~

I) 1ComJnonu>ealth qfMassachusetts

fJ! Executive Qffice of.Health 
~ \\\r'f and Human Seroices


\!!}~l Division ofMedical Assistance 
. ." 600 Washington Street 

Boston, MA 02111 

Medical Assistance Program 
Municipally Based Health Services 
BUlletin 31tNovember 
1995 

TO: Municipally Based Health Services Providers Participating in the Medical Assistance 

f./ 

Program . \ Af\tT~ 

Bruce M. Bullen, commiSSione~~ ~ V ~/

FROM: 

'-' 

RE: NEW SERVICE CODES FOR PRIVATE DUTY NURSING REIMBURSEMENT 

Background The Division of Medical Assistance (DMA) has determined 
reimbursement rates for municipally based health services providers, to 
enable them to bill DMA for private duty nursing (PDN) services for 
special education students, as described in the Chapter 766 Regulations 
of the Department of Education at 603 CMR 28.00. These rates are 
effective November 1, 1995, and are subject to future adjustments by 
the Division. 

In order to have the PDN specialty added, providers must make a 

written request to the DMA Provider Enrollment and Information 

Unit before submitting claims for payment with the new service 

codes. 

Definition PDN services administered by a registered nurse (RN) or a licensed 
practical nurse (LPN) are defined as "continuous specialized skilled 
nursing services" lasting two hours or more at a time and provided 
directly to one child or not more than two children. 

Through agreement with the Department of Education, all PDN services 

determined to be related to the special education program, included in 

the student's Individual Education Plan (IEP), and paid for directly by 

school districts do not require prior authorization from DMA. Chapter 

766 Evaluation TEAMS will describe the need for the number of private 

duty nursing hours necessary to be delivered by school systems for 

students to make effective progress in school. The TEAMS will base 

their decisions on their own assessments and determinations of medical 

necessity. 

Receipt of PDN services must be verified based on information 
contained in the Special Education Service Delivery section (also known 
as the "service delivery grid") of the recipient's IEP. The PDN services 
provided must be related to the student's special education progress. 


Medical Assistance Program 
Municipally Based Health 

Services Bulletin 3 
November 1995 
Page 2 

Service Codes Municipal Medicaid providers must bill for these PON services using the 
hourly rates that are listed on the following chart. 

. ...:╖.:╖.$e..Х:.ХХХХ╖.:::.C6.B~з. .....:.;.;.;.;.;..::;.;:;.::;:;:;.;.:.:.;:::::;::...;.:.;.:.::..;.; 
:.╖.╖.i.:.::.::.H..:..:...:'.: ..'..:.:tt..Х..'.i..:..:..:.~.╖.╖...;.i.::.Х:.:╖.Х.Х.a..'.::.:.╖...ХХ.a.Х.Х'.Х:
::.. '.:.:.i..'..'.es..Х ..:
::.Х'.i.Х:.. :..'..:.'..:.Х:.Х.Х.Х:.╖.Х.:.::...╖.,1::: ХХ.ХХХХХХХХХ ╖Fid~~r:Sh~ ..;.:.;.;.;.;.:.:.:.; ...Х. :.:.:.;.;.;.:-:.:-;.;.:.;.:.:-..;.;.:.:.;.:::.:-..: . 
x7670 RN Agency (one patient) $29.50 $14.75 
x7671 RN Individual (one patient) $19.10 $ 9.55 
x7672 RN Agency (two patients) $22.13 $11.06 
x7673 RN Individual (two patients) $14.33 $ 7.16 
x7674 LPN Agency (one patient) $22.25 $11.12 
x7675 LPN Individual (one patient) $14.40 $ 7.20 
x7676 LPN Agency (two patients) $16.70 $ 8.35 
x7677 LPN Individual (two patients) $10.80 $ 5.40 

/:::: 
Federal Reimbursement The federal share amount of the rate for these PON services will be 
returned to the city, town, or regional school district on a quarterly basis, 
along with reimbursement for other claimed services. The disbursement 
is currently scheduled to take place during the fourth week of the 
months of April, July, October, and January. The federal share 
amount for the above services is 50 percent of the hourly rate (FFP). 

Retroactive Billing Claims for PON services may be submitted retroactively. All claims 
must be received by Unisys within 24 months of the date of service. 
Claims received after the 24-month deadline will not be reimbursed. 

Claims Submission Municipal Medicaid providers must adhere to the following requirements 
when billing for PON services. 

Х All RNs and LPNs providing PDN services must be licensed 
by the Commonwealth of Massachusetts. 


Medical Assistance Program 
Municipally Based Health 

Services Bulletin 3 
November 1995 
Page 3 

Claims Submission 

(cant.) 

.Х No less than two hours and no more than 10 hours may be 
provided per school day per student. (Each hour is equal to 
one unit.) No more than 50 units per week may be provided. 

Х Claim form no. 9 Block 27: Description of Service must be 
"PDN Hour Wkdy." 

The total number of hours to be considered for PDN services will be 
evaluated by DMA's Private Duty Nurse Program reviewers. Non-school 
hours will be prorated to meet the total hourly requirements listed in the 
Private Duty Nurse Manual at 130 CM A 414.407. Copies of the Private 
Duty Nurse Manual may be obtained by making a written request to 
Unisys. 

Questions If you have any questions concerning the information in this bulletin, 
please call the Provider Services Unit at Unisys at (617) 628-4141 or 
1-800-325-5231, or the Division's Municipal Medicaid Program at (617) 
348-5464.