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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 : 4.1.4.7 * Required Coordination between PDN and Prescribed Pediatric Extended Care Centers (PPECCs)

4.1.4.7
When a client or client’s physician notifies the PDN provider that the client also receives services from a Medicaid enrolled PPECC provider, the PDN provider must coordinate services with the PPECC provider. Both PDN and PPECC services are considered ongoing skilled nursing. A client has a choice of PDN, PPECC, or a combination of both PDN and PPECC for ongoing skilled nursing where PPECC services are available. Skilled Nursing services are authorized for a set number of hours based on the client’s medical necessity at the time of the prior authorization request. Skilled nursing hours are not expected to increase when the client utilizes a combination of both PDN and PPECC services, unless there is a documented change in medical condition, or the authorized hours are not commensurate to the client’s medical needs and additional hours are medically necessary.
PDN and PPECC providers must collaborate in developing their respective 24-hour flow charts found in the Nursing Addendum to Plan of Care for Private Duty Nursing and/or Prescribed Pediatric Extended Care Centers form each time a client’s authorization for ongoing skilled nursing is initiated, renewed and revised.
Both providers must maintain documentation that the client or the client’s responsible adult has participated in the development of the POC (e.g., the completed Home Health Plan of Care and Nursing Addendum, with client or client’s responsible adult signatures.
Both providers must discuss with the client or the client’s responsible adult how care will be coordinated between the two providers.
When a new service is initiated for ongoing skilled nursing services, and the client wants to receive both PDN and PPECC services, the Texas Medicaid Claims Administrator will compare the Nursing Addendum’s 24 hour daily care flow sheets and medical necessity documentation (e.g., authorization requests). Upon subsequent approval of PDN or PPECC services, the provider who submitted the initial prior authorization request that established the number of authorized skilled nursing hours will have their authorized hours reduced to prevent duplication.
When hours are reduced, the PDN or PPECC provider affected by the reduction will be notified by the Texas Medicaid Claims Administrator when the reduction is effective, and the revised amount of authorized hours. A revision request documenting medical necessity is required only if there is a change in the client’s medical condition or the client’s medical needs are not commensurate with authorized hours and additional ongoing skilled nursing hours are medically necessary. No action is required if additional hours are not medically necessary.

Texas Medicaid & Healthcare Partnership
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