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2012 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2. Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.9 Private Duty Nursing (CCP) : 2.9.3 Prior Authorization and Documentation Requirements : Nursing Addendum to Plan of Care (CCP) Form
The Nursing Addendum to Plan of Care (CCP) Form addresses PDN eligibility criteria, nursing care plan summary, health history summary, 24‑hour schedule, and the rationale for the hours of PDN requested.
The following is a description of the nursing care plan summary:
The problem list must reflect the reasons that nursing services are needed. The problem list is not the nursing care plan. Providers must identify two-to-four current priority problems from their nursing care plan. The problem does not need to be stated as a nursing diagnosis. The problems listed must focus on the primary reasons that a licensed nurse is required to care for the client. Other attached documents are not accepted in lieu of this section.
The Goals must relate directly to the problems listed and be client-specific and measurable. Goals may be short- or long-term; however, for many clients who receive PDN, the goals generally are long-term.
The Outcomes are the effects of the provider’s nursing interventions and must be measurable. Generally, these are more short-term than goals. For initial requests, list expected outcomes. Extension requests should note the results of nursing interventions.
The Progress must be viewed as a “yardstick” or continuum on which progress toward goals is marked. Initial requests must state expected progress for the authorization period. Extension requests must list the progress noted during the previous authorization period. It is recognized that all progress may not be positive.
The summary of recent health history is imperative in determining whether the client’s condition is stable or if new nursing care needs have been identified. This section gives the PDN provider an opportunity to describe the client’s recent health problems, including acute episodes of illness, hospitalizations, injuries, and so on. The summary should create a complete picture of the client’s condition and nursing care needs. The summary may cover the previous 90 days, even though the authorization period is 60 days; however, the objective of the summary is to capture the client’s recent health problems and current health priorities. This section should not be merely a list of events. This section is the place to indicate the frequency of nursing interventions if they are different from the physician’s order on the POC, such as, the order may be for a procedure to be PRN (Pro Re Nata “As Needed”), but it is actually being performed every two hours.
The addendum must include the rationale for increasing, decreasing, or maintaining the level of PDN and must relate to the client’s health problems and goals. The client’s 24‑Hour Daily Schedule
All direct-care services must be identified. It is understood that the schedule may change, as the client’s needs change. CCP does not have to be notified of changes in the schedule except as they occur when a PDN recertification is requested.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2011 American Medical Association. All rights reserved.