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Apple Health (Medicaid) Provider Alert

What is changing?

Retroactive to dates of service on and after March 1, 2020, until further notice, two additional add-on codes may be billed for private duty nursing services during the COVID-19 pandemic. These private duty nursing services are administered by the Department of Social and Health Services (DSHS), Developmental Disabilities Administration (DDA) through the Medically Intensive Children’s Program (MICP).

What are the add-on codes and rate?

The following codes may be billed as add-on codes for private duty nursing services that are authorized for the client and provided by approved agencies.

*HCA-contracted managed care organizations (MCOs) must also follow this policy.

How do I bill for PDN services in a home setting (T1000) to receive the increased payment due to COVID-19?

• Bill T1000 with appropriate modifier(s) and authorization number, as usual, for the services rendered.

Add an additional line and bill T1002 with modifier CR. This add-on rate may be billed at a 1:1 ratio for every unit provided of private duty nursing and should be included on the same claim. The units entered for the add-on code may not exceed the total units of provided private duty nursing services billed on the claim.

Note: The range of date of services (DOS) for code T1002 should be the first DOS on the claim to the last DOS on the claim. For example, if T1000 modifier TD is billed 3/1/2020-3/5/2020 for 50 units and T1000 modifier TE is billed 3/6/2020-3/12/2020 for 100 units, add a line and bill using code T1002 modifier CR with DOS span 3/1/2020-3/12/2020 for 150 units.    

Can I bill for T1002 add-on code if I already have submitted a claim and have received payment?

Yes. If you have already submitted a claim and received payment, please adjust the previously paid claim. Select the claim you want to adjust, add an additional line and use the code T1002 with modifier CR and enter units of provided service. The units entered for the add-on code may not exceed the total units of provided private duty nursing service billed on the claim.

Note: The range of DOS for code T1002 should be the first DOS billed for T1000 on the claim to the last DOS of T1000 billed on the claim. For example if T1000 modifier TD is billed 3/1/2020-3/5/2020 for 50 units and T1000 modifier TE is billed 3/6/2020-3/12/2020 for 100 units, add a line and bill using code T1002 modifier CR with DOS span 3/1/2020-3/12/2020 for 150 units. Submit the adjustment.

How do I bill for PDN services in a medically fragile group home (T1030) to receive the increased payment due to COVID-19?

• Bill T1030 with authorization number, as usual, for services rendered.

• Add an additional line and bill T1031 with modifier CR. This add-on rate may be billed at a 1:1 ratio for every unit provided of private duty nursing and should be included on the same claim.  

Note: T1031 is a daily rate. The units entered for the add-on code may not exceed the total units of provided private duty nursing service billed on the claim. For example, if T1030 is billed for DOS 6/1/2020-6/30/2020 for 30 units, add a line bill code T1031 modifier CR for DOS 6/1/2020-6/30/2020 for 30 units.  

Can I bill for T1031 add-on code if I already have submitted a claim and have received payment?

Yes. If you have already submitted a claim and received payment, please adjust the previously paid claim. Select the claim you want to adjust, add an additional line and use the code T1031 with modifier CR. This add-on rate may be billed at a 1:1 ratio for every unit provided of private duty nursing.  

Note: T1031 is a daily rate. The units entered for the add-on code may not exceed the total units of provided private duty nursing service billed on the claim. For example, if T1030 is billed for DOS 6/1/2020-6/30/2020 for 30 units, add a line bill code T1031 modifier CR DOS 6/1/2020-6/30/2020 for 30 units.  

Where else can I find this information?

We have updated the Private Duty Nursing Services Billing Guide to include a note about these add-on codes with a hyperlink to HCA’s Information about novel coronavirus (COVID-19) web page, under Providers, Billers and Partners, All Other Providers, Apple Health (Medicaid) private duty nursing services billing and policy during COVID-19 pandemic (FAQ).