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December 2016 Texas Medicaid Provider Procedures Manual

Home Health Nursing and Private Duty Nursing Services Handbook : 1 General Information : 1.2 Client Eligibility for PDN Services

PDN is considered medically necessary when a client has a disability, physical, or mental illness, or chronic condition and requires continuous, skillful observations, judgments, and interventions to correct or ameliorate his or her health status.
To be eligible for PDN services, a client must meet all the following criteria:
Provide continuing medical care and supervision of the client, including, but not limited to, examination or treatment within 30 calendar days prior to the start of PDN services, or examination or treatment that complies with the THSteps periodicity schedule, or is within six months of the PDN extension SOC date, whichever is more frequent (for extensions of PDN services). This requirement may be waived based on review of the client’s specific circumstances.
The physician visit may be waived when a diagnosis has already been established by the physician, and the client is under the continuing care and medical supervision of the physician. A waiver is valid for no more than 365 days, and the client must be seen by his or her physician at least once every 365 days. The waiver must be based on the physician’s written statement that an additional evaluation visit is not medically necessary. This documentation must be maintained by the physician and the provider in the client’s medical record.
Clients who are birth through 17 years of age must reside with a responsible adult who is either trained to provide nursing care or is capable of initiating an identified contingency plan when the scheduled private duty nurse is unexpectedly unavailable.
PDN is based on the need for skilled care in the client’s home; however, these services may follow the client and may be provided in accordance with 42 CFR §440.80. The POS must be able to support the client’s health and safety needs. It must be adequate to accommodate the use, maintenance, and cleaning of all medical devices, equipment, and supplies required by the client. Necessary primary and backup utilities, communication, fire, and safety systems must be available at all times.
The amount and duration of PDN must always be commensurate with the client’s medical needs. Requests for services must reflect changes in the client’s condition that affect the amount and duration of PDN.

Texas Medicaid & Healthcare Partnership
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