Table of Contents Previous Next

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 : 4.1.5 Procedure Codes and Limitations

4.1.5
4.1.5.1
PDN services provided by home health agencies must be billed in 15-minute increments using procedure codes T1002 and T1003 based on the type of provider rendering the services.
PDN services provided by independently enrolled RNs must be billed in 15-minute increments with the TD modifier using the procedure code T1000 based on the type of provider rendering the services.
PDN services provided by independently enrolled LVNs must be billed in 15-minute increments with the TE modifier using procedure code T1000 based on the type of provider rendering the services.
PDN services that are provided by home health agencies must be billed in 15-minute increments with procedure code T1000 and either the TD or the TE modifier, which is based on the type of provider rendering the services.
When PDN services are provided in a provider or client ratio other than 1:1, only the time spent on direct PDN services for each client will be reimbursed. Total PDN services billed for all clients cannot exceed an individual provider’s total number of hours at the place of service.
When clients are receiving both PDN services and PCS from an individual person over the same span of time, all services will be reimbursed according to the maximum allowable fee schedule.
For reimbursement purposes, PDN services is always billed as place of service 2 (home) regardless of the setting in which services are actually provided. PDN services may be provided in the following settings, but are not limited to the:
Note:
Texas Medicaid will not reimburse PDN services that duplicate services that are the legal responsibility of the school districts. The school district, through the SHARS program is required to meet the client’s SN needs while the client is at school. However, if those needs cannot be met by SHARS or the school district, documentation supporting medical necessity may be submitted to the THSteps-CCP authorization department.
A parent or guardian of a minor client, or the client’s spouse may not be reimbursed for PDN services even if he or she is an enrolled provider or employed by an enrolled provider.
PDN services may be billed on the same day as PPECC services, but may not be billed simultaneously with PPECC services. PDN may be billed when it occurs before or after PPECC services.
PDN services is subject to retrospective review and possible recoupment when the medical record does not document the provision of PDN services is medically necessary based on the client’s situation and needs. The PDN services provider’s record must explain all discrepancies between the service hours approved and the service hours provided. For example: the parents released the provider from all responsibility for the service hours or the agency was not able to staff the service hours. The release of provider responsibility does not indicate the client does not have a medical need for the services during those time periods.

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