1 Private Duty Nursing Program Training for Medicaid Private Duty Nursing Providers Prepared by the Home Care Initiatives Unit Home and Community Care.

1

Private Duty Nursing

Program Training for

Medicaid Private Duty Nursing ProvidersPrepared by the Home Care Initiatives Unit

Home and Community Care SectionN. C. Division of Medical Assistance

Private Duty Nursing Definitions

• Private Duty Nursing (PDN) is a Medicaid program providing substantial, complex, and continuous skilled nursing services (see slides 3-6) to beneficiaries at home.

• PDN services are provided – only in a beneficiary’s private primary residence, – under the direction of a physician-signed individualized plan of

care, – by a RN or LPN licensed with the NCBON and employed by a

licensed home care agency.

Definitions

Skilled Nursing

Skilled nursing is defined by 10A NCAC 13J.1102.

Definitions

Skilled Nursing (continued)

Skilled nursing does not include tasks that can be delegated to unlicensed personnel pursuant to 2l NCAC 36.0401

Definitions

Substantial

Requires the assessment and judgment of a licensed nurse.

Definitions

Complex

Complex means that there are scheduled, hands-on nursing interventions. Observation ‘in case something happens’ is not covered.

Definitions

Continuous

Continuous means there are nursing assessments requiring interventions at least every 3-4 hours during the period Medicaid covered PDN services are provided.

Definitions

Significant Change in Condition

Significant change is defined as a change in the beneficiary’s care needs that impacts more than one area of functional health status and requires more multidisciplinary review or a revision of the plan of care.

General Provisions

• A beneficiary must have NC Medicaid on the date of service.

• PDN is not covered for NC Health Choice beneficiaries.

EPSDT

• There are exceptions to policy limitations for beneficiariess under 21

EPSDT

Exceptions to EPSDT • unsafe, ineffective, or experimental/investigational.

• not medical in nature or not generally recognized as an accepted method of medical practice or treatment.

• Not medically necessary “to correct or ameliorate a defect, physical or mental illness, or a condition” [health problem]

EPSDT and Prior Approval Requirements

– If the service, product, or procedure requires prior approval, the fact that the recipient is under 21 years of age does NOT eliminate the requirement for prior approval.

– IMPORTANT ADDITIONAL INFORMATION about EPSDT and prior approval is found in the Basic Medicaid and NC Health Choice Billing Guide, sections 2 and 6, and on the EPSDT provider page. The Web addresses are specified below.

• Basic Medicaid and NC Health Choice Billing Guide: http://www.ncdhhs.gov/dma/basicmed/

• EPSDT provider page: http://www.ncdhhs.gov/dma/epsdt/

When the Procedure,Product,or Service Is Covered

General Eligibility Criteria• Procedures,products,and services are covered when medically necessary

and – the plan is individualized and consistent with symptoms and diagnosis,and not in

excess of the beneficiary’s needs.

– can be furnished safely and no equally effective and less costly treatment is available.

– are not be for the convenience of the beneficiary,family,or provider.

Specific Eligibility Criteria• The beneficiary may have limitations on coverage based on

their eligibility category– Fee-for-Service Medicaid Categories

Beneficiaries covered by regular Medicaid are eligible to apply for PDN services.– Medicaid for Pregnant Women (MPW)

Pregnant women are eligible to apply for PDN services if the services are medically necessary for a pregnancy-related condition.– Medicare Qualified Beneficiaries (MQB)

Medicaid recipients who are Medicare-qualified beneficiaries (MQB) are not eligible for Private Duty Nursing.– Managed Care

Medicaid recipients participating in a managed care program, including Medicaid health maintenance organizations and Community Care of North Carolina programs (Carolina ACCESS and ACCESS II/III), must access home services, including PDN, through their primary care physician.

Specific Eligibility Criteria

• Physician Order– PDN services must be requested by and

ordered by the beneficiary’s attending physician using the CMS-485

(MD or DO licensed by the North Carolina Board of Medicine and enrolled with Medicaid) on the CMS-485

Specific Eligibility Criteria

• Prior approval by DMA

Specific Eligibility Criteria

• Location of Service– PDN is provided in the private residence of the

beneficiary. The basis for PDN approval is based on the need for skilled nursing care in the home. A beneficiary who is authorized to receive PDN services in the home may make use of the approved hours outside of that setting when normal life activities temporarily take him or her outside that setting. Normal life activities include supported or sheltered work settings, licensed child care, school and school related activities, and religious services and activities. Normal life activities do not include inpatient facilities, outpatient facilities, hospitals, physicians’ offices, or other medical settings.

