016.06.05 Ark. Code R. 010

Current through Register Vol. 49, No. 10, October, 2024

Rule 016.06.05-010 - Private Duty Nursing Update Transmittal #56

Section II Private Duty Nursing Services

201.100Private Duty Nursing Services Providers

Providers of Private Duty Nursing Services (PDN) must meet the following criteria in order to be eligible for participation in the Arkansas Medicaid Program:

A. The PDN provider must have either a Class A or Class B license issued by the Arkansas Department of Health. It must be designated on the license that the PDN agency is a provider of extended care services.

1. A copy of the license must accompany the provider application and Medicaid contract.

2. Subsequent licensure must be provided when issued by the Arkansas Department of Health.

3. For purposes of review under the Arkansas Medicaid Program, agencies enrolled as Class B operators providing private duty nursing services must adhere to those standards governing quality of care, skill and expertise applicable to Class A operators.

B. The PDN provider must complete a provider application (form DMS-652), Medicaid contract (form DMS-653) and a Request for Taxpayer Identification Number and Certification (Form W-9). View or print a provider application (form DMS-652), a Medicaid contract (form DMS-653) and a Request for Taxpayer Identification Number and Certification (Form W-9).

C. The Arkansas Medicaid Program must approve the provider application and the Medicaid contract as a condition of participation in the Medicaid program. Persons and entities that are excluded or debarred under any state or federal law, regulation, or rule, are not eligible to enroll, or to remain enrolled as Medicaid providers.

Providers who have agreements with Medicaid to provide other services to Medicaid recipients must have a separate provider application and Medicaid contract to provide private duty nursing services. A separate provider number is assigned.

201.200School District or Education Service Cooperative Private Duty Nursing Services Providers

Arkansas Medicaid will enroll Arkansas school districts and Education Service Cooperatives (ESC) as Private Duty Nursing Services (PDN) providers when the following criteria are met:

A. The school district or Education Service Cooperative must complete a provider application (form DMS-652), Medicaid contract (form DMS-653) and a Request for Taxpayer Identification Number and Certification (Form W-9). View or print a provider application (form DMS-652), a Medicaid contract (form DMS-653) and a Request for Taxpayer Identification Number and Certification (Form W-9).

B. The school district or ESC must be certified by the Arkansas Department of Education (ADE) as a Local Educational Agency (LEA). The ADE will provide verification of LEA certification to the Provider Enrollment Unit of the Arkansas Division of Medical Services. Subsequent certifications must be provided when issued.

C. The Arkansas Medicaid Program must approve the provider application and the Medicaid contract as a condition of participation in the Medicaid program. Persons and entities that are excluded or debarred under any state or federal law, regulation, or rule, are not eligible to enroll, or to remain enrolled as Medicaid providers.

241.000Introduction to Billing

Private Duty Nursing providers use the CMS-1500 form to bill the Arkansas Medicaid Program on paper for services provided to eligible Medicaid recipients. Each claim may contain charges for only one recipient.

Section III of this manual contains information about Provider Electronic Solutions (PES) and other available options for electronic claim submission.

242.000CMS-1500 Billing Procedures

242.100Procedure Codes

242.110Private Duty Nursing Services Procedure Codes

The following procedure codes are applicable when billing the Arkansas Medicaid Program for private duty nursing services.

Procedure Code	Description
S9123	Private Duty Nurse, R.N.
S9124	Private Duty Nurse, L.P.N.

242.120Simultaneous 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.

242.130Medical Supplies Procedure Codes

The following HCPCS procedure codes must be used when billing the Arkansas Medicaid Program for medical supplies.

