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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 : 4.1.2 * PDN Services

4.1.2
All PDN services must be prior authorized.
Note:
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.
PDN services provide nursing care and parent, guardian, or responsible adult training and education intended to:
PDN services are nursing services ordered by a physician, included in the nursing plan of care (POC), and provided by an RN or LVN.
Note:
An advanced practice registered nurse (APRN) or a physician assistant (PA) may sign all documentation related to the provision of private duty nursing services on behalf of the client’s physician when the physician delegates this authority to the APRN or PA. The APRN or PA provider’s signature and license number must appear on the forms where the physician signature and license number blocks are required.
Professional nursing provided by an RN, as defined in the Texas Nursing Practice Act, means that 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.
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:
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, and are further defined as nursing services in the Code of Federal Regulations (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 beneficiary, 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 a nursing care on the basis of complexity alone (e.g., intravenous and intramuscular injections or insertion of catheters), and if medically necessary for the treatment of the client’s illness or injury, would be covered on that basis. However, in some cases, the client’s condition may cause a service that would ordinarily be considered unskilled 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 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 responsible adults.
Because Texas Medicaid is obligated to provide all medically necessary PDN services, a parent or guardian is not obligated to provide PDN services even if the parent or guardian has received the appropriate training. Medically necessary PDN services will not be denied to clients based on the parent or guardian’s ability to provide the necessary PDN services.
PDN services that are intended to provide mainly respite care; child care; or do not directly relate to the client’s medical needs or disability are not a benefit of Texas Medicaid.
The delivery of PDN services may inherently result in the relief of the parent, guardian, or responsible adult, child care, or some nonmedical, nonskilled activities in the course of providing nursing care.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.