Specific Eligibility Criteria

• Caregiver Support

The beneficiary has at least one trained primary informal caregiver to provide direct care to the beneficiary during the planned and unplanned absences of PDN staff.

It is recommended that there be a second trained informal caregiver for instances when the primary informal caregiver is unavailable due to illness, emergency, or need for respite.

Health Eligibility Criteria

Standard PDN Services

To be eligible for standard PDN services, the beneficiary shall:

1. be dependent on a ventilator for at least eight hours per day, or

2. meet at least four of the following criteria:– unable to wean from a tracheostomy.

– require nebulizer treatments at least two scheduled times per day and one as needed time per day.

– require pulse oximetry readings every nursing shift.

– require skilled nursing or respiratory assessments every shift due to a respiratory insufficiency.

– need (PRN) oxygen or has PRN rate adjustments at least two times per week.

– require tracheal care at least daily.

– require PRN tracheal suctioning. Suctioning is defined as tracheal suctioning requiring a suction machine and a flexible catheter.

– at risk for requiring ventilator support.

Expanded PDN Services

• Beneficiaries who meet all of the criteria for standard nursing services plus at least one of the criteria below may be eligible for expanded PDN services:

– use of respiratory pacer.– dementia or other cognitive deficits in an otherwise alert or ambulatory

recipient.– Infusions, such as through an intravenous, PICC, or central line.– seizure activity requiring use of PRN use of Diastat, oxygen, or other

interventions that require assessment and intervention by a licensed nurse.

– primary caregiver who is 80 or more years of age or who had disability confirmed by the Social Security Administration and disability interferes with care-giving ability.

– determination by Child Protective Services or Adult Protective Services that additional hours of PDN would help ensure the recipient’s health, safety, and welfare.

– Expanded PDN services in most cases allows an additional 14 hours per week - as long as that new total does not exceed the program maximum limit of 112 hours per week.

Significant Change In Condition • Beneficiaries who meet one of the following criteria may be

eligible for a short-term increase in service. The amount and duration of the increase is based on medical necessity and approved by the PDN Nurse Consultant. No short-term-increase may last more than four calendar weeks.– beneficiary with new tracheostomy, ventilator, or other

technology need, immediately post discharge, to accommodate the transition and the need for training of informal caregivers. Services will generally start at a high number of hours and be weaned down to within normal policy limits over the course of the four weeks. For ex: 24 hrs x 1wk, 20hrs.x1 wk

– an acute, temporary change in condition causing increased amount and frequency of nursing interventions.

– a family emergency, when the back-up caregiver is in place but requires additional support because of less availability or need for reinforcement of training.

When PDN Is Not Covered

• Procedures, products, and services related to this policy are not covered when:

– the beneficiary does not meet the Medicaid category, general, specific, or health eligibility requirements

– the beneficiary does not meet the medical necessity criteria the procedure, product, or service unnecessarily duplicates another provider’s procedure, product, or service; or

– the procedure, product, or service is experimental, investigational, or part of a clinical trial.

Specific Non-Covered Criteria

PDN is not covered if any of the following are true :• the beneficiary is receiving medical care in a hospital, nursing

facility, or other setting where licensed personnel are employed;• the beneficiary is a resident of an adult care home, group home,

family care home, or nursing facility;• the service is for custodial, companion, or respite services (short-

term relief for the caregiver) or medical or community transportation services;

• the nursing care rendered can be delegated to unlicensed personnel (Nurse Aide I or Nurse Aide II), in accordance with 21 NCAC 36.0401 and 21 NCAC 36.0221(b);

• the purpose of having a licensed nurse with the beneficiary is for observation or monitoring in case an intervention is required;

Continued Non-Coverage Criteria • the service is for the beneficiary or caregiver to go on vacation or overnight

trips away from the beneficiary’s private primary residence. – Note: Short-term absences from the home that allow the beneficiary to receive

care in an alternate setting for a short period of time may be allowed as approved by the PDN Nurse Consultant and when not provided for respite, when not provided in an institutional setting, and when provided according to nurse and home care licensure regulations;

• services are provided exclusively in the school or home school;• the beneficiary does not have informal caregiver support available • the service duplicates services provided by

– home health nursing services – respiratory therapy treatment (except as allowed under Policy 10D Independent

Practitioners Respiratory Therapy Services) – The Home Infusion Therapy (HIT) program, – The Community Alternatives Program for Children (CAP/C)

• the beneficiary is receiving Hospice Services, except as those services may apply to children under the Affordable Care Act.

