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3.9.2 Services/Benefits and Limitations
Medicaid clients who are birth through 20 years of age are entitled to all medically necessary private duty nursing (PDN) services and home health skilled nursing services.
PDN is nursing services, as described by the Texas Nursing Practice Act and its implementing regulations, for clients who meet medical necessity criteria listed below and who require individualized, continuous, skilled care beyond the level of skilled nursing visits provided under Texas Medicaid (Title XIX) Home Health Services skilled nursing (SN).
Nursing services are medically necessary under the following conditions:
• The requested services are nursing services as defined by the Texas Nursing Practice Act and its implementing regulations.
•The requested services correct or ameliorate the client's disability, physical, mental illness, or condition. Nursing services correct or ameliorate the client's disability, physical or mental illness, or condition when the services improve, maintain, or slow the deterioration of the client's heath status.
•There is no TPR financially responsible for the services.
Medically necessary nursing services maybe either PDN services or home health skilled nursing services, depending on whether the client's nursing needs can be met on a per-visit basis.
"Responsible adult" means an individual who is an adult, as defined by the Texas Family Code, and who has agreed to accept the responsibility for providing food, shelter, clothing, education, nurturing, and supervision for the recipient. Responsible adults include, but are not limited to: biological parents, adoptive parents, foster parents, guardians, court-appointed managing conservators, and other family members by birth or marriage.
PDN must be ordered or prescribed by a physician and provided by an RN, an LVN, or a licensed practical nurse (LPN).
Professional nursing provided by an RN, as defined in the Texas Nursing Practice Act, means the performance of an act that requires substantial specialized judgment and skill, the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science, as acquired by a completed course in an approved school of professional nursing. The term does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures. Professional nursing involves:
•The observation, assessment, intervention, evaluation, rehabilitation, care and counsel, or health teachings of a person who is ill, injured, infirm, or experiencing a change in normal health processes.
•The maintenance of health or prevention of illness.
•The administration of a medication or treatment as ordered by a physician, podiatrist, or dentist.
•The supervision of delegated nursing tasks or teaching of nursing.
•The administration, supervision, and evaluation of nursing practices, policies, and procedures.
•The performance of an act delegated by a physician.
•Development of the nursing care plan.
Vocational nursing, as defined in the Texas Nursing Practice Act, means a directed scope of nursing practice, including the performance of an act that requires specialized judgment and skill, the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of vocational nursing. The term does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures. Vocational nursing involves:
•Collecting data and performing focused nursing assessments of the health status of an individual.
•Participating in the planning of the nursing care needs of an individual.
•Participating in the development and modification of the nursing care plan.
•Participating in health teaching and counseling to promote, attain, and maintain the optimum health level of an individual.
•Assisting in the evaluation of an individual's response to a nursing intervention and the identification of an individual's needs.
•Engaging in other acts that require education and training, as prescribed by board rules and policies, commensurate with the nurse's experience, continuing education, and demonstrated competency.
Professional and vocational nursing care consists of those services that must, under state law, be performed by an RN or LVN as defined by the Texas Nursing Practice Act §301.002. These services include observation, assessment, intervention, evaluation, rehabilitation, care and counseling, and health teaching, and which are further defined as nursing services in 42 CFR §§409.32, 409.33, and 409.44.
•In determining whether a service requires the skill of a licensed nurse, consideration must be given to the inherent complexity of the service, the condition of the client, and the accepted standards of medical and nursing practice.
•The fact that the nursing care can be, or is, taught to the client or to the client's family or friends does not negate the skilled aspect of the service when the service is performed by a nurse.
•If the service could be performed by the average nonmedical person, the absence of a competent person to perform it does not cause it to be a nursing service.
•If the nature of a service is such that it can safely and effectively be performed by the average nonmedical person without direct supervision of a licensed nurse, the services cannot be regarded as nursing care.
•Some services are classified as nursing care on the basis of complexity alone (e.g., intravenous and intramuscular injections or insertion of catheters), and if reasonable and necessary to the treatment of the client's illness or injury, would be covered on that basis. In some cases, however, the client's condition may cause a service that would ordinarily not be considered nursing care to be considered nursing care. This would occur when the client's condition is such that the service can be safely and effectively provided only by a nurse.
