The Private Duty Nursing/Personal Cares (PDN/PC) program is part of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program that provides in home private duty nursing and personal cares services by Medicare-certified home health agencies. Children up to age 21 are eligible to receive this program. A maximum of 16 hours, based on medical need, may be prior authorized per day. A child does not have to be determined homebound in order to receive PDN-PC services. A physician must certify that a child has a medical need for PDN/PC through a face-to-face encounter. The physician must, also, review and sign the PDN/PC plan of care every 60 days. The physician’s signature on the Plan of Care (POC) authorizes the service(s) as assessed medical need(s). PDN/PC does not include medical needs that can be met by a family member, significant other, friend, neighbor, community or other unpaid resources. PDN/PC services must be prior authorized by the Iowa Medicaid Enterprise (IME) Medical Services.
The following documentation must be faxed to IME Medical Services for prior authorization (IME Medical Services fax number is 515- 725-1356):
1. Form 470-0829, Request for Prior Authorization, must be completed and signed by the requesting provider
2. POC that includes the start date of the request for prior authorization
The billing codes and units for billing PDN/PC program services are as follows:
| Billing Code | Service | Billing Unit |
|---|---|---|
| T1000 | Private Duty Nursing (Skilled Nursing) | Per 15 minute unit |
| S9122 | Personal Cares (Home Health Aid) | Per hour unit |
The rates for PDN/PC are determined through a cost report and then rates are set prospectively with a retrospective cost settlement.