Requirements and Limitations on Coverage

Prior approval is required for Medicaid beneficiaries.

Documents required for prior approval:– the PDN Prior Approval referral form – a physician’s request. The physician’s request consists of either:

• Physician’s Request Form for PDN Services • letter of medical necessity.

– all health care records and any other records that support the beneficiary has met the program criteria

– if the Medicaid beneficiary is under 21 years of age, information supporting that all EPSDT criteria are met and evidence-based literature supporting the request, if available.

– Verification of caregiver employment schedule. • Verification consists of a statement on employer letterhead signed by a supervisor

or representative from the employer’s Human Resources Department, detailing the employee’s current status of employment (such as active or on family medical leave) and typical work schedule. If a caregiver is self employed or unable to obtain a letter, the Verification of Employment form may be used.

– Home Health Certification and Plan of Care form (CMS-485)

Physician Request Should Include:

• The current diagnosis(es);• History of the illness, injury, or medical condition requiring PDN services;• Date of onset and date(s) of any related surgeries;• The projected date of hospital discharge, if applicable;• A prognosis that identifies the specific expectations for the beneficiary’s

recovery from the illness, injury, or medical condition requiring the PDN hours;

• The specific licensed nursing interventions requested, the frequency of those interventions, and the estimated length of time PDN will be required; and

• The family members and other caregivers available to furnish care and the training they have been or will be provided.

A complete request for initial prior approval contains the following information :

• beneficiary’s name, address, date of birth and Medicaid Identification Number MID ;

• the specific number of hours per day requested;• the name, address, and phone number, and provider number of the PDN

provider chosen by the beneficiary;• requested start of care date for PDN;• diagnosis and skilled interventions required;• if applicable, recent hospital admission and discharge summaries;• third party insurance coverage;• caregiver availability and teaching required; and• the name of the beneficiary’s attending physician who will be signing the

plan of care.

Prior Approval Continued • Documentation that is submitted without this information will be treated as

unable to process or as an incomplete request per Medicaid due process procedures.Note: Per the current due process procedures, an initial request is defined as a request that the beneficiary was not authorized to receive on the day immediately preceding the date of the receipt of the request.

• If DMA or its designee approves the initial request for PDN services, DMA will send the PDN service provider a notification letter within 15 business days of the receipt of all required information. Required information includes notification of the start of care date and the unsigned orders from the agency. A copy of the letter will be sent to the beneficiary’s attending physician, the beneficiary, or the beneficiary’s representative. The approval letter includes:

– the beneficiary’s name and MID number;– the name and provider number of the authorized PDN service provider;– the number of hours per week approved for PDN services, beginning with

Sunday at 12:01 am; and– the starting and ending dates of the approved period, usually 30 to 60 calendar

days, depending on the beneficiary’s medical condition.

Prior Approval of Reauthorization

The following documents are required for reauthorizations:• The clinical medical record as per Subsection 7.2 and in accordance with

10A NCAC 13J.1401 and 10A NCAC 13J.1402;• A copy of the completed PDN Medical Update/Beneficiary Information Form,

which also indicates the date of the last physician visit orA copy of the Medical Update and Patient Information Form (CMS-486)

• A copy of the Home Health Certification and Plan of Care Form (CMS-485) signed and dated by the attending physician and indicating specific recertification dates, frequency, and duration of PDN services being requested. A verbal order is acceptable in order to have the CMS-485 submitted within ten calendar days prior to the recertification date and receive a verbal authorization for services; however, the physician-signed form must be submitted to DMA before final written approval is granted

Reauthorizations Continued • The completed HNRC • At DMA’s discretion, an in-home assessment may be performed by DMA

or its designee;• Verification of caregiver’s employment schedule annually and with any

changes. Verification consists of a statement on employer letterhead signed by a supervisor or representative from the employer’s Human Resources Department, detailing the employee’s current status of employment (such as active or on family medical leave) and typical work schedule. If a caregiver is self employed or unable to obtain a letter, the Verification of Employment form may be used; and

• Nurses notes from the latest certification period as requested by Consultant.

