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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 : 4.1.4 Authorization Requirements : 4.1.4.3 PDN Provider Requirements

4.1.4.3
When a provider receives a referral for PDN services, the provider must have an RN perform a nursing assessment of the client within the client’s home environment. This assessment must be performed before seeking prior authorization for PDN services, with any request for PDN services recertification, or any request to modify PDN service hours. The assessment includes, but is not limited to, the determination of:
The existing level of care and any additional health-care services to include, but not limited to; SHARS, MDCP, PT, OT, ST, PHC, or case management services. Services provided under these programs will not prevent a client from obtaining medically necessary services. Certain school services are provided to meet education needs, not medical needs.
When an RN completes a client assessment and identifies a medical necessity for ADLs or health-related functions to be provided by a nurse, the scope of PDN services may include these ADLs or health-related functions.
Note:

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