20 CAR Part 609 — Autism Waiver Provider Manual

Chapter XV

Subchapter B

20 CAR pt. 609 Autism Waiver Provider Manual {#sec-20-car-pt.-609 omnilex-key=us-ar-regs-official--title-20-part-609--20 CAR pt. 609}

Autism Waiver Section II Section II-1

SECTION II - AUTISM WAIVER CONTENTS

200.000 AUTISM WAIVER GENERAL INFORMATION 201.000 Arkansas Medicaid Participation Requirements for Autism Waiver Providers 201.100 Individual Service Provider Participation Requirements 201.200 Group Service Provider Participation Requirements 201.300 Providers in Arkansas and Bordering States 202.000 AUTISM WAIVER PROVIDER REQUIREMENTS 202.100 Intensive Intervention Providers 202.200 Consultative Clinical and Therapeutic Provider Participation Requirements 202.300 Interventionist Participation Requirements 202.400 Lead Therapist Participation Requirements 202.500 Line Therapist Participation Requirements 202.600 Clinical Services Specialist (CSS) Participation Requirements 203.000 Supervision 204.000 Documentation Requirements 204.100 Documentation Requirements for all Medicaid Providers 204.200 Autism Waiver Service Documentation Requirements 204.300 Electronic Signatures 210.000 PROGRAM ELIGIBILITY 211.000 Scope 212.000 Beneficiary Eligibility Requirements 212.100 Age Requirement 212.200 Qualifying Diagnosis 212.300 Institutional Level of Care 220.000 PROGRAM SERVICES 221.000 Non-covered Services 222.000 Covered Services 222.100 Individual Assessment, Treatment Development, and Monitoring Services 222.200 Consultative Clinical and Therapeutic Services 222.300 Lead Therapy Intervention Services 222.400 Line Therapy Intervention Services 222.500 Therapeutic Aides and Behavioral Reinforcers 222.600 Telemedicine Services 223.000 Plan of Care 224.000 Individualized Treatment Plan 250.000 REIMBURSEMENT 251.000 Method of Reimbursement 251.100 Fee Schedules

200.000 AUTISM WAIVER GENERAL INFORMATION

201.000 Arkansas Medicaid Participation Requirements for Autism Waiver Providers 1-1-25 201.100 Individual Service Provider Participation Requirements 1-1-25 Individual providers of Autism Waiver services must meet the following requirements to be eligible to participate in Arkansas Medicaid: A. Complete the provider participation and enrollment requirements contained within section 140.000 of this Medicaid manual;

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B. Meet the credentialing, experience, training, and other qualification requirements of the applicable Autism Waiver service under section 202.000 of this Medicaid manual; and C. Obtain certification as an Autism Waiver provider from Arkansas Department of Human Services, Division of Developmental Disabilities Services or its contracted vendor. 201.200 Group Service Provider Participation Requirements 1-1-25 Group providers of Autism Waiver services must meet the following requirements to be eligible to participate in Arkansas Medicaid: A. Complete the provider participation and enrollment requirements contained within section 140.000 of this Medicaid manual; B. Each individual performing Autism Waiver services on behalf of the group must complete the individual provider participation and enrollment requirements under section 201.100 of this Medicaid manual; and C. Obtain certification as an Autism Waiver provider from the Arkansas Department of Human Services, Division of Developmental Disabilities Services or its contracted vendor. 201.300 Providers in Arkansas and Bordering States 1-1-25 Providers with a principal place of business in Arkansas and within fifty (50) miles of the state line in the six (6) bordering states (Louisiana, Mississippi, Missouri, Oklahoma, Tennessee and Texas) may enroll as Autism Waiver providers if they meet all Arkansas Medicaid participation requirements of this Arkansas Medicaid manual.