Reauthorizations Continued

• Documentation that is submitted without this information will be treated as unable to process or as an incomplete request per Medicaid due process procedures.

• To receive approval for continuation of PDN services beyond the approved period, the PDN service provider shall submit the reassessment information to DMA at least 10 calendar days PRIOR to the end date of the recertification period (current approved period). Authorization will be finalized upon receipt of all requested information, including signed physician order.

• Note: If the request is received by DMA’s Home Care Initiatives HCI Unit MORE than one day after the end of the current authorization period, the request will be treated as an Initial Request

Approved Reauthorizations

DMA will

• forward a written notification to the PDN service provider in accordance with the current beneficiary notices procedure;

• forward a copy of the authorization for services to the beneficiary (and the beneficiary’s representative, if applicable); and

• once the signed physician order is received, enter the required information into the Medicaid fiscal agent’s claims system to allow payment of claims submitted for the approved services.

Payment of claims for approved services will not be generated until the physician signed CMS 485 is submitted to DMA for the current certification period. Please note the amount of time billed must match the amount of time provided and documented .

Limitation or Requirements

Re-evaluation during the Approved Period

• If the beneficiary experiences a significant change of condition, the PDN service provider shall notify DMA or it’s designee of the need either to change the number of PDN hours required to meet the beneficiary’s needs or to terminate PDN, based on physician’s orders. Services will be re-evaluated at that time. Please note that the PDN consultant may require documentation such as discharge summaries or physician progress notes to substantiate the need for an increase or decrease in services.

Verbal Orders

• If the physician requests that PDN services begin before the service provider receives written orders, the PDN service provider may act on the physician’s verbal orders subject to DMA approval. A licensed nurse or other appropriate home care professional shall record the verbal orders on the Home Health Certification and Plan of Care Form (CMS-485) and in accordance with 10A NCAC 13J, The Licensing of Home Care Agencies. The verbal order must be submitted to DMA HCI office, with 10 days prior to recertification end date. The verbal order shall include recertification dates, frequency and duration of request PDN hours.

Plan of Care

The plan of care must have:

• All pertinent diagnoses, including the beneficiary’s mental status;• The type of services, medical supplies, and equipment ordered;• Weekly limit of hours or daily limit. • Specific assessments and interventions to be administered by the nurse;• individualized nursing goals with measurable outcomes;• Verbal order, date, signed by RN if CMS-485 (Locator 23) is not signed by the

physician in advance of the recertification period;• The beneficiary’s prognosis, rehabilitation potential, functional limitations, permitted

activities, nutritional requirements, medications-indicating new or changed in last 30 calendar days, and treatments;

• Teaching and training of caregivers;• Safety measures to protect against injury;• Disaster plan. • Discharge plans individualized to the beneficiary; and• The POC recertification period is a maximum of 60 days unless otherwise authorized

by DMA.• Note: Refer to Attachment B for an example of the Home Health Certification and

Plan of Care Form (CMS-485).

Retroactive Coverage

• Retroactive coverage for Initial Requests

PDN services may be requested for up to five business days prior to the initial request of PDN coverage. If the request is not received within five business days, services are not eligible for reimbursement. This only applies to initial requests; not ongoing recertification's where coverage has lapsed due to failure to submit in accordance with due process procedures.

PDN in Schools

• Individuals and caregivers are responsible for determining if the beneficiary is receiving the appropriate nursing benefit in the school system and formulating the child’s Individualized Education Plan (IEP) to include nursing coverage in the school system. If any nursing hours are approved for school coverage, these hours are included in the total hours approved by DMA.

• The nurse shall document the hours and specific place of service when care is rendered in a school, included how transported to school (bus, parent vehicle, etc). All other PDN requirements must be met; for example, there must be a CMS-485 in addition to the IEP and it must be signed only be a Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO).

