Private Duty Nursing Billing for STAR, STAR Health and STAR Kids Members

Date: 07/13/20

Superior HealthPlan complies with all applicable rules and guidelines in the provision of Private Duty Nursing (PDN) services under the federal Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program, known in Texas as Texas Health Steps. Superior Medicaid members (STAR, STAR Health, STAR Kids) under 21 years of age are entitled to all medically necessary EPSDT services that: (1) correct or ameliorate defects and physical and mental illnesses and conditions; and (2) are eligible for federal financial participation.

Superior administers the benefits for PDN as specified in the Texas Medicaid Provider Procedures Manual (TMPPM), Home Health Nursing and Private Duty Nursing Services Handbook, Chapter 4, as well as the STAR Kids Billing Matrix and Crosswalk for STAR Kids. Both billing resources provide the applicable procedure codes and associated modifier for accurate billing and payment for PDN services, per the categories below:

• PDN RN, PDN LVN
• PDN Specialized RN, PDN Specialized LVN
• PDN Independently Enrolled RN, PDN Independently Enrolled LVN
• PDN Independently Enrolled Specialized RN, PDN Independently Enrolled Specialized LVN

Specialized PDN services can be billed and reimbursed for PDN services delivered by an RN or LVN, to a member who has a tracheostomy or is ventilator dependent, when applicable.

Please note: Claims for specialized services must include modifier “UA” to indicate specialized services were provided, and must also include an appropriate diagnosis on the claim for members with a tracheostomy or who are ventilator dependent.

To ensure providers are accurately reimbursed for specialized services for applicable members, providers must comply with the following requirements:

• Diagnosis codes for a member who has a tracheostomy or is ventilator dependent must be submitted, consistent with the TMPPM diagnosis codes for use with Modifier UA; AND
• Diagnosis codes for a member who has a tracheostomy or is ventilator dependent must be included in the primary diagnosis on the claim; AND
• Modifiers for specialized PDN must include Modifier UA, as well as the applicable modifiers to indicate RN (Modifer TD) or LVN (Modifier TE) performing provider, as well as modifier U3 if the provider is independently enrolled through the Texas Medicaid Program; AND
• Primary, secondary and tertiary modifiers for specialized PDN for STAR Kids members must be submitted consistent with the ‘order’ of modifiers in the STAR Kids Billing Matrix and Crosswalk.

NOTE:  Providers must comply with all applicable billing requirements for PDN, including the billing requirements for specialized PDN services specified above, to ensure applicable services are accurately reimbursed. For STAR Health, please reference the STAR Health PDN Billing Guide (PDF).