202.000 AUTISM WAIVER PROVIDER REQUIREMENTS 202.100 Intensive Intervention Providers 1-1-25 A. Intensive Intervention providers are those Autism Waiver service providers that are certified to provide one or more of the following Autism Waiver services:

1. Individual Assessment, Treatment Development, and Monitoring services;
2. Lead Therapy Intervention services;
3. Line Therapy Intervention services; and
4. Therapeutic Aides and Behavioral Reinforcers. B. Each individual rendering Autism Waiver services on behalf of a group intensive intervention provider must meet the credentialing, experience, training, and other qualification requirements for the applicable service. 202.200 Consultative Clinical and Therapeutic Provider Participation Requirements 1-1-25 A. Consultative Clinical and Therapeutic providers must:
5. Be an Institution of Higher Education with the capacity to conduct research specific to autism spectrum disorders;
6. Have a central/home office located within the State of Arkansas; and
7. Have the capacity to provide services in all areas within the State of Arkansas. B. A Consultative Clinical and Therapeutic provider and each Clinical Services Specialist employed or contracted to provide Consultative Clinical and Therapeutic services must be independent of the intensive intervention provider selected by the parent/guardian. 202.300 Interventionist Participation Requirements 1-1-25

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An Interventionist performing Individual Assessment, Treatment Development, and Monitoring Services must: A. Have a minimum of two (2) years’ experience performing one (1) or more of the following for children with autism spectrum disorder:

1. Developing individualized treatment;
2. Providing intensive intervention services; or
3. Overseeing an intensive intervention program; and B. Hold either:
4. A Master’s (or more advanced) degree in psychology, speech-language pathology, occupational therapy, special education, or related field; or
5. A certificate as a board certified behavior analyst (BCBA) from the Behavior Analyst Certification Board. 202.400 Lead Therapist Participation Requirements 1-1 -25 A. A Lead Therapist performing Lead Therapy Intervention services must:
6. Hold a Bachelor’s (or more advanced) degree in education, special education, psychology, speech-language pathology, occupational therapy, or related field;
7. One of the following: a. Have completed one hundred twenty (120) hours of autism spectrum dsorder training; or b. Have both: i. Received an Autism Certificate offered by the University of Arkansas; and ii. A minimum of two (2) years of experience in intensive intervention services to children with autism spectrum disorder. B. In a hardship situation, DDS or its contracted vendor may allow an individual to act as a Lead Therapist and perform Lead Therapist Intervention services prior to meeting all the requirements in section 202.400(A).
8. A hardship situation exists when a beneficiary needs Lead Therapy Intervention services and staff is not available who meet all training/experience requirements.
9. In a hardship situation, the individual or group performing Lead Therapy Intervention services must meet all training/experience requirements in section 202.400(A) within one (1) year. 202.500 Line Therapist Participation Requirements 1-1 -25 A. A Line Therapist performing Line Therapy Intervention services must:
10. Be at least eighteen (18) years of age;
11. Hold at least a high school diploma or GED;
12. Have completed eighty (80) hours of autism spectrum disorder training; and
13. Have a minimum of two (2) years’ experience working with children. B. In a hardship situation, DDS or its contracted vendor may allow an individual to act as a Line Therapist and perform Line Therapist Intervention services prior to meeting all the requirements in section 202.500(A).
14. A hardship situation exists when a beneficiary needs Line Therapy Intervention services and staff is not available who meet all training/experience requirements.
15. In a hardship situation, the individual or group performing Line Therapy Intervention services must meet all training/experience requirements in section 202.500(A) within one (1) year.

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202.600 Clinical Services Specialist (CSS) Participation Requirements 1-1 -25 Each Clinical Services Specialist employed or contracted by a Consultative Clinical and Therapeutic provider to perform Consultative Clinical and Therapeutic services must hold a certificate in good-standing as a board-certified behavioral analyst (BCBA) from the Behavior Analyst Certification Board. 203.000 Supervision 1-1 -25 A. The Clinical Services Specialist providing consultative clinical and therapeutic services to a beneficiary must perform quality reviews to ensure appropriate implementation of the intensive intervention services included in the plan of care:

1. Quality reviews are initially conducted monthly.
2. If the beneficiary is progressing as expected through the first quarter of Autism Waiver services, quarterly quality reviews are permitted as long as the beneficiary continues to progress as expected. B. The Interventionist must perform monthly on-site monitoring of intensive intervention service(s) delivery by the parent/guardian, Lead Therapist, and Line Therapist. C. The Lead Therapist must perform weekly or more frequent in-person monitoring of intensive intervention service(s) delivery by the Line Therapist. 204.000 Documentation Requirements 1-1 -25 204.100 Documentation Requirements for all Medicaid Providers 1-1 -25 See section 140.000 of this Arkansas Medicaid manual for the documentation that is required for all Arkansas Medicaid providers. 204.200 Autism Waiver Service Documentation Requirements 1-1 -25 Autism Waiver providers must maintain in each beneficiary’s service record in the Autism Waiver Database maintained by Arkansas Department of Human Services, Division of Developmental Disabilities Services (DDS) or its contracted vendor: A. The beneficiary’s autism spectrum disorder diagnosis; B. The beneficiary’s applicable medical records; C. The beneficiary’s plan of care; D. The beneficiary’s individualized treatment plan (ITP); E. The evaluations conducted as part of any level of care determination or in the development of the beneficiary’s comprehensive clinical profile; F. The beneficiary’s form DHS-3330; G. All clinical progress assessments of the beneficiary; H. The parent/guardian’s signed election to receive Autism Waiver services; I. The parent/guardian’s signed choice of provider form; J. The quarterly reviews conducted by the clinical services specialist; K. Each session of intensive intervention service delivery must include the following documentation:
3. Beneficiary name;
4. The date and beginning and ending time of intensive intervention service delivery;

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3. A description of specific intensive intervention techniques or activities that were utilized during the session;
4. The location and type of setting where the intensive intervention services were provided;
5. Name(s), credential(s), and signature(s) of the personnel who performed the intensive intervention services;
6. Which of the beneficiary’s ITP goals and objectives the session’s intensive intervention services were intended to address;
7. Weekly or more frequent progress notes signed or initialed by the Lead Therapist describing the beneficiary’s status with respect to their ITP goals and objectives; and
8. Any other documentation and information required by the Arkansas Department of Human Services, Division of Developmental Disabilities Services (DDS) or its contracted vendor. 204.300 Electronic Signatures 1-1-25 Arkansas Medicaid will accept electronic signatures, in compliance with Arkansas Code § 25-31- 103, et seq.

210.000 PROGRAM ELIGIBILITY 211.000 Scope 1-1-25 The purpose of the Autism Waiver is to provide one-on-one, intensive early intervention treatment in a natural environment setting to beneficiaries between eighteen (18) months and eight (8) years of age with a diagnosis of autism spectrum disorder. 212.000 Beneficiary Eligibility Requirements 1-1-25 212.100 Age Requirement 1-1-25 A. A beneficiary must be between eighteen (18) months and eight (8) years of age to receive Autism Waiver services. B. A beneficiary must enroll in the Autism Waiver on or before their fifth (5th) birthday to allow for the maximum three (3) consecutive years of Autism Waiver services prior to turning eight (8) years old. See section 221.000(C) of this Arkansas Medicaid manual. 212.200 Qualifying Diagnosis 1-1-25 A. A beneficiary must have an autism spectrum disorder (ASD) diagnosis as defined in Ark. Code Ann. § 20-77-124. B. The beneficiary’s ASD diagnosis must be the primary contributing factor to their developmental or functional delays, deficits, or maladaptive behaviors to receive Autism Waiver services. 212.300 Institutional Level of Care 1-1-25 A. A beneficiary must require an institutional level of care (LOC) to enroll in the Autism Waiver and receive Autism Waiver services. A beneficiary is deemed to require an institutional LOC for Autism Waiver eligibility purposes if they meet one of the following:

1. A beneficiary scores seventy (70) or less in any two (2) of the Vineland Adaptive Behavior Scales (Vineland) domains.
2. A beneficiary three (3) years of age or older: a. Scores eighty-five (85) or less in any two (2) Vineland domains; and

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b. Has a Vineland Maladaptive Behavior Index Score between twenty-one (21) and twenty-four (24). 3. A beneficiary under the age of three (3): a. Scores eighty-five (85) or less in any two (2) Vineland domains; and b. Has a Temperament Atypical Behavior Scale score of at least eight (8). i. Vineland scores falling within a domain’s confidence interval for the beneficiary’s developmental age will not preclude a beneficiary from Autism Waiver eligibility. For example, a beneficiary with a Vineland Communication domain score of seventy-four (74) where the beneficiary’s developmental age confidence interval for the domain is four (4) points would be treated as a score of seventy (70) for purposes of this section 212.300. B. A beneficiary must receive an annual LOC evaluation to demonstrate continued eligibility for the Autism Waiver. 220.000 PROGRAM SERVICES

