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WARNING: THIS IS A TEXAS HEALTH AND HUMAN SERVICES INFORMATION RESOURCES SYSTEM THAT CONTAINS STATE AND/OR U.S. GOVERNMENT INFORMATION. BY USING THIS SYSTEM YOU ACKNOWLEDGE AND AGREE THAT YOU HAVE NO RIGHT OF PRIVACY IN CONNECTION WITH YOUR USE OF THE SYSTEM OR YOUR ACCESS TO THE INFORMATION CONTAINED WITHIN IT. BY ACCESSING AND USING THIS SYSTEM YOU ARE CONSENTING TO THE MONITORING OF YOUR USE OF THE SYSTEM, AND TO SECURITY ASSESSMENT AND AUDITING ACTIVITIES THAT MAY BE USED FOR LAW ENFORCEMENT OR OTHER LEGALLY PERMISSIBLE PURPOSES. ANY UNAUTHORIZED USE OR ACCESS, OR ANY UNAUTHORIZED ATTEMPTS TO USE OR ACCESS, THIS SYSTEM MAY SUBJECT YOU TO DISCIPLINARY ACTION, SANCTIONS, CIVIL PENALTIES, OR CRIMINAL PROSECUTION TO THE EXTENT PERMITTED UNDER APPLICABLE LAW.
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AMA/ADA End User License Agreement
LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT® ")

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PPECC Benefit Criteria Updates Effective December 1, 2024

Last updated on 10/14/2024

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

Effective for dates of service on or after December 1, 2024, benefit criteria will be updated for prescribed pediatric extended care center (PPECC) services for Texas Medicaid.

The changes to the PPECC services benefit criteria are summarized as follows:

Updates to the PPECC plan of care (POC) requirements and to the PPECC Plan of Care Form and Instructions
Updates to prior authorization requirements
Updates to documentation requirements

Plan of Care (POC)

The POC requirements have been updated and must include the following, as applicable:

Indication of whether the client is stable enough to receive transportation services provided by the PPECC as determined by the client’s ordering physician.
- If the client’s ordering physician determines that the client is stable, the client’s ordering physician, in collaboration with the PPECC, must specify the type of provider—registered nurse (RN), licensed vocational nurse (LVN), or direct care staff—who must be on board the PPECC transport vehicle to assist the client during the transportation to and from the PPECC.
- Transportation must be provided by a PPECC when the client’s ordering physician has determined that the client is stable, and the client or the client’s responsible adult wants the client to receive transportation services to and from the PPECC.
- When a client’s ordering physician has determined that a client is stable enough to receive PPECC transportation, and the client or the client’s responsible adult wants the client to receive transportation services, the client must be able to use transportation services offered by the PPECC with the assistance of a PPECC nurse or direct care staff member to and from the PPECC rather than a nonemergency ambulance.

Note: A client or a client’s responsible adult may decline a PPECC’s transportation services entirely, on a specific date or for part of a day and choose to be transported by other means. The decision by a client or a client’s responsible adult to use or not use PPECC transportation services does not preclude a PPECC from being eligible for reimbursement of non-transportation services.

The Prescribed Pediatric Extended Care Center (PPECC) Plan of Care Form and the Prescribed Pediatric Extended Care Center (PPECC) Plan of Care Instructions will be updated to:

Remove the requirement for the ordering physician to indicate whether or not PPECC transportation services are required.
Add the requirement for the ordering physician to indicate that a client is stable to receive PPECC transportation services.
Include the type of staff (RN, LVN, or direct care staff) who must accompany the client during transport to and from a PPECC.
No longer require the signature of a client or a client’s responsible adult on the PPECC Plan of Care form.

When a PPECC provides transportation for a PPECC client, an RN, LVN, or direct care staff member—as determined by the client’s ordering physician in collaboration with the PPECC—must be on board the PPECC transport vehicle to assist the client during transportation.

Prior Authorization Requirements

The documentation of medical necessity that is required for PPECC services will be updated to include the following:

A physician’s order prescribing PPECC services signed and dated by an ordering physician who has personally examined the client in person within 30 calendar days prior to admission and reviewed all appropriate medical records.

The physician may waive the examination when:

A diagnosis has already been established by the physician.
The client is under the continuing care and medical supervision of the physician.
The physician has stated in writing that an examination of the client 30 calendar days prior to admission is not medically necessary.

If the physician waives an examination, the physician must examine the client in person within 365 calendar days after the date of the client’s last examination. The physician and PPECC must maintain documentation of the waived examination in the client’s medical record.

Prior Authorization Requests

Initial, recertification, and revision prior authorization requests for PPECC services sections have been updated as follows:

PPECC services may be authorized based on the client’s individual needs as hours per day, hours per week, or days per week.

Consistent with PPECC licensure requirements, an initial comprehensive nursing assessment must be completed, signed, and dated by the PPECC RN no earlier than three business days before the start of care at the PPECC and no later than the day the client is admitted to the center.

A written order prescribing PPECC services that is signed and dated by the client’s ordering physician must be in place by the SOC date.

The signatures of the ordering physician, the PPECC RN, and the client or the client’s responsible adult must be current on the initial, recertification, and revised prior authorization request forms. Prior authorization requests that have signatures dated after the SOC date will be denied for dates of service prior to the latest dated signature.

When initial, recertification, and revised prior authorization requests are submitted with verbal approval of the POC, the ordering physician’s signature on the POC must be dated within 14 calendar days following the receipt of the authorization request by the claims administrator. If the POC is not received with a physician’s signature dated within 14 calendar days of the receipt of the authorization request by the claims administrator, the prior authorization request will be considered incomplete and will be denied.

