Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.05-010 - Private Duty Nursing Update Transmittal #56

Procedure Code

Description

S9123

Private Duty Nurse, R.N.

S9124

Private Duty Nurse, L.P.N.

Procedure Code

Required Modifier

Description

S9123

UB

Private duty nurse, RN, 2nd patient. Medicaid maximum allowable is 50% of the rate for S9123.

S9124

UB

Private duty nurse, LPN, 2nd patient. Medicaid maximum allowable is 50% of the rate for S9124.

A4206

A4216

A4217

A4221

A4222

A4253

A4256

A4259

A4265

A4310

A4311

A4312

A4313

A4314

A4315

A4316

A4320

A4322

A4326

A4327

A4328

A4330

A4338

A4340

A4344

A4346

A4347

A4348

A4351

A4352

A4354

A4355

A4356

A4357

A4358

A4359

A4361

A4362

A4364

A4367

A4369

A4371

A4397

A4398

A4399

A4400

A4402

A4404

A4405

A4406

A4414

A4452

A4454

A4455

A4558

A4560

A4561

A4562

A4623

A4624

A4625

A4626

A4628

A4629

A4772

A4927

A5051

A5052

A5053

A5054

A5055

A5061

A5062

A5063

A5071

A5072

A5073

A5081

A5082

A5093

A5102

A5105

A5112

A5113

A5114

A5119

A5121

A5122

A5126

A5131

A6154

A6234

A6241

A6242

A6248

A6441

A6442

A6443

A6444

A6445

A6446

A6447

A6448

A6449

A6450

A6451

A6452

A6453

A6454

A6455

A7520

A7521

A7522

A7524

A7525

B4086

E0776

Procedure Code

Required Modifier

Description

A6257

Transparent Film, each (16 square inches or less)

A6258

Transparent Film, each (more than 16, but less than 48 square inches)

A6259

Transparent Film, each (more than 48 square inches)

A6216 A6219 A6228

Gauze Pad, Medicated or Non-Medicated, each (16 square inches or less)

A6220 A6229 A6217

Gauze Pads, Medicated or Non-Medicated, each (more than 16, but less than 48 square inches)

A6221 A6230 A6218

Gauze Pads, Medicated or Non-Medicated, each (more than 48 square inches)

A4450

Gauze, Non-Elastic, Per Roll (1 linear yard)

A6245 A6242

Hydro gel Dressing, each (16 square inches or less)

A6246

Hydro gel Dressing, each (more than 16, but less than 48 square inches)

A6247 A6244

Hydro gel Dressing, each (more than 48 square inches)

A6248

Hydro gel Dressing, each (1 ounce)

A6237 A6234

Hydrocolloid Dressing, each (16 square inches or less)

A6238 A6235

Hydrocolloid Dressing, each (more than 16, but less than 48 square inches)

A6236 A6239

Hydrocolloid Dressing, each (more than 48 square inches)

A6196

Alginate Dressing, each (16 square inches or less)

A6197

Alginate Dressing, each (more than 16, but less than 48 square inches)

A6198

Alginate Dressing, each (more than 48 square inches)

A6197

UB

Alginate Dressing, each (1 linear yard)

A6209

Foam Dressing, each (16 square inches or less)

A6210

Foam Dressing, each (more than 16, but less than 48 square inches)

A6211

Foam Dressing, each (more than 48 square inches)

A6200

Composite Dressing, each (16 square inches or less)

A6201

Composite Dressing, each (more than 16, but less than 48 square inches)

A6202

Composite Dressing, each (more than 48 square inches)

A4253

UB

Blood Glucose test or reagent strip for home blood glucose monitor, per 25 strips

A4353

Urinary intermittent catheter with insertion tray

A4394

Ostomy deodorant, all types, per ounce

A4365

Adhesive remover wipes, 50 per box

A4368

Ostomy filters, any type, each

A4483

Tracheostomy vent-heat moisture device

L8239*

Stocking (Jobst)

Field

Name and Number

Instructions for Completion

1.