A4206	A4216	A4217	A4221	A4222	A4253
A4256	A4259	A4265	A4310	A4311	A4312
A4313	A4314	A4315	A4316	A4320	A4322
A4326	A4327	A4328	A4330	A4338	A4340
A4344	A4346	A4347	A4348	A4351	A4352
A4354	A4355	A4356	A4357	A4358	A4359
A4361	A4362	A4364	A4367	A4369	A4371
A4397	A4398	A4399	A4400	A4402	A4404
A4405	A4406	A4414	A4452	A4454	A4455
A4558	A4560	A4561	A4562	A4623	A4624
A4625	A4626	A4628	A4629	A4772	A4927
A5051	A5052	A5053	A5054	A5055	A5061
A5062	A5063	A5071	A5072	A5073	A5081
A5082	A5093	A5102	A5105	A5112	A5113
A5114	A5119	A5121	A5122	A5126	A5131
A6154	A6234	A6241	A6242	A6248	A6441
A6442	A6443	A6444	A6445	A6446	A6447
A6448	A6449	A6450	A6451	A6452	A6453
A6454	A6455	A7520	A7521	A7522	A7524
A7525	B4086	E0776

National HCPCS Codes

Procedure Code	Required Modifier	Description
A6257	Transparent Film, each (16 square inches or less)
A6258	Transparent Film, each (more than 16, but less than 48 square inches)
A6259	Transparent Film, each (more than 48 square inches)
A6216 A6219 A6228	Gauze Pad, Medicated or Non-Medicated, each (16 square inches or less)
A6220 A6229 A6217	Gauze Pads, Medicated or Non-Medicated, each (more than 16, but less than 48 square inches)
A6221 A6230 A6218	Gauze Pads, Medicated or Non-Medicated, each (more than 48 square inches)
A4450	Gauze, Non-Elastic, Per Roll (1 linear yard)
A6245 A6242	Hydro gel Dressing, each (16 square inches or less)
A6246	Hydro gel Dressing, each (more than 16, but less than 48 square inches)
A6247 A6244	Hydro gel Dressing, each (more than 48 square inches)
A6248	Hydro gel Dressing, each (1 ounce)
A6237 A6234	Hydrocolloid Dressing, each (16 square inches or less)
A6238 A6235	Hydrocolloid Dressing, each (more than 16, but less than 48 square inches)
A6236 A6239	Hydrocolloid Dressing, each (more than 48 square inches)
A6196	Alginate Dressing, each (16 square inches or less)
A6197	Alginate Dressing, each (more than 16, but less than 48 square inches)
A6198	Alginate Dressing, each (more than 48 square inches)
A6197	UB	Alginate Dressing, each (1 linear yard)
A6209	Foam Dressing, each (16 square inches or less)
A6210	Foam Dressing, each (more than 16, but less than 48 square inches)
A6211	Foam Dressing, each (more than 48 square inches)
A6200	Composite Dressing, each (16 square inches or less)
A6201	Composite Dressing, each (more than 16, but less than 48 square inches)
A6202	Composite Dressing, each (more than 48 square inches)
A4253	UB	Blood Glucose test or reagent strip for home blood glucose monitor, per 25 strips
A4353	Urinary intermittent catheter with insertion tray
A4394	Ostomy deodorant, all types, per ounce
A4365	Adhesive remover wipes, 50 per box
A4368	Ostomy filters, any type, each
A4483	Tracheostomy vent-heat moisture device
L8239*	Stocking (Jobst)

