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
will 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
will 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
will 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
will 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
will be
billed using the U1 modifier.
(F) A
visit conducted by a registered nurse (RN) for the provision of PDN servcies
must
will be
billed to Ohio medicaid using the TD modifier. A visit conducted by a licensed
practical nurse (LPN) for the provision of PDN servcies
services
must
will 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, 11/04/2021
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