Type of Coverage

This field is not required for Medicaid.

1a.

Insured's I.D. Number

Enter the patient's 10-digit Medicaid identification number.

2.

Patient's Name

Enter the patient's last name and first name.

3.

Patient's Birth Date

Enter the patient's date of birth in MM/DD/YY format as it appears on the Medicaid identification card.

Sex

Check "M" for male or "F" for female.

4.

Insured's Name

Required if there is insurance affecting this claim. Enter the insured's last name, first name and middle initial.

5.

Patient's Address

Optional entry. Enter the patient's full mailing address, including street number and name, (post office box or RFD), city name, state name and ZIP code.

6.

Patient Relationship to Insured

Check the appropriate box indicating the patient's relationship to the insured if there is insurance affecting this claim.

7.

Insured's Address

Required if insured's address is different from the patient's address.

8.

Patient Status

This field is not required for Medicaid.

9.

Other Insured's Name

If patient has other insurance coverage as indicated in Field 11D, enter the other insured's last name, first name and middle initial.

a. Other Insured's Policy or Group Number

Enter the policy or group number of the other insured.

b. Other Insured's Date of Birth

This field is not required for Medicaid.

Sex

This field is not required for Medicaid.

c. Employer's Name or School Name

Enter the employer's name or school name.

d. Insurance Plan Name or Program Name

Enter the name of the insurance company.

10.

Is Patient's Condition Related to:

a. Employment

Check "YES" if the patient's condition was employment related (current or previous). If the condition was not employment related, check "NO."

b. Auto Accident

Check the appropriate box if the patient's condition was auto accident related. If "YES," enter the place (two letter state postal abbreviation) where the accident took place. Check "NO" if not auto accident related.

c. Other Accident

Check "YES" if the patient's condition was other accident related. Check "NO" if not other accident related.

10d

. Reserved for Local Use

This field is not required for Medicaid.

11.

Insured's Policy Group or FECA Number

Enter the insured's policy group or FECA number.

a. Insured's Date of Birth

This field is not required for Medicaid.

Sex

This field is not required for Medicaid.

b. Employer's Name or School Name

Enter the insured's employer's name or school name.

c. Insurance Plan Name or Program Name

Enter the name of the insurance company.

d. Is There Another Health Benefit Plan?

Check the appropriate box indicating whether there is another health benefit plan.

12.

Patient's or Authorized Person's Signature

This field is not required for Medicaid.

13.

Insured's or Authorized Person's Signature

This field is not required for Medicaid.

14.

Date of Current:

Illness

Injury

Pregnancy

Required only if medical care being billed is related to an accident. Enter the date of the accident.

15.

If Patient Has Had Same or Similar Illness, Give First Date

This field is not required for Medicaid.

16.

Dates Patient Unable to Work in Current Occupation

This field is not required for Medicaid.

17.

Name of Referring Physician or Other Source

Primary Care Physician (PCP) referral is required for Private Duty Nursing services. Enter the referring physician's name.

17a

. I.D. Number of Referring Physician

Enter the 9-digit Medicaid provider number of the referring physician.

18.

Hospitalization Dates Related to Current Services

For services related to hospitalization, enter hospital admission and discharge dates in MM/DD/YY format.

19.

Reserved for Local Use

Local Education Agency (LEA) code that identifies the school district in which therapy services are provided.

20.

Outside Lab?

This field is not required for Medicaid.

21.

Diagnosis or Nature of Illness or Injury

Enter the diagnosis code from the ICD-9-CM. Up to four diagnoses may be listed. Arkansas Medicaid requires providers to comply with CMS diagnosis coding requirements found in the ICD-9-CM edition current for the claim dates of service.

22.

Medicaid Resubmission Code Original Ref No.

Reserved for future use. Reserved for future use.

23.

Prior Authorization Number

Enter the prior authorization number, if applicable.

24.

A. Dates of Service

Enter the "from" and "to" dates of service, in MM/DD/YY format, for each billed service.