When initial, recertification, and revised prior authorization requests are submitted with verbal approval of the POC, all other documentation forms must still be signed and dated within 30 calendar days before the SOC date. If the other required documentation forms are received with signatures dated after the SOC date, the prior authorization requests will be denied for dates of service prior to the latest dated signature.

Recertification or Extension Request

The PPECC provider must notify the claims administrator and the client’s ordering physician at any time during a recertification period if the client’s condition changes, the authorized services are not commensurate with the client’s medical needs, or the client requires additional hours of ongoing skilled nursing services. The submission of a revised authorization request with physician signatures on required documentation meets the notification requirement.

Appeal of Authorization Decisions

The following language describing when PPECC services may be denied will be added to the Texas Medicaid Provider Procedures Manual (TMPPM):

The prior authorization request is submitted with documentation of a verbal physician approval of the POC, and the physician signed and dated POC is not received by the claims administrator within 14 calendar days of the receipt of the authorization request by the claims administrator.
The prior authorization request is submitted late.

Documentation Requirements

The documentation requirements below will be updated to clearly outline the documentation that a PPECC must obtain and maintain to be eligible for reimbursement.

The physician’s order has been updated to remove the transportation authorization and will now require the following:

Written orders from the ordering physician that prescribe PPECC services. If the PPECC obtains a verbal order for a revision request from the ordering physician, dated documentation of this verbal order must also be maintained in the client’s medical record.
Determination of whether the client is stable enough to receive PPECC transportation services and, if the client is determined to be stable, the provider type that must be on board: RN, LVN, or direct care staff, if applicable.
The ordering physician must also maintain a copy of the signed and dated physician order and a copy of a signed and dated POC.

A completed PPECC Plan of Care form must be signed and dated by the ordering physician and the PPECC RN completing the POC. If the PPECC obtains verbal approval of the POC from the ordering physician, the PPECC must maintain dated documentation of this verbal approval of the POC in the client’s medical record. The POC, using either the PPECC POC form or a PPECC-developed form, must include the following components:

The determination by the client’s ordering physician of whether the client is stable enough to receive PPECC transportation.
The description of the type of provider—RN, LVN, or direct care staff—who must be present on board the PPECC vehicle to assist the client if the client is determined stable.

The Nursing Addendum has been updated to clarify the essential fields on the POC that must be completed:

The client’s name and Medicaid number
The requested SOC date and requested end date for PPECC services
A nursing care plan summary, including a current problem list
A current summary and rationale page
A 24-hour daily care flow sheet
An acknowledgments page that includes the signed and dated signature of the client or the client’s responsible adult, the RN who completed the POC, and the ordering physician

Clarifying language will be added for the signed and dated consent of the client or the client’s responsible adult documenting the following:

The client’s or client’s responsible adult’s choice for PPECC services
Acknowledgment that the client or client’s responsible adult has been informed that their PDN service hours might be reduced as a result of accepting PPECC services
Consent to share the client’s personal health information with the client’s other providers to ensure coordination of care

Note: The signature of a client or a client’s responsible adult on the Nursing Addendum to Plan of Care for Private Duty Nursing and/or Prescribed Pediatric Extended Care Centers meets the client consent requirements.

For each day that PPECC services are provided, the PPECC must maintain a daily attendance log that includes:

The date of attendance.
The name of the client.
The signature of the responsible adult and the time when the PPECC assumes responsibility for the care of the client, which is the time the client boards the PPECC transport vehicle or the time the client is brought to the PPECC by a responsible adult.
The signature of the responsible adult and the time when the responsible adult assumes responsibility for the care of the client, which is the time the client is taken off the PPECC transport vehicle at their return destination or the time the client is picked up from the PPECC by a responsible adult.
The name of the PPECC staff member riding in the PPECC transport vehicle when PPECC transportation services are used and whether the staff member is an RN, LVN, or direct care staff.

The PPECC must ensure that the driver and the RN, LVN, or direct care staff member on board the PPECC transport vehicle maintain a daily transportation log that must include:

The driver’s name.
The name of the PPECC staff member and whether the staff member is an RN, LVN, or direct care staff member.
The date of service.
The name of the client.
The time that the client is put on the transport vehicle to deliver the client to the PPECC.
The time that the client arrives at the PPECC.
The time that the client is put on the transport vehicle to return to their responsible adult or authorized adult.
The time that the client arrives at their return destination and the name of the person to whom the client was released.
The reason that the transport time was longer than one hour for a client who is in transport longer than one hour traveling to the PPECC or longer than one hour traveling to their return destination.

The PPECC must coordinate the following with the client or the client’s responsible adult:

The client’s transportation schedule
The pick-up and drop-off locations (such as home or school)
The authorized persons to whom the client may be released

Coordination with Private Duty Nursing

Clarifying language will be added for the coordination with private duty nursing (PDN) services.

Clients who are eligible to receive PDN services may also receive PPECC services. A client may choose to receive all authorized PPECC and PDN service hours through PPECC services only, PDN services only, or a combination of both PPECC and PDN services. If a client chooses to receive both PPECC and PDN services, the client must not receive service hours in addition to what was initially authorized for PPECC and PDN unless additional hours are medically necessary.

Reimbursement

PPECC per diem procedure code T1025 and hourly procedure code T1026 may be billed without nonemergency transportation procedure code T2002 on the same date of service.

For more information, call the TMHP Contact Center at 800-925-9126.