221.000 Non-covered Services 1-1-25 A. Arkansas Medicaid will only reimburse for those services listed in sections 220.000 through 222.600, subject to all applicable limits. B. Autism Waiver services are reimbursable if, and only to the extent, authorized in the beneficiary’s plan of care. See section 223.000. C. A beneficiary can receive a maximum of three (3) years of Autism Waiver services. Autism Waiver services are not covered beyond the three (3) year maximum limit. 222.000 Covered Services 1-1-25 222.100 Individual Assessment, Treatment Development, and Monitoring Services 1-1-25 A. Individual Assessment, Treatment Development, and Monitoring services include the following components:

1. Administering the evaluation instrument(s) and conducting the clinical observations necessary to create a comprehensive clinical profile of the beneficiary’s skill deficits across multiple domains, including without limitation language/communication, cognition, socialization, self-care, and behavior. a. The administration of the Assessment of Basic Language and Learning Skills- Revised instrument (ABLLS-R) is a required part of the comprehensive clinical profile. b. Other evaluation instruments and clinical judgment may also be utilized so long as it supports the development of the beneficiary’s comprehensive clinical profile.
2. Developing the individualized treatment plan (ITP) that guides the day-to-day delivery of intensive intervention services and includes without limitation the:
   1. Intensive intervention service(s) delivery schedule;
   2. Short and long-term goals and objectives; and
   3. Data collection that will be implemented to assess progress towards those
   short and long-term goals and objectives.
3. Training and educating the parent/guardian, Lead Therapist, and Line Therapist on how to: a. Implement and perform the intensive intervention service(s) included on the ITP;

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2. Collect the required data; and
3. Record the service session notes necessary to assess the beneficiary’s

progress towards ITP goals and objectives.

4. Performing monthly monitoring of intensive intervention service delivery by the

parent/guardian, Lead Therapist, and Line Therapist.

5. Completing beneficiary clinical progress assessments and adjusting the

comprehensive clinical profile and ITP as required. Clinical progress assessments

must be completed for each beneficiary at least every four (4) months and must

always include:

a. The administration of an ABLLS-R; and

b. A written assessment of the beneficiary’s progress based on an in-depth review

of the data and session notes entered by the Lead Therapist and Line

Therapist.

B. Individual Assessment, Treatment Development, and Monitoring services must be

performed by a qualified Interventionist.

C. Individual Assessment, Treatment Development, and Monitoring services may be

completed through telemedicine if in compliance with section 222.600 of this Medicaid

manual, except for a beneficiary’s initial evaluation, which must be conducted in-person in

the beneficiary’s natural environment setting.

D. Individual Assessment, Treatment Development, and Monitoring services are reimbursed

on a per unit basis. The unit of service calculation should only include time spent

administering beneficiary evaluations, conducting clinical observation, monitoring Lead and

Line Therapist service delivery, or providing face-to-face training to the parent/guardian

and Lead and Line Therapists. The unit of service calculation does not include time spent

in transit to and from a service setting.

View or print the billable Individual

Assessment, Treatment Development, and Monitoring procedure codes and

descriptions.

222.200 Consultative Clinical and Therapeutic Services

1-1-25

A. Consultative Clinical and Therapeutic services provide high level, independent clinical

oversight of the implementation of the beneficiary’s plan of care and individualized

treatment plan, and include the following components:

1. Conducting quality reviews to ensure appropriate implementation of the intensive intervention services included in the plan of care.
   1. Quality reviews are initially conducted monthly.
   2. If the beneficiary is progressing as expected through the first quarter of Autism
   Waiver services, quarterly quality reviews are permitted as long as the beneficiary continues to progress as expected.
2. Providing technical assistance to the parent/guardian, Lead Therapist, and Line Therapist when the beneficiary is not progressing as expected.
3. Notifying DDS or its contracted vendor if any issues related to Autism Waiver compliance are discovered. B. Consultative Clinical and Therapeutic services must be performed by a qualified Clinical Services Specialist. C. Consultative Clinical and Therapeutic services may be conducted through telemedicine in accordance with section 222.600 of this Medicaid manual, unless:
4. The beneficiary, parent/guardian, Lead Therapist, or Line Therapist needs dictate that Consultative Clinical and Therapeutic services should be performed by the Clinical Services Specialist in-person; or
5. The beneficiary is not progressing as expected.