Determining the Amount, Duration, Scope, and Sufficiency of Services

DMA or its designee determines the amount, duration, scope, and sufficiency of PDN services required after reviewing the recommendations of the beneficiary’s attending physician and the following characteristics of the beneficiary:

• Primary and secondary diagnoses.• Overall health status.• Level of technology dependence.• Current and updated individualized plan of care • Need for specific medical care and services provided under the Medicaid

PDN services benefit.• Clinical health care record • Amount of family assistance available. Verification of employment hours will

be conducted annually. Allowances will not be made for second jobs, overtime, or combination of work and school, when the additional hours will cause the policy limit to be exceeded.

• PDN services are authorized in the amounts that are medically necessary based on the medical condition of the beneficiary and the amount of caregiver assistance available.

Approved hours determined

Caregiver

availability

Standard Expanded

2 caregivers 56 hrs 70hrs

1 caregiver with or without any other CG’s

76 hrs. 90 hrs.

2 or more partial CG’s 56 plus work time max 96 hrs.

70hrs plus work time max 110hrs.

1 partial CG 70 hrs plus work time up

tp 112hrs. Per week 90 hrs per week plus work time for max up to 112hrs per week

Definitions :

• Fully available caregiver is on who lives with beneficiary ,not employed, and is physically and cognitively able to provide care.

• Partially available caregiver is one who lives with the beneficiary and has verified employment, or who is disabled as determined by the SSA and that disability interferes with the ability to provide care.

Other considerations in determining hours

• Approved hours for other formal support programs such CAPIDD apply towards the maximum of 112hrs.

• Hours approved are on a per week basis beginning 12.01am Sunday and ending 12:00am Saturday.

• Maximum for any beneficiary is 112.

• Unused hours can not be banked.

• Individuals who were receiving greater than max when the policy took effect (12/1/2012) may continue receiving that amount of services until nursing interventions decrease, there change in caregiver status, or the beneficiary hospitalized greater than 30 days.

• Individuals who, when the policy took effect (12/1/2012), were receiving less than 112 hrs but exceeding the parameters have until 12/1/2013 to decrease their hours to within the parameters.

Request for changes

Any request for change in amount,scope,frequency,or duration must be ordered by physician and approved by PDN consultants

• Plan of Care Changes –any increase or decrease in amount,scope,duration must be approved by the consultants. Must have physician order faxed to DMA.

• Temporary changes –To decrease services for a holiday or vacations less than seven days do not require DMA approval. Agency to document missed shifts and notify MD.

• Emergency changes-Emergency changes after hours that are based on a true emergency must be reported to DMA next business day and must get supplemental order from MD. Note: Follow-up reports will be requested.

Termination/Reduction

• The PDN service provider ,the physician, or DMA may terminate or reduce PDN services. Upon termination or reduction DMA enters the information into the fiscal agent claims system.

Notification of Termination

• Notify DMA within 5 business days of discharge and send a copy of the MD order to stop servcies. DMA will send a letter to the agency acknowledging receipt.

• PDN services can be terminated for the following : another payer source has been identified, the beneficiary is no longer Medicaid eligible, or the beneficiary is hospitalized longer than 30 days.

• If DMA initiates the termination because it has determined that the beneficiary no longer meets eligibility based on review, Medicaid due process procedures will be followed.

Note: If the beneficiary’s physician or service provider initiates the discharge, that decision cannot be appealed to DMA. Only DMA decisions may be appealed to DMA.

Notification of Reduction

• Notify DMA within five business days of reduction and fax MD order. DMA will send letter to the provider acknowledging receipt.

• If DMA initiates the reduction additional information may be requested from the service provide for medical review. If the information is not provided in 10 business the provider will be notified in writing of the reduction of PDN services and due process procedures will be followed.

Changing Service Providers

Transfer of Care Two Branch offices of the Same Agency

The new PDN provider shall facilitate the change by being responsible for the following :

Submitting information to DMA within 5 business days of the request

Coordinating the date of transfer

Obtaining a signed 485

Obtaining written permission from the beneficiary or legal guardian for the transfer.

Ensuring that written and verbal orders are verified and documented according to 10A NCAC13J,Licensing of Home Care Agencies.

Forwarding to DMA prior to transfer written notification.

Transfer Between 2 Different Agencies

• Submit to DMA the following :

The prior approval form

The letter of medical necessity

Any other requested documents by DMA consultant

Discharge Summary

• The PDN service provider shall forward to DMA a discharge summary that specifies the last day PDN services were provided.

