it does not have to be listed.
• If a behavior is not a problem/not serious, the frequency should be "never."
• This section is for recording serious problem behavior; if a behavior is not a problem or is not serious, the individual should not be penalized for it.

The ABL is assessed at least every five years, or as necessary if the individual’s situation changes. The ABL assessment must be reviewed at the time of every reassessment to verify continuing accuracy.

• Children may need to be assessed more frequently.
• Necessary whenever a situation or needs change.
• Maintain an original record for the files.

Perform Quality Control Before Submitting ID/RC Packets to DADS

Only the most recent ID/RC packet submission is relevant as this information renews at least annually.

All required forms must be complete and accurate:

• No blank fields (other than those identified in the instructions).
• Check consistency – birth dates, onset dates.
• Check previous Level of Care forms (Form 8578 or Form 3650) – diagnosis, code, birth date, onset date.
• Ensure that remands have been thoroughly checked and that all remand reasons have been fully addressed.
• The submission must be within the appropriate time frame.
• The submission for reassessments must be within the 120- to 60-day time frame.
• Compare the diagnosis and code against the current DADS List of Approved Diagnostic Codes for Persons with Related Conditions.

Remands

Return all material, including the material that was originally submitted plus all new material and all remand forms, with each re-submission to DADS. DADS must be able to track the history of the packet with each re-submission, including:

• what has been requested and corrected;
• who worked the packet before; and
• all dates must be clearly defined.

Corrections/Additions – Mark through the incorrect value, insert the correct value, initial, and date each correction or addition of missing information. For RCESI or the ABL assessment, provide clear indication of the correct response.

Consistency Within and With Other Information Provided

• Birth dates; completion dates on other forms;
• Legal status (field 15), RCESI, ICAP, etc.;
• ABL Assessment, and ABL (field 30);
• Field 74 (Score identified by ABL Instrument – same as field 33 for the ICAP); and
• Behavior Program (field 34), Nursing (39), Day Services (41), Employment Services (44):
  • If a service is indicated, the related fields must be populated, and vice versa.
  • Nursing is a required service and these fields should always be completed for a Purpose Code 3; at the very least this represents the nursing that is allotted on the IPC.
  • Behavior Program (field 34) and fields 35 – 38; if no behavior program, these fields must be 0 and vice versa.

ID/RC Processing Timeline

DADS requires 15 working days to process ID/RC packets. Working days do not include weekend days or state or federal holidays. In addition, the provider must allow four days of mail time from the date the provider mailed the packet, and four days following the DADS processing timeline for the mail to be received back by the provider.

Contact Information

For ID/RC inquiries, staff:

• Fax a name or a list of individuals to DADS Administrative Assistant at 512-438-5135.
• Include the name, Medicaid number (or Social Security number), and date the packet is mailed.
• If not within the processing timeline outlined, wait to inquire until the processing timeline has lapsed.

For questions related to an assessment or status, contact the IDD Waivers Program Enrollment/Utilization Review Unit in Access and Intake at DADS at 512-438-3609.

• Voice message – Speak slowly and distinctly.
• Leave name, number and a brief message.

Mail – All ID/RC packets are mailed to DADS unless other arrangements are made.

Regular Mail

Department of Aging and Disability Services
P.O. Box 149030, Mail Code W-521
Austin TX 78714-9030

Priority or Overnight Mail – Physical Address

Department of Aging and Disability Services
701 W. 51st St., Mail Code W-521
Austin, TX 78751

Note: Always include Mail Code W-521 for accurate routing.

CLASS Fax Number – 512-438-5135