On a single claim detail (one charge on one line), bill only for services within a single calendar month.

B. Place of Service

Enter the appropriate place of service code. See Section 242.200 for codes.

C. Type of Service

Enter the appropriate type of service code. See Section 242.200 for codes.

D. Procedures, Services or Supplies

CPT/HCPCS

Enter the correct CPT or HCPCS procedure code.

Modifier

A modifier is required when billing for a second patient's PDN services.

E. Diagnosis Code

Enter a diagnosis code that corresponds to the diagnosis in Field 21. If preferred, simply enter the corresponding line number ("1," "2," "3," "4") from Field 21 on the appropriate line in Field 24E instead of reentering the actual corresponding diagnosis code. Enter only one diagnosis code or one diagnosis code line number on each line of the claim. If two or more diagnosis codes apply to a service, use the code most appropriate to that service. The diagnosis codes are found in the ICD-9-CM.

F. $ Charges

Enter the charge for the service. This charge should be the provider's usual charge to private clients. If more than one unit of service is being billed, enter the charge for the total number of units billed.

G. Days or Units

Enter the units (in whole numbers) of service rendered within the time frame indicated in Field 24A.

H. EPSDT/Family Plan

Enter "E" if services rendered were a result of a Child Health Services (EPSDT) screening/referral.

I. EMG

Emergency - This field is not required for Medicaid.

J. COB

Coordination of Benefit - This field is not required for Medicaid.

K. Reserved for Local Use

When billing for a clinic or group practice, enter the 9-digit Medicaid provider number of the performing provider in this field and enter the group provider number in Field 33 after "GRP#."

When billing for an individual practitioner whose income is reported by 1099 under a Social Security number, DO NOT enter the provider number here. Enter the number in Field 33 after "GRP#."

25.

Federal Tax I.D. Number

This field is not required for Medicaid. This information is carried in the provider's Medicaid file. If it changes, please contact Provider Enrollment.

26.

Patient's Account No.

This is an optional entry that may be used for accounting purposes. Enter the patient's account number, if applicable. Up to 16 numeric or alphabetic characters will be accepted.

27.

Accept Assignment

This field is not required for Medicaid. Assignment is automatically accepted by the provider when billing Medicaid.

28.

Total Charge

Enter the total of Field 24F. This field should contain a sum of charges for all services indicated on the claim form. (See NOTE below Field 30.)

29.

Amount Paid

Enter the total amount of funds received from other sources. The source of payment should be indicated in Field 11 and/or Field 9. Do not enter any amount previously paid by Medicaid. (See NOTE below Field 30.)

30.

Balance Due

Enter the net charge. This amount is obtained by subtracting the amount received from other sources from the total charge.

NOTE: For Fields 28, 29 and 30, up to 28 lines may be billed per claim. To bill a continued claim, enter the page number of the continued claim here (e.g., page 1 of 3, page 2 of 3). On the last page of the claim, enter the total charges due.

31.

Signature of Physician or Supplier, Including Degrees or Credentials

The provider or designated authorized individual must sign and date the claim certifying that the services were personally rendered by the provider or under the provider's direction. "Provider's signature" is defined as the provider's actual signature, a rubber stamp of the provider's signature, an automated signature, a typewritten signature or the signature of an individual authorized by the provider rendering the service. The name of a clinic or group is not acceptable.

32.

Name and Address of Facility Where Services Were Rendered (If Other Than Home or Office)

If other than home or office, enter the name and address, specifying the street, city, state and ZIP code of the facility where services were performed.

33.

Physician's/Supplier's Billing Name, Address, ZIP Code & Phone #

Enter the billing provider's name and complete address. Telephone number is requested but not required.

PIN #

This field is not required for Medicaid.

GRP #

Clinic or Group Providers: Enter the 9-digit pay-to provider number in Field 33 after "GRP#" and the individual practitioner's number in Field 24K.

Individual Providers: Enter the 9-digit pay-to provider number in Field 33 after "GRP#."