*Refer to section 242.430

242.310Completion of CMS-1500 Claim Form

Field	Name and Number	Instructions for Completion
1.	Type of Coverage	This field is not required for Medicaid.
1a.	Insured's I.D. Number	Enter the patient's 10-digit Medicaid identification number.
2.	Patient's Name	Enter the patient's last name and first name.
3.	Patient's Birth Date	Enter the patient's date of birth in MM/DD/YY format as it appears on the Medicaid identification card.
Sex	Check "M" for male or "F" for female.
4.	Insured's Name	Required if there is insurance affecting this claim. Enter the insured's last name, first name and middle initial.
5.	Patient's Address	Optional entry. Enter the patient's full mailing address, including street number and name, (post office box or RFD), city name, state name and ZIP code.
6.	Patient Relationship to Insured	Check the appropriate box indicating the patient's relationship to the insured if there is insurance affecting this claim.
7.	Insured's Address	Required if insured's address is different from the patient's address.
8.	Patient Status	This field is not required for Medicaid.
9.	Other Insured's Name	If patient has other insurance coverage as indicated in Field 11D, enter the other insured's last name, first name and middle initial.
a. Other Insured's Policy or Group Number	Enter the policy or group number of the other insured.
b. Other Insured's Date of Birth	This field is not required for Medicaid.
Sex	This field is not required for Medicaid.
c. Employer's Name or School Name	Enter the employer's name or school name.
d. Insurance Plan Name or Program Name	Enter the name of the insurance company.
10.	Is Patient's Condition Related to:
a. Employment	Check "YES" if the patient's condition was employment related (current or previous). If the condition was not employment related, check "NO."
b. Auto Accident	Check the appropriate box if the patient's condition was auto accident related. If "YES," enter the place (two letter state postal abbreviation) where the accident took place. Check "NO" if not auto accident related.
c. Other Accident	Check "YES" if the patient's condition was other accident related. Check "NO" if not other accident related.
10d	. Reserved for Local Use	This field is not required for Medicaid.
11.	Insured's Policy Group or FECA Number	Enter the insured's policy group or FECA number.
a. Insured's Date of Birth	This field is not required for Medicaid.
Sex	This field is not required for Medicaid.
b. Employer's Name or School Name	Enter the insured's employer's name or school name.
c. Insurance Plan Name or Program Name	Enter the name of the insurance company.
d. Is There Another Health Benefit Plan?	Check the appropriate box indicating whether there is another health benefit plan.
12.	Patient's or Authorized Person's Signature	This field is not required for Medicaid.
13.	Insured's or Authorized Person's Signature	This field is not required for Medicaid.
14.	Date of Current: Illness Injury Pregnancy	Required only if medical care being billed is related to an accident. Enter the date of the accident.
15.	If Patient Has Had Same or Similar Illness, Give First Date	This field is not required for Medicaid.
16.	Dates Patient Unable to Work in Current Occupation	This field is not required for Medicaid.
17.	Name of Referring Physician or Other Source	Primary Care Physician (PCP) referral is required for Private Duty Nursing services. Enter the referring physician's name.
17a	. I.D. Number of Referring Physician	Enter the 9-digit Medicaid provider number of the referring physician.
18.	Hospitalization Dates Related to Current Services	For services related to hospitalization, enter hospital admission and discharge dates in MM/DD/YY format.
19.	Reserved for Local Use	Local Education Agency (LEA) code that identifies the school district in which therapy services are provided.
20.	Outside Lab?	This field is not required for Medicaid.
21.	Diagnosis or Nature of Illness or Injury	Enter the diagnosis code from the ICD-9-CM. Up to four diagnoses may be listed. Arkansas Medicaid requires providers to comply with CMS diagnosis coding requirements found in the ICD-9-CM edition current for the claim dates of service.
22.	Medicaid Resubmission Code Original Ref No.	Reserved for future use. Reserved for future use.
23.	Prior Authorization Number	Enter the prior authorization number, if applicable.
24.	A. Dates of Service	Enter the "from" and "to" dates of service, in MM/DD/YY format, for each billed service. On a single claim detail (one charge on one line), bill only for services within a single calendar month.
B. Place of Service	Enter the appropriate place of service code. See Section 242.200 for codes.
C. Type of Service	Enter the appropriate type of service code. See Section 242.200 for codes.
D. Procedures, Services or Supplies
CPT/HCPCS	Enter the correct CPT or HCPCS procedure code.