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D. Consultative Clinical and Therapeutic services are reimbursed on a per unit basis. The unit of service calculation does not include time spent in transit to and from a service setting. View or print the billable Consultative Clinical and Therapeutic procedure codes and descriptions. 222.300 Lead Therapy Intervention Services 1-1-25 A. Lead Therapy Intervention services include the following components:

1. Providing intensive intervention service(s) in accordance with the individualized treatment plan (ITP);
2. Weekly or more frequent in-person monitoring of the intensive intervention service(s) delivery by the Line Therapist;
3. Reviewing all data collected and service session notes recorded by the Line Therapist and parent/guardian;
4. Training, assisting, and supporting the parent/guardian and Line Therapist;
5. Receiving parent/guardian feedback and responding to parent/guardian concerns or forwarding them to the appropriate person; and
6. Notifying the Interventionist when issues arise.
   2. Lead Therapy Intervention services must be performed by a qualified Lead Therapist.
   3. Lead Therapy Intervention services involving the beneficiary must:
7. Be conducted in a typical home or community setting for a similarly aged child without a disability or delay that the beneficiary and their family frequent, such as the beneficiary’s home, neighborhood playground or park, church, or restaurant; and
8. Include the participation of a parent/guardian. D. Lead Therapy Intervention services are reimbursed on a per unit basis. The unit of service calculation should only include time spent delivering face-to-face services to the beneficiary and parent/guardian, monitoring Line Therapist service delivery, or providing face-to-face training to a Line Therapist. The unit of service calculation does not include time spent in transit to and from a service setting. View or print the billable Lead Therapy Intervention procedure codes and descriptions. 222.400 Line Therapy Intervention Services 1-1-25 A. Line Therapy Intervention services include the following components:
9. Providing intensive intervention service(s) in accordance with the individualized treatment plan (ITP);
10. Collecting data and recording session notes in accordance with the ITP; and
11. Reporting progress and concerns to the Lead Therapist or Interventionist, as needed.
    2. Line Therapy Intervention services must be performed by a qualified Line Therapist.
    3. Line Therapy Intervention services involving the beneficiary must:
12. Be conducted face-to-face in a typical home or community setting for a similarly aged child without a disability or delay that the beneficiary and their family frequent, such as the beneficiary’s home, neighborhood playground or park, church, or restaurant; and
13. Include the participation of a parent/guardian. D. Line Therapy Intervention services are reimbursed on a per unit basis. The unit of service calculation should only include time spent delivering face-to-face services to the beneficiary and parent/guardian, and does not include time spent in transit to and from a service setting. View or print the billable Line Therapy Intervention procedure codes and descriptions.

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222.500 Therapeutic Aides and Behavioral Reinforcers 1-1 -25 A. Therapeutic aides and behavioral reinforcers are tools, aides, or other items a beneficiary uses in their home when necessary to implement and carry out the beneficiary’s individualized treatment plan (ITP) and substitute materials or devices are otherwise unavailable. B. The Interventionist determines when therapeutic aides and behavioral reinforcers should be included in the ITP. C. A beneficiary may keep any therapeutic aides and behavioral reinforcers after exiting the Autism Waiver as long as the requirements of the Parent/Guardian Participation Agreement are met. D. Therapeutic aides and behavioral reinforcers are limited to a maximum reimbursement of one thousand dollars ($1,000.00) per beneficiary, per lifetime. View or print the billable Therapeutic Aides and Behavioral Reinforcers codes and descriptions. 222.600 Telemedicine Services 1-1 -25 A. Consultative Clinical and Therapeutic services and Individual Assessment, Treatment Development, and Monitoring services may be delivered through telemedicine in accordance with this section 222.600.

