Ohio Admin. Code 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 servcies must be billed to Ohio medicaid using
the TD modifier. A visit conducted by a licensed practical nurse (LPN) for the
provision of PDN servcies 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.
Notes
Promulgated Under: 119.03
Statutory Authority: 5164.02,
Rule Amplifies: 5164.02, 5164.70.
Prior Effective Dates: 05/01/1987, 04/01/1988, 05/15/1989, 07/01/1998, 06/30/2006 (Emer.), 09/28/2006, 07/01/2008, 01/01/2010, 10/01/2011, 07/01/2015, 01/01/2017
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