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Private Duty Nursing Billing Manual

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Private Duty Nursing

Providers must be enrolled as a Health First Colorado provider in order to:

  • Treat a Health First Colorado member
  • Submit claims for payment to Health First Colorado

The Private Duty Nursing (PDN) program provides skilled nursing services on a continuous basis to Health First Colorado members in their place of residence. A plan of care as ordered by the attending physician is developed by the Home Health agency. The plan of care is reviewed periodically by the physician. All plan of care services are subject to post-payment review for medical necessity and regulation compliance.

Providers should refer to the Code of Colorado Regulations, Program Rules (10 C.C.R. 2505-10), for specific information when providing PDN services.

Billing Information

Refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down menu for general billing information.

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Ordering, Prescribing, and Referring (OPR) Providers 

Effective July 1 , 2022, the Department began enforcing the federal requirement 42 CFR § 455.440, which requires that all claims for Home Health services include the National Provider Identifier (NPI) of the provider who ordered the service and 42 CFR 455.440, that requires the NPI is associated with an actively enrolled with Health First Colorado Provider.
Providers are required to enter the NPI of the ordering provider into the following locations for claim submission. In the Provider Web Portal, this field may be labeled "Referring Provider". 

Institutional claims

  • The Attending Provider field (#76) or the Other ID fields (#78 or #79) for both paper and electronic claims
  • Providers should refer to their applicable UB-04 billing manuals for guidance on how each field is used

Private Duty Nursing services can be ordered by either a physician or an allowed practitioner. Allowed practitioners are defined in accordance with State law as physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS). The ordering provider must also be actively enrolled [Health First Colorado. If these conditions are not met, the claim will be denied.

Providers should refer to the OPR web page or Program Rule 10 CCR 2505-10 8.125.8.A for further information.
 

 

General Prior Authorization Requirements

All PDN Prior Authorization Requests (PARs) must be submitted via the ColoradoPAR web page. The additional forms necessary for PDN PAR submission are located on the Provider Forms web page or from the authorizing agency. PAR forms must be completed and sent to the authorizing agency before services can be billed. Instructions for completing the PAR form are included in this manual. Authorizing agency information is listed in Appendices C and D under the Appendices drop-down menu on the Billing Manuals web page.

Health First Colorado requires the completion of a PAR form for:

  • All PDN services prior to starting services.
  • Orders must specify how often treatment or visits will be and the length of visit.
  • Time submitted that is outside of or different from the orders will be deducted and the units adjusted accordingly.
  • Do not submit claims before a copy of the PAR is received or made available unless submission is necessary to meet timely filing requirements. Refer to the Department Program Rules - Code of Colorado Regulations for required attachments.

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General Prior Authorization Request Instructions

Submit all appropriate documentation to support your PDN request including detailed demographics, diagnosis, physician's orders, treatment plans, nursing summaries, nurse aide assignment sheets, medications, etc. via the ColoradoPAR web page.

Revision must also be submitted via the ColoradoPAR web page and must be completed in a timely manner prior to the expiration of the PAR Revenue Coding.

The following table identifies the only valid revenue codes for billing Private Duty Nursing to Health First Colorado. Valid revenue codes are not always a Health First Colorado benefit. When valid non- benefit revenue codes are used, the claim must be completed according to the billing instructions for non-covered charges.

PDN providers billing on the UB-04 claim form for services provided to authorized members must use the appropriate condition code in form locators 18 through 28 (Condition Codes) and use the revenue codes listed below. Claims submitted with revenue codes that are not listed below are denied.

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UB-04 Paper Claim Reference Table

The information in the following table provides instructions for completing form locators (FL) as they appear on the paper UB-04 claim form. Instructions for completing the UB-04 claim form are based on the current National Uniform Billing Committee (NUBC) UB-04 Reference Manual. Unless otherwise noted, all data form locators on the UB-04 have the same attributes (specifications) for Health First Colorado as those indicated in the NUBC UB-04 Reference Manual.

