Lawriter - OAC - 5160-12-06 Reimbursement: private duty nursing services.

5160-12-06 Reimbursement: private duty nursing services.

(A) Definitions of terms used for billing private duty nursing services (PDN) rates set forth in appendix A to this rule are:

(1) "Base rate," as used in this rule and appendix A to this rule, means the amount reimbursed by Ohio medicaid for the initial thirty-five to sixty minutes of service delivered.

(2) "Unit rate," as used in this rule and appendix A to this rule, means the amount reimbursed by Ohio medicaid for each fifteen minute units of service delivered when the initial visit is:

(a) Greater than sixty minutes in length; or

(b) Less than or equal to thirty-four minutes in length.

(B) PDN services are delivered and billed as PDN visits in accordance with rules 5160-12-02, 5160-12-2.3 and 5160-12-04 of the Administrative Code. The services must be provided by medicare certified home health agencies, "otherwise accredited agencies," or "non-agency nurses." PDN service rates are identified in appendix A to this rule.

(C) The amount of reimbursement for a PDN visit shall be the lesser of the provider's billed charge or the medicaid maximum rate. The medicaid maximum rate is determined by using a combination of the base rate and unit rate found in appendix A to this rule using the number of units of service that were provided during a visit in accordance with this chapter.

(D) The amount of reimbursement for a PDN visit shall be the lesser of the provider's billed charge or seventy-five per cent of the total medicaid maximum as specified in paragraph (C) of this rule when billing with the modifier HQ "group setting" for group visits conducted in accordance with rule 5160-12-04 of the Administrative Code.

(E) The modifiers set forth in appendix B to this rule must be used to provide additional information in accordance with this chapter. A visit made for the purpose of home infusion therapy in accordance with 5160-12-02 of the Administrative Code must be billed using the U1 modifier.

(F) A visit conducted by a registered nurse (RN) for the provision of PDN services must be billed to Ohio medicaid using the TD modifier. A visit conducted by a licensed practical nurse (LPN) for the provision of PDN services must be billed to Ohio medicaid using the TE modifier.

(G) Providers of PDN will not be reimbursed for PDN services provided to an individual that duplicate services already paid by medicaid or another funding source. For example, if the facility/home where a residential state supplemental recipient or individual receiving medicaid resides, such as an adult foster home, adult family home, adult group home, residential care facility, or other facility is paid to provide nursing services, PDN services are not reimbursable by medicaid.

(H) Providers of PDN may be reimbursed for PDN services provided to an individual who resides in a facility/home if the provider has written documentation from a facility/home stating that the facility/home is not responsible for providing the same or similar PDN services to the individual.

(I) PDN services provided to the individual enrolled in the assisted living home and community based services waiver in accordance with rule 5160-1-60 and Chapter 173-39 of the Administrative Code do not constitute a duplication of services.

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Effective: 1/1/2017
Five Year Review (FYR) Dates: 07/01/2020
Promulgated Under: 119.03
Statutory Authority: 5164.02, 5164.77
Rule Amplifies: 5164.02, 5164.70, 5164.77
Prior Effective Dates: 5/01/87, 4/01/88, 5/15/89, 7/01/98, 6/30/06 (Emer), 9/28/06, 7/01/08, 1/01/10, 10/01/11, 7/01/15.