Approval process

• After all requirements are met, DMA approves the new PDN provider and forwards an approval letter to the provider and the beneficiary or the beneficiary’s representative.

Limitations on the Amount ,Frequency, and Duration

• Unused service hours –cannot bank

• Unauthorized Hours-excess hours not approved by DMA are provider’s financial responsibility.

• Transportation-PDN nurse cannot drive the beneficiary.

• Medical settings –Not covered in a setting where licensed personnel are employed.

Weaning of a Medical Device

• The DMA Nurse Consultant may authorize continuation of PDN services for a brief period after the beneficiary no longer requires a medical device that qualified him/her for the program. Normally this period will not exceed two weeks.

Coordination of Care

The attending physician and the PDN provider agency are responsible for monitoring the beneficiary’s care and initiating appropriate changes in PDN services.

1. Transfer between Health Care Settings-If a beneficiary is placed in a different health care setting the PDN provider shall contact DMA prior to discharge to discuss any changes in services. An H&P and /or discharge summary shall be submitted.

2. Drug Infusion Therapy-The Durable Medical Equipment supplier provides the equipment, drugs, and supplies under Medicare Part D or Medicaid coverage. The PDN Provider is responsible for the administration and caregiver teaching.

3. Enteral/Parental Nutrition-DME supplier provides the equipment and supplies . Home Health nursing would be a duplication.

Coordination of Care

4.Home Health Nursing –May not be provided concurrently with PDN services.

5.Medical Supplies-Supplies are covered as defined in Clinical Coverage Policy3A Home Health Services.

Providers Eligible to Bill

To be eligible to bill for services, products, and procedures the PDN provider shall meet the following :

• Meet Medicaid qualifications

• Be currently Medicaid enrolled

• Bill only for services that are within scope of practice.

• Nursing documentation must substantiate and match services billed. Can not bill for more units/hours than authorized.

Agency type

• PDN agencies are licensed by the North Carolina Division of Health Service Regulation. Each office providing services shall have an individual PDN provider number.

Agency Responsibilities

• Ensure qualified and competent staff

• Be accredited by June 1, 2014 by JCAHO,ACHC,or CHAP.

• Ensure staff have appropriate training and experience.

• Verify education, license, and training prior to hire

• Ensure the nurse assigned has the skills to meet the POC

• Ensure staff have continuing education hours

• Develop orientation plan for policies and procedures.

Provider Relationship to Beneficiary

In order for PDN services to be reimbursed the agency may not employ:

• Member of the beneficiary’s family

• One who maintains his or her residence with the beneficiary

• Nurse who lives with the beneficiary

Nurse supervisor

• The PDN supervisor shall have at least 2 years experience of home care with medically fragile beneficiaries.

Additional Requirements

• Compliance- Must comply with all federal,state,HIPPA,local laws, and record retention requirements.

• Documentation-The PDN agency must document complete accurate records of all care, beneficiary condition, nursing interventions, treatment and include the following:

date, time of skilled care

Interventions including beneficiary response

Signature of legal representative acknowledging time spent and services

Hourly Nursing Review form

Supplies used

Who is taking report or giving report

Caregiver availability , training , and competency

Safety issues and interventions

Coordination with other home care services such PT,OT,ST.

Supervisory visits

Verification of Eligibility

PDN provider is responsible for verifying eligibility, other insurance coverage, and living arrangements before initiating services.

Family and Other Caregivers

• Caregivers-Shall have one trained primary caregiver and it is recommended to have a second caregiver in case of emergencies.

• Training-PDN provider will document the training needs of the caregiver. Training by the PDN provider and the hospital should be documented.

• Competency-Family will demonstrate competence, skills, and ability to carry out the plan of care.

• Emergency Plan-Emergency plan shall be part of the POC and caregivers aware if the beneficiary requires emergency care.

• Evaluation of Health & Safety-PDN provider is responsible for the health, safety, and welfare of the beneficiary. Notify DMA of DSS involvement.