Modifier	A modifier is required when billing for a second patient's PDN services.
E. Diagnosis Code	Enter a diagnosis code that corresponds to the diagnosis in Field 21. If preferred, simply enter the corresponding line number ("1," "2," "3," "4") from Field 21 on the appropriate line in Field 24E instead of reentering the actual corresponding diagnosis code. Enter only one diagnosis code or one diagnosis code line number on each line of the claim. If two or more diagnosis codes apply to a service, use the code most appropriate to that service. The diagnosis codes are found in the ICD-9-CM.
F. $ Charges	Enter the charge for the service. This charge should be the provider's usual charge to private clients. If more than one unit of service is being billed, enter the charge for the total number of units billed.
G. Days or Units	Enter the units (in whole numbers) of service rendered within the time frame indicated in Field 24A.
H. EPSDT/Family Plan	Enter "E" if services rendered were a result of a Child Health Services (EPSDT) screening/referral.
I. EMG	Emergency - This field is not required for Medicaid.
J. COB	Coordination of Benefit - This field is not required for Medicaid.
K. Reserved for Local Use	When billing for a clinic or group practice, enter the 9-digit Medicaid provider number of the performing provider in this field and enter the group provider number in Field 33 after "GRP#." When billing for an individual practitioner whose income is reported by 1099 under a Social Security number, DO NOT enter the provider number here. Enter the number in Field 33 after "GRP#."
25.	Federal Tax I.D. Number	This field is not required for Medicaid. This information is carried in the provider's Medicaid file. If it changes, please contact Provider Enrollment.
26.	Patient's Account No.	This is an optional entry that may be used for accounting purposes. Enter the patient's account number, if applicable. Up to 16 numeric or alphabetic characters will be accepted.
27.	Accept Assignment	This field is not required for Medicaid. Assignment is automatically accepted by the provider when billing Medicaid.
28.	Total Charge	Enter the total of Field 24F. This field should contain a sum of charges for all services indicated on the claim form. (See NOTE below Field 30.)
29.	Amount Paid	Enter the total amount of funds received from other sources. The source of payment should be indicated in Field 11 and/or Field 9. Do not enter any amount previously paid by Medicaid. (See NOTE below Field 30.)
30.	Balance Due	Enter the net charge. This amount is obtained by subtracting the amount received from other sources from the total charge. NOTE: For Fields 28, 29 and 30, up to 28 lines may be billed per claim. To bill a continued claim, enter the page number of the continued claim here (e.g., page 1 of 3, page 2 of 3). On the last page of the claim, enter the total charges due.
31.	Signature of Physician or Supplier, Including Degrees or Credentials	The provider or designated authorized individual must sign and date the claim certifying that the services were personally rendered by the provider or under the provider's direction. "Provider's signature" is defined as the provider's actual signature, a rubber stamp of the provider's signature, an automated signature, a typewritten signature or the signature of an individual authorized by the provider rendering the service. The name of a clinic or group is not acceptable.
32.	Name and Address of Facility Where Services Were Rendered (If Other Than Home or Office)	If other than home or office, enter the name and address, specifying the street, city, state and ZIP code of the facility where services were performed.
33.	Physician's/Supplier's Billing Name, Address, ZIP Code & Phone #	Enter the billing provider's name and complete address. Telephone number is requested but not required.
PIN #	This field is not required for Medicaid.
GRP #	Clinic or Group Providers: Enter the 9-digit pay-to provider number in Field 33 after "GRP#" and the individual practitioner's number in Field 24K. Individual Providers: Enter the 9-digit pay-to provider number in Field 33 after "GRP#."

242.421Simultaneous Care of Two Patients in the Recipients' Home or a DDS Facility

When a private duty nurse is caring for two patients simultaneously in a location other than a public school, Arkansas Medicaid reimburses 100% of the maximum allowable rate for the first patient and 50% of the maximum allowable rate for the second patient.

Providers must file separate claims indicating the number of hours of care for each patient.

Providers must request prior authorization for procedure codes S9123 and S9124.

242.430Private Duty Nursing Medical Supplies

Procedure code L8239 must be prior authorized. Form DMS-679 may be used to request prior authorization. View or print form DMS 679.

Refer to Section 242.130 for procedure codes of covered medical supplies.

016.06.05 Ark. Code R. 010

6/3/2005