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December 2016 Texas Medicaid Provider Procedures Manual

Home Health Nursing and Private Duty Nursing Services Handbook : 4 Private Duty Nursing (PDN) Services - CCP : 4.1 * Services, Benefits, Limitations, and Prior Authorization

PDN services are a benefit of the Texas Health Steps-Comprehensive Care Program (THSteps-CCP) for Medicaid clients who are 20 years of age or younger. PDN services are nursing services, as described by the Texas Nursing Practice Act and its implementing regulations, for clients who meet the medical necessity criteria, and who require individualized, continuous, skilled care beyond the level of SN visits normally authorized under Texas Medicaid Home Health SN and Home Health Aide (HHA) Services. PDN services may be provided by a registered nurse (RN) or a licensed vocational nurse (LVN).
The procedure codes T1002 and T1003 are benefits of Texas Medicaid when PDN services are provided by a home health agency.
The procedure code T1000 is a benefit of Texas Medicaid when PDN services are provided by a home health agency or an independently enrolled RN or LVN.
When services are delivered by an RN, the independently enrolled RN or the home health agency should include modifier TD. When services are delivered by an LVN, the independently enrolled LVN or home health agency should include modifier TE.
The TD and TE modifiers are required for reimbursement purposes when procedure code T1000 is submitted on a claim. The modifiers do not have to be submitted with a prior authorization request.
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 the 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 must 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 must be billed for 8 hours (32 15-minute units) on one detail for that date of service.
PDN may be delivered in a provider to 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 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.
If the prior authorized PDN hours for Client A is four hours, Client B is six hours, and the actual time spent with both clients is eight 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 four hours for Client A and four hours for Client B, or three hours for Client A and five hours for Client B. It would not be acceptable to bill five hours for Client A and three hours for Client B. It would be acceptable to bill ten hours if the nurse actually spent ten hours onsite providing prior authorized PDN services split as four hours for Client A and six hours for Client B. A total of ten hours cannot be billed if the nurse worked only eight hours.
For reimbursement purposes, PDN must 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:

Texas Medicaid & Healthcare Partnership
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