Patient Self Determination Act

• The Patient Self Determination Act of 1990, Sections 4206 and 4751 of the Omnibus Budget Reconciliation Act of 1990, P.L.101-508 requires that Medicaid-certified hospitals and other health care providers and organizations, give patients information about their right to make their own health decisions, including the right to accept or refuse medical treatment. Providers shall comply with these guidelines. Basic Medicaid and NC Health Choice Billing Guide: http://www.ncdhhs.gov/dma/basicmed/

Marketing Prohibition

Agencies providing PDN under the Medicaid program are prohibited for offering gifts or services for the purpose of inducing or enticing beneficiaries to choose them as their PDN provider.

How to Complete the POC(485)

Completion of Form CMS-485, Home Health Certification and Plan of Care.--Form CMS-485 meets the regulatory requirements (State and Federal) for both the physician's home health plan of care and home health certification and recertification requirements.

Complete the following:1. Patient's Medicaid #2. Start of Care Date.--Enter the 6 digit month, day, year on which covered

home health services began ,i.e., MMDDYY (e.g., 101593). The start of care (SOC) date is the first Medicaid billable visit. This date remains the same on subsequent plans of treatment until the patient is discharged.

3. Certification Period.--Enter the 2 digit month, day, year, MMDDYY (e.g., 101593- 121593), which identifies the period covered by the physician's plan of care. The "From" date for the initial certification must match the start of care date. The "To" date can be but never exceed, two calendar months and mathematically never exceed 62 days.

485 continued

4 . Medical Record No -This is the patient's medical record number that is assigned by the HHA and is an optional item. If not applicable, the agency enters "N/A."

5. Provider No. -This is the &-digit number issued by Medicaid to the HHA. It always starts with 7100___.

6 .Patient's Name and Address - The HHA enters the patient's last name, first name, and middle initial as shown on the health insurance card and the street address, city, State, and ZIP code.

.7 Provider's Name Address and Telephone No. -The HHA enters its name and/or branch office (if appropriate), street address (or other legal address), city, State and ZIP code and telephone number.

8.Date of Birth The patient's date of birth (month, day, year) in numbers, i.e.,MMDDYYYY (04031920) is entered.

9. Sex The patient's sex is checked in the appropriate box.

.

485 continued

10 .Medications: Dose, Frequency, Route. The physician's orders for all medications including the dosage, frequency and route of administration for each drug must be listed. Drugs, which cannot be listed on the plan of care due to lack of space, are listed on an addendum.

11. Principal Diagnosis,ICD-9-CM Code and Date of Onset, Exacerbation.

The principal diagnosis is the diagnosis most related to the current POC. The diagnosis may or may not be related to the patient's most recent hospital stay, but must relate to the services rendered by the HHA. If more than one diagnosis is treated concurrently, the diagnosis that represents the most acute condition and requires the most intensive services should be entered.

485 Continued

12. Surgical Procedure, Date, ICD-9-CM Code. The surgical procedure relevant to the care being rendered is entered.

13. Other Pertinent Diagnoses: Dates of Onset/Exacerbation ICD-9-CM Codes. Enter all pertinent diagnoses relevant to the care rendered.

14. DME and Supplies- All non-routine supplies must be specifically ordered by the physician or the physician's order for services must require use of the specific supplies. See PDN policy 5.3.3 Plan of Care.

15. Safety Measures -The physician's instructions for safety measures are listed.

485 Continued

16. Nutritional Requirements-The HHA enters the physician's orders for the diet. This includes specific therapeutic diets and/or any specific dietary requirements. Fluid needs or restrictions are recorded. Total parenteral nutrition (TPN) can be listed under this item or under medications if more space is needed.

17. Allergies-Medications to which the patient is allergic and any food or products such as adhesive tape,etc.

18A. Functional Limitations-All items that describe the patient's current limitations assessed by the physician and the agency are indicated.

18B. Activities Permitted -The activity(ies) that the physician allows and/or for which physician orders are present are indicated.

19. Mental Status- The block(s) most appropriate to describe the patient's mental status is checked.

485 Continued

20. Prognosis -A check is placed in the box, which specifies the most appropriate prognosis for the patient.

21. Orders for Discipline and Treatments (Specify Amount, Frequency, Duration). Orders must include all disciplines and treatments, even if they are not billable to Medicaid.Please include any other services the recipient is receiving such as CAPMR/IDD,PT,OT,Speech, and PCS services. POC must be specific include size of tracheostomy,how often changed and by whom, vent settings, # hours on the vent, sizes of suction and Foley catheters,etc, For example: 12 hours of PDN x 7 days. Maintain patency of 3.5Ped Bivona.Trach change by SN/PCG q week and prn respiratory distress.