1. A beneficiary’s initial evaluation by the Interventionist may not be conducted through telemedicine and must be performed through traditional in-person methods.
2. Parental or guardian consent is required prior to telemedicine service delivery.
3. All telemedicine services must be delivered in accordance with the Arkansas Telemedicine Act, Ark. Code Ann. § 17-80-401 to -407, or any successor statutes, and section 105.190 of this Medicaid manual. B. The Autism Waiver service provider is responsible for ensuring service delivery through telemedicine is equivalent to in-person, face-to-face service delivery.
4. The Autism Waiver service provider is responsible for ensuring the calibration of all clinical instruments and proper functioning of all telecommunications equipment.
5. All Autism Waiver services delivered through telemedicine must be delivered in a synchronous manner, meaning through real-time interaction between the practitioner and beneficiary, parent/guardian, or practitioner via a telecommunication link.
6. A store and forward telecommunication method of service delivery where either the beneficiary, parent/guardian, or practitioner records and stores data in advance for the other party to review at a later time is prohibited, although correspondence, faxes, emails, and other non-real time interactions may supplement synchronous telemedicine service delivery. C. Autism Waiver services delivered through telemedicine delivered in compliance with this section 222.600 are reimbursed in the same manner and subject to the same benefit limits as in-person, face-to-face service delivery. 223.000 Plan of Care 1-1 -25 A. The Division of Developmental Disabilities Services or its contracted vendor must develop an individualized plan of care for each beneficiary.
7. The plan of care must be developed by an individual who has either:
   1. A Registered Nurse license; or
   2. A Bachelor’s (or more advanced) degree in psychology, nursing, speech-
   language pathology, education, or related field.
8. The plan of care must be developed in collaboration with:

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1. The parent/guardian; and
2. Any other individuals requested by the parent/guardian.
3. Each beneficiary’s plan of care must include the following:

1. The beneficiary’s identification information, which includes without limitation the beneficiary’s:
   1. Full name;
   2. Address;
   3. Date of birth;
   4. Medicaid number; and
2. The name and credentials of the individual responsible for plan of care development;
3. The beneficiary’s needs and potential risks;
4. The intensive intervention service(s) that will be implemented to meet those needs;
5. The amount, frequency, and duration of each intensive intervention service; and
6. The parent/guardian’s choice of intensive intervention service provider(s). C. A beneficiary’s plan of care must be updated at least annually and any time the beneficiary is not progressing as expected. 224.000 Individualized Treatment Plan 1-1 -25 A. The Individual Assessment, Treatment Development, and Monitoring service provider selected by the beneficiary’s parent/guardian must develop an individualized treatment plan (ITP) for the beneficiary.
7. The individual responsible for developing and updating the ITP must be a qualified Interventionist.
8. The Interventionist must develop and update the ITP in in collaboration with the:
   1. Lead Therapist;
   2. Line Therapist;
   3. Parent/guardian; and
   4. Any other individuals requested by the parent/guardian.
   5. Each ITP must include the following:
9. The beneficiary’s identification information, which includes without limitation the beneficiary’s:
   1. Full name;
   2. Address;
   3. Date of birth; and
   4. Medicaid number; and
10. The name and credentials of the Interventionist responsible for ITP development;
11. A written description of a minimum of three (3) goals and objectives, which must each be: a. Written in the form of a regular function, task, or activity the beneficiary is working toward successfully performing; b. Measurable; and c. Specific to the individual beneficiary;
12. The intensive intervention service(s) delivery schedule;
13. Detailed instructions for implementation of intensive intervention services including the job title(s) or credential(s) of the personnel that will furnish the intensive intervention service(s);
14. The data collection that will be required to monitor and assess progress towards the beneficiary’s goals and objectives; and

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7. When appropriate, a positive behavior supports plan for maladaptive behavior. C. A beneficiary’s ITP must be updated every four (4) months after the administration of the Assessment of Basic Language and Learning Skills-Revised instrument, and anytime a beneficiary is not progressing as expected. 250.000 REIMBURSEMENT 251.000 Method of Reimbursement 1-1-25 Except as otherwise provided in this manual, covered Autism Waiver services use fee schedule reimbursement methodology. Under fee schedule methodology, reimbursement is made at the lower of the billed charge for the service or the maximum allowable reimbursement for the service under Arkansas Medicaid. The maximum allowable reimbursement for a service is the same for all Autism Waiver providers. A. A full unit of service must be rendered to bill a unit of service. B. Partial units of service may not be rounded up and are not reimbursable. C. Non-consecutive periods of service delivery over the course of a single day may be aggregated when computing a unit of service. 251.100 Fee Schedules 1-1-25 A. Arkansas Medicaid provides fee schedules on the DHS website. View or print the Autism Waiver fee schedule. B. Fee schedules do not address coverage limitations or special instructions applied by Arkansas Medicaid before final payment is determined. C. Fee schedules and procedure codes do not guarantee payment, coverage, or the reimbursement amount. Fee schedule and procedure code information may be changed or updated at any time.