MaineCare in Education: Private Duty Nursing (PDN) Medical Necessity

Jun 30, 2022

As a reminder for all providers of PDN services for members under the age of 21, the determination of medical necessity for PDN services in the home should not be contingent on whether the member receives PDN services at school.   

Under the Federal Individuals with Disabilities Education Act (IDEA), the student’s Individualized Education Program (IEP) team decides whether PDN services are medically necessary for a student to access their education. MaineCare does not make that determination. The MaineCare in Education 2022 provider guide explains the process by which requests for PDN services at school are approved.    

An agency should not approve or deny at home PDN services based on decisions made by an IEP team about the delivery of and/or eligibility of a member for nursing services at school. Under Chapter I, Section 1, of the MaineCare Benefits Manual (MBM), a provider may not interfere with a member’s freedom of choice in seeking medical care from any institution, agency, pharmacy, or person who is qualified to perform a required service and is a MaineCare provider (Section 1.03-8(C)). Additionally, providers may not discourage or interfere with a MaineCare member accessing medically necessary MaineCare services for which the member is eligible (MBM 1.03-8(D)). MaineCare providers must provide services and supplies to members in the same quality and mode of delivery as they are provided to the general public (MBM1.03-8(G)). Providers must also provide adequate access to medically necessary covered health care services for MaineCare members (MBM 1.03-8(W)).   

Instructions for accurate billing:   

• Home service hours should be billed separately from services provided in the school setting (two claims billed for each type of PDN services on the same day)  

• Place of service code 12 should be used for home PDN hours  

• Place of service code 03 should be used for school PDN hours  

• If a member has an IEP, modifier TL should be added to the claim line in addition to any existing modifiers  

• If a member has an Individualized Family Service Plan (IFSP), modifier TM should be added to the claim line in addition to any existing modifiers  

• If a member has both home and school PDN services on the same day, providers will need to add a separate modifier  

• The complete list of Alpha-Numeric Healthcare Common Procedure Coding System (HCPCS) modifiers (by year) can be found on the CMS Alpha-Numeric HCPCS webpage.   

For more information or questions MaineCare providers can email Tammy Usher, Provider Relations Specialist. School Administrators can contact Trista Collins, State Medicaid Education Liaison.