TX.CP.MP.520 Private Duty Nursing (Medicaid)
TX.CP.MP.521 Private Duty Nursing (CHIP)
| Medicaid (STAR, STAR Health, STAR Kids), CHIP
| PDN Modifiers added:
- The PDN provider must use the CCP Prior Authorization Request Form (PDF) for all prior authorization requests. The form must include the following:
- Procedure code T1000 with appropriate modifiers:
- UA (specialized care) if appropriate
- TE (LVN) and/or TD (RN) specify allotted time /use of each modifier.
- A brief description of the services requested.
- Documentation of medical necessity.
Note: Documentation of medical necessity must also be included on the Home Health Plan of Care (POC) and the Nursing Addendum to Plan of Care for Private Duty Nursing and if appropriate Prescribed Pediatric Extended Care Centers forms.
- Modifier TD (RN) vs TE (LVN):
- Modifier TD (RN) is medically necessary when a member with complex health care needs requires independent nursing care with substantial specialized judgment and skill. Documentation of member specific needs that require independent care with the substantial specialized judgment and skill of an RN must be submitted with the request.
- Modifier TE (LVN) should be used when a member requires care involving nursing judgment and skill but within a more limited framework than a RN. LVNs provide care to members with predictable healthcare needs.
- Authorization requests that are received without modifier will be reviewed and determined as PDN request with a TE modifier (LVN).
- PDN providers that request prior authorization for specialized care (procedure code T1000 with modifier UA) must submit all the documentation required for PDN services.
- The primary practitioner must include the settings or modes for required equipment (e.g., ventilator, oxygen) in the physician-recommended plan of care (POC).
- PDN providers must also submit the clinical indications, as supported by a practitioner’s order and documented in the Home Health POC, that justify the specialized care. Clinical indications for specialized care include the following:
- Members who require a home ventilator with invasive interface (e.g., tracheostomy) associated with one of the following:
- Neuromuscular disease
- Thoracic restrictive disease
- Chronic respiratory failure consequent to chronic obstructive pulmonary disease
- Congenital central hypoventilation syndrome
- Chronic lung disease of infancy (e.g., bronchopulmonary dysplasia)
- Obesity hypoventilation syndrome
- Restrictive disorder of chest wall
- Other conditions requiring invasive ventilation supported with documentation of medical necessity by a physician
- Members with a functioning tracheostomy requiring both suctioning and other specified types of nursing care (e.g., dressing changes, skin care, humidification, or changing tracheostomy tubes and ties). Documentation in the treatment plan must include specific interventions and care.
- Requests for specialized care are considered not medically necessary if the member has a tracheostomy but does not meet the above requirements.
- It is the policy of Superior HealthPlan that PDN for specialized care are considered not medically necessary for the following indications:
- Members who use a non-invasive ventilator
- Members who use a ventilator exclusively to function as a respiratory assistance device, including continuous positive airway pressure (CPAP), auto-titrating positive airway pressure (PAP), bilevel positive airway pressure (BPAP, BiPAP), or adaptive servo-ventilation
- Superior will still consider prior authorization for PDN services even if Superior does not approve the services for specialized care.
Private Duty Nursing Discharge Planning added:
- Discharge planning is for a maximum duration of up to 14 calendar days, depending upon the extent of PDN needs. Requests beyond 14 calendar days are not appropriate for discharge planning and should be submitted as a standard request with all necessary documentation.
- Discharge planning PDN is medically necessary with all the following:
- Submission of a discharge order from the hospital (signed prescription, discharge paperwork, electronic or verbal order) with the following:
- Number of hours per day or week
- Duration (may not exceed 14 calendar days)
- Appropriate diagnosis
- Placement of the nurse in the home is done to meet the medically necessary skilled need of the member only and not for the convenience of the family or caregiver.
- And one of the following:
- Dependent on technology to sustain life; or
- Requires ongoing and frequent skilled interventions to maintain or improve health status; or
- Delaying skilled intervention directly impacts the health status of the member, due to the risk of sudden decompensation in the absence of direct ongoing nursing care (not observation).
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