•A service that, by its nature, requires the skills of a nurse in order for it to be provided safely and effectively, continues to be a skilled service even if it is taught to the client, the client's family, or other caregivers.
PDN should prevent prolonged and/or frequent hospitalizations or institutionalization and provide cost-effective and quality care in the most appropriate, least restrictive environment. PDN provides direct nursing care and caregiver training and education. The training and education is intended to optimize client health status and outcomes and to promote family-centered, community-based care as a component of an array of service options.
A request must include documentation from the provider to support the medical necessity of the service, equipment, or supply. CCP is obligated to authorize all medically necessary PDN to promote independence and support the client living at home.
PDN cannot be considered for the primary purpose of providing respite care, childcare, activities of daily living for the client, housekeeping services, or comprehensive case management beyond the service coordination required by the Texas Nursing Practice Act.
Claims for PDN services should be submitted to TMHP as follows:
Note: Independently enrolled LVNs should use TE modifier, and independently enrolled RNs should use the TD modifier.
Home health agencies that provide PDN services for clients with a tracheostomy or clients who are ventilator-dependent receive additional reimbursement. Providers must bill using procedure codes T1000, T1002, or T1003 with UA modifier and one of the following diagnosis codes.
Because of the nature of the service being provided, some billing situations are unique to PDN. These billing requirements are as follows:
•All hours worked on one day should be billed together, on one detail, even if they involve two shifts. For example, if Nurse A works 7 a.m. to 11 a.m. and then returns and works 7 p.m. to 11 p.m., services should be billed for 8 hours (32 15-minute units) on one detail for that date of service.
•An individually enrolled nurse will not be reimbursed for more than 16 hours of PDN services in one day.
PDN may be delivered in a provider/client ratio other than one-on-one. An RN or LVN may provide PDN services to more than one client over the span of the day as long as each client's care is based on an individualized POC, and each client's needs and POC do not overlap with another client's needs and POC. Only the time spent on direct PDN for each client is reimbursed. Total PDN billed for all clients cannot exceed an individual provider's total number of hours at the POS.
A single nurse may be reimbursed for services to more than one client in a single setting when the following conditions are met:
•The hours for PDN for each client have been authorized through CCP.
•Only the actual "hands-on" time spent with each client is billed for that client.
•The hours billed for each client do not exceed the total hours approved for that client and do not exceed the actual number of hours for which services were provided.
Example: If the prior authorized PDN hours for Client A is 4 hours, Client B is 6 hours, and the actual time spent with both clients is 8 hours, the provider must bill for the actual one-on-one time spent with each client, not to exceed the client's prior authorized hours or total hours worked. It would be acceptable to bill 4 hours for Client A and 4 hours for Client B, or 3 hours for Client A and 5 hours for Client B. It would not be acceptable to bill 5 hours for Client A and 3 hours for Client B. It would be acceptable to bill 10 hours if the nurse actually spent 10 hours onsite providing prior authorized PDN services split as 4 hours for Client A and 6 hours for Client B. A total of 10 hours cannot be billed if the nurse worked only 8 hours.
For reimbursement purposes, PDN should always be submitted with POS 2 (home) regardless of the setting in which services are actually provided. PDN may be provided in any of the following settings:
•Client's home
•Client's school
•Client's daycare facility
PDN that duplicate services that are the legal responsibility of the school districts are not reimbursed. The school district, through the SHARS program, is required to meet the client's skilled nursing needs while the client is at school; however, if those needs cannot be met by SHARS or the school district, documentation supporting medical necessity may be submitted to the CCP with documentation that nursing services are not provided in the school.
A responsible adult of a minor client or a client's spouse may not be reimbursed for PDN even if the responsible adult is an enrolled provider or employed by an enrolled provider.
PDN is subject to retrospective review and possible recoupment when the medical record does not document that the provision of PDN is medically necessary based on the client's situation and needs. The PDN provider's record must explain all discrepancies between the service hours approved and the service hours provided. For example, the parents released the provider from all responsibility for the service hours or the agency was not able to staff the service hours. The release of provider responsibility does not indicate the client does not have a medical need for the services during those time periods.
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