22. Goals/Rehabilitation Potential/Discharge-This reflects the physician's description of the achievable goals and the patient's ability to meet them as well as plans for care after discharge.

485 Continued 22.Rehabilitation potential -addresses the patient's ability to attain the goals

and an estimate of the time needed to achieve them. 23 Nurse's Signature and Date of Verbal Start of Care. This verifies for

surveyors, CMS' representatives, including Medicaid that a registered nurse or qualified therapist responsible for furnishing or supervising the patient's care spoke to the attending physician and received verbal authorization to visit the patient. Each reauthorization requires an updated verbal start of care every 60 days.

24. Physician's Name and Address. The agency prints the physician's name and address. The attending physician is the physician who established the plan of treatment and who certifies and re-certifies the medical necessity of the home health visits and/or services. Supplemental physicians involved in a patient's care are mentioned on the addendum only. The physician must be qualified to sign the certification and plan of care in accordance with 42 CFR 424 Subpart B.

485 Continued

25.The date the agency received the signed POC from the attending/referring physician is entered. It is required only if the physician does not date Item 27.

26. Physician Certification-This statement serves to verify that the physician has reviewed the POC and certifies the need for the services.

27. Attending Physician's Signature and Date- The attending physician signs and dates the plan of care prior to the claim being submitted for payment; rubber signature stamps are not acceptable. The form may be signed by another physician who is authorized by the attending physician to care for his/her patients in his/her absence.

28 .Penalty Statement -This statement specifies the penalties imposed form is representation, falsification or concealment of essential information on the Form CMS-485.

Medical Update

Top of page Recipient Name and MID#

Provider name and # 7100___

Additional insurance coverage in addition to Medicaid including private insurance. Explain coverage.

Last Approval period

Physician

Updated information-Please do not re- state orders. Summarize care and any new or changes in orders. Example: 5.5 Shiley changed every 2 weeks by SN and CG without difficulty. No unplanned trach changes in the last 60 days. Suctioned every 2 hrs. with #8 suction catheter for mod. amt of yellowish secretions. Scheduled nebs bid and required prn nebs x 3 this cert period for increased secretions. MD aware and PO antibiotics ordered. #20 Foley changed every other month. No s/sx of UTI’s.

Medical Update Continued

Weight

Date of last exam by MD

Changes in condition-can state see above

Home safety and environment-Include caregivers who they are and any safety concerns.

Critical Incidents-Falls ,Hospitalizations,etc

Therapies currently receiving and frequency –PT,OT,play therapist

Emergency Plan when nurse not available-Please list available and trained caregivers

Training needs

Education provided and on-going needs

Hourly Nursing Review Criteria • Technology needs1. Vent dependent2. Tracheostomy no vent3. CPAP/BIPAP-no trach4. Hospitalizations

• Skilled Care needs1. Endotracheal Suctioning-frequency2. Sterile Dressing-Do not include trach site dressing3. NG/GT/GJ tube feedings- For continuous points must have feedings

over at least 8 hours. Points for reflux must be on medications for GERD or swallowing study.

4. I&O-Ineligible for points unless intervention such as adjustment to tube feedings.

5. Intermittent catheterization.

Hourly Nursing Review Continued

6.Intravenous: Fluids,medications,or nutrition-baseline not when ill7.Pulse Oximetry,CO2 monitoring,nebs,chest PT-can not receive more than

8 pts. No matter how many recipient receives..8. Medication-Moderate and Complex pts. Include those that are prn and

require adjustment by the nurse. Must be more than 3 given in a 8 hour period.

• Activities of Daily Living Needs-Age Appropriate 1. Naso –orophargeal suctioning.2. Dressing/site care-not trach dressing3. Oral /feeding assistance4. Recording intake and output5. Incontinence care6. Personal care7. Range of Motion8. Ambulation/transfer/bed mobility

Hourly Nursing Review Continued

• Home Environment/Caregiver InformationInclude caregiver health issues, other programs, stressors,etc. If on CAPMR

provide case-manager name and contact information.

• Questions?