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December 2016 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2 Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.14 * Prescribed Pediatric Extended Care Centers (PPECC) (CCP) : 2.14.1 Services, Benefits, and Limitations

2.14.1
PPECC services are provided in a non-residential facility licensed by the Texas Department of Aging and Disability Services (DADS). PPECCs serve four or more medically dependent or technologically dependent clients who are 20 years of age or younger and who require ongoing skilled nursing prescribed by the client’s physician to avert death or further disability or require the routine use of a medical device to compensate for a deficit in life-sustaining body function.
Services must be included in a PPECC plan of care (POC) and are limited to no more than 12 hours in a 24-hour period. PPECC services may not be provided overnight. PPECC services are intended as an alternative to private duty nursing (PDN). When the services duplicate, PPECC services must be a one-to-one replacement of private duty nursing (PDN) hours, unless additional hours are medically necessary.
PPECCs must comply with:
Clients who receive PPECC services through THSteps-CCP require ongoing medical supervision by the ordering physician who has a therapeutic relationship with and ongoing clinical knowledge of the client. A face-to-face evaluation must be performed each year by the ordering physician for each client. A physician order is required for each authorization period including initial, revisions, and recertification. A physician in a relationship with a PPECC (employed by or contracted with a PPECC) cannot provide the physician’s order, unless the physician is the client’s treating physician and has examined the client outside of the PPECC setting.
The following services may be rendered at a PPECC, but are not considered part of the PPECC services covered by Texas Medicaid, and must be billed separately by Medicaid-enrolled service providers:
When the client’s plan of care indicates that therapy services are required while the client is at the PPECC, clients must be provided a choice in speech, occupational, and physical therapy providers, as well as certified respiratory care providers. PPECC providers must coordinate care with the therapy providers to ensure the client receives therapy services as required in the PPECC setting.
Clients from birth through 36 months of age must be given the option of receiving ECI services in addition to their PPECC services. The PPECC providers must coordinate care with the client’s ECI service coordinator.
ECI services rendered in a PPECC are provided by entities that are contracted with the state to provide early intervention services.
When therapy services (occupational, speech, and/or physical therapy), or certified respiratory care services are rendered in a PPECC, they may be provided by:
Refer to:
The Certified Respiratory Care Practitioner (CRCP) Services Handbook (Vol. 2, Provider Handbooks) for information about CRCP (CCP) services.
An admission authorized under this section is not intended to supplant the right of a client to access private duty nursing (PDN), personal care services (PCS), home health skilled nursing (HHSN), home health aide (HHA), and therapies (PT, OT, ST), as well as certified respiratory care practitioner services and early childhood intervention (ECI) services rendered in the client’s residence when medically necessary.
PPECC providers must collaborate and coordinate care with the client’s existing service providers, including physicians, therapists, certified respiratory care practitioners, and home health agencies rendering services such as private duty nursing and/or home health skilled nursing, home health aide services, personal care services, hospice, and other providers who render medically necessary services. The PPECC must ensure the provision of the following basic services:
The development, implementation, and monitoring of a comprehensive POC in collaboration with the client or the client’s responsible adult that addresses the client’s medical, nursing, psychosocial, therapeutic, and developmental services, including the following prescribed services:
Note:
When a PPECC provides transportation to a PPECC client, Registered Nurse (RN) or Licensed Vocational Nurse (LVN) employed by the PPECC must be on board the transport vehicle.
When a client has a stated need or prescription for transportation, the client must be able to utilize transportation services offered by the PPECC with the assistance of a PPECC nurse to and from the PPECC, rather than a non-emergency ambulance.
Note:
Individualized, specific, and consistent with symptoms or confirmed diagnosis of the condition, illness or injury under treatment, not in excess of the client’s needs;
Consistent with generally accepted professional medical standards as determined by the Medicaid program and may not be experimental or investigational;
Note:
The fact that a client’s ordering physician has prescribed, recommended, or approved medical care, goods or services does not, in itself, make such care or services medically necessary or a covered service.

Texas Medicaid & Healthcare Partnership
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