Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.09-008 - Private Duty Nusing Services Update #104

Current through Register Vol. 49, No. 6, June, 2024
Section II
Private Duty Nursing
			 Services
222.000
Request for
			 Prior Authorization
A request for prior authorization for private duty nursing
				services must originate with the provider. The provider is responsible for
				completion of the Request for Private Duty Nursing Services Prior Authorization
				and Prescription Initial Request or Recertification (form DMS-2692) and
				obtaining the required medical information. Form DMS-2692 must be signed by the
				beneficiary's physician with documentation that a physical examination was
				performed within 12 months of the beginning of the initial request or the
				recertification. View or print form DMS-2692 and instructions for
				completion.
For PDN services in the beneficiary's home a
				social/environmental evaluation indicating a commitment on the part of the
				beneficiary's family to provide a stable and supportive home environment must
				accompany the request for prior authorization. Refer to Section
				224.000 of this manual for
				additional information required for the initial request.
All PA requests for Medicaid-eligible beneficiaries will be
				evaluated by the Division of Medical Services, Utilization Review (UR) Section,
				to determine the level of care and amount of nursing services to be authorized.
				View or print Utilization Review Section contact information.
The UR Section will notify the provider of the approval or
				denial of the PDN services PA request within 15 working days following the
				receipt of the PA request. If the PA request for PDN services is approved, page
				5 of form DMS-2692 will be returned to the provider with the number of hours
				approved indicated on the form. The PA number will be assigned
after
the provider sends in documentation of the
				actual hours worked.
Prior authorization is required for private duty nursing
				supervisory visits. The Prior Authorization request must be submitted with the
				monthly service billing along with supporting documentation. The PA number will
				be assigned after the provider sends in documentation of the actual hours
				worked.
NOTE: The prior authorization number MUST be entered on
				the claim form filed for payment of these services. The initial PA approval
				will only be authorized for a maximum of 90 days. A new request must be made
				for services needed for a longer period of time. Recertification may be
				authorized for a maximum of six (6) months. Refer to Section
				224.000 of this manual for
				information regarding recertification of PDN services. The effective date of
				the PA will be the date the patient begins receiving PDN services or the day
				following the last day of the previous PA approval.
Providers are cautioned that a prior authorization approval
				does not guarantee payment. Reimbursement is contingent upon eligibility of
				both the beneficiary and provider at the time service is provided and upon
				completeness and timeliness of the claim filed for the service. The provider is
				responsible for verifying the beneficiary's eligibility.
242.110
Private Duty Nursing Services
			 Procedure Codes
The following procedure codes are applicable when billing the
				Arkansas Medicaid Program for private duty nursing services.
Procedure Code
Modifier
Description
S9123
Private Duty Nurse, R.N.
S9124
Private Duty Nurse, L.P.N.
S9123*
U1
Supervisory Visit ;R.N
*Effective for dates of service on and after April 4, 2008
				procedure code S9123 U1 can be billed for a RN supervisory visit. The maximum
				time allowed for reimbursement per visit is 3 hours, with a maximum of 18
				visits per state fiscal year. Supervisory visits (as defined by the Arkansas
				Department of Health Rules and Regulations for Home Health Agencies) must be
				face-to-face and provided in a setting approved for private duty nursing
				services (see section
				242.200 ). Beneficiaries
				receiving extended care will require no less frequency than every two weeks of
				supervision. For beneficiaries classified as stable or chronic (beyond the
				first 3 months of extended care), RN supervisory visits will be no less than
				every 30 days.
242.120
Simultaneous Care of Two Patients
When a private duty nurse is caring for two patients
				simultaneously in the same location, the following procedure codes are to be
				used for the care provided to the second patient:
Procedure Code
Required Modifier
Description
S9123
UB
Private duty nurse, RN, 2nd
						  patient. Medicaid maximum allowable is 50% of the rate for S9123.
S9124
UB
Private duty nurse, LPN, 2nd
						  patient. Medicaid maximum allowable is 50% of the rate for S9124.
S9123*
UB U1
Supervisory Visit ;R.N 2nd
						  patient Medicaid maximum allowable is 50% of the rate for S9123
242.410
Private Duty Nursing Billing
			 Procedures
Private duty nursing services (PDN) are billed on a per unit
				basis. One unit equals one hour. Arkansas Medicaid will reimburse for the
				actual amount of cumulative PDN time on a monthly basis. Service time of less
				than one hour will not be rounded up to a full hour. Attach supervisory visit
				billing information with supporting documentation and assessment with the
				monthly private duty nursing billing. No supervisory visits will be covered
				without first providing prior authorized private duty nursing services within
				the same month. Billing units are cumulative up to one hour for the duration of
				one month. Supervisory visits of less than an hour can be billed cumulatively
				on a monthly basis but any visit less than a unit (hour) cannot be rounded up.
				Providers must file separate claims indicating the number of hours for each
				patient.
Type of service code "1" must be used when filing paper claims.
				Public schools must use type of service code "S" when filing paper claims for
				beneficiaries under age 21.
Refer to Sections
				242.110 and
				242.120 for PDN procedure codes
				for single patient care and multiple patient care.