All code values listed in the NUBC UB-04 Reference Manual for each form locator may not be used for submitting paper claims to Health First Colorado. The appropriate code values listed in this manual must be used when billing Health First Colorado.

The UB-04 Certification document must be completed and attached to all claims submitted on the paper UB-04. Completed UB-04 paper Health First Colorado claims, including hardcopy Medicare claims, should be mailed to the correct fiscal agent address listed in Appendix A, under the Appendices drop-down section on the Billing Manuals web page.

Do not submit "continuation" claims. Each claim form has a set number of billing lines available for completion. Do not crowd more lines on the form.

Billing lines in excess of the designated number are not processed or acknowledged. Claims with more than one page may be submitted through the Provider Web Portal.

Bill with a date span (From and To dates of service) only if the service was provided every consecutive day within the span. The From and To dates must be in the same month.

The Paper Claim Reference Table below lists the required, optional and/or conditional form locators for submitting the paper UB-04 claim form to Health First Colorado for nursing facility services.

Form Locator and Labels Completion Format Instructions
1. Billing Provider Name, Address, Telephone Number Text Required
Enter the provider or agency name and complete mailing address of the provider who is billing for the services:
  • Street
  • City
  • State
  • Zip Code
Abbreviate the state using standard post office abbreviations. Enter the telephone number.
2. Pay-to Name, Address, City, State Text Required only if different from FL 1.
Enter the provider or agency name and complete mailing address of the provider who will receive payment for the services:
  • Street/Post Office box City
  • State Zip Code
  • Abbreviate the state using standard post office abbreviations. Enter the telephone number.
3a. Patient Control Number Up to 20 characters: Letters, numbers or hyphens Optional
Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).
3b. Medical Record Number 17 digits Optional
Enter the number assigned to the member to assist in retrieval of medical records.
4. Type of Bill 3 digits Required
Private Duty Nursing
Effective 3/1/2017 use 32X for Home Health/Private Duty Nursing services. 33X is no longer valid.
(These instructions supersede all prior publications)

Use 321-324 or 341-344 for Medicare crossover claims.

Enter the three-digit number indicating the specific type of bill. The three-digit code requires one digit each in the following sequences (Type of facility, Bill classification, and Frequency):
Digit 1 Type of Facility
1 Hospital
2 Skilled Nursing
3 Home Health Services
4 Religious Non-Medical Health Care Institution
6 Intermediate Care
7 Clinic (Rural Health/FQHC/Dialysis Center)
8 Special Facility (Hospice, RTCs)
Digit 2 Bill Classification (Except clinics & special facilities):
1 Inpatient (Including Medicare Part A)
2 Inpatient (Medicare Part B only)
3 Outpatient
4 Other (for hospital referenced diagnostic services or home health not under a plan of treatment)
5 Intermediate Care Level I
6 Intermediate Care Level II
7 Sub-Acute Inpatient (Revenue Code 019X required with this bill type)
8 Swing Beds
9 Other
Digit 2 Bill Classification (Clinics Only):
1 Rural Health/FQHC
2 Hospital Based or Independent Renal Dialysis Center
3 Freestanding
4 Outpatient Rehabilitation Facility (ORF)
5 Comprehensive Outpatient Rehabilitation Facilities (CORFs)
6 Community Mental Health Center
Digit 3 Frequency:
0 Non-Payment/Zero Claim
1 Admit through discharge claim
2 Interim - First claim
3 Interim - Continuous claim
4 Interim - Last claim
7 Replacement of prior claim
8 Void of prior claim
5. Federal Tax Number None Submitted information is not entered into the claim processing system.
6. Statement covers period From/Through From:6 digits MMDDYY
Through: 6 digits MMDDYY		 Required
Private Duty Nursing
"From" date is the actual start date of services.

"From" date cannot be prior to the start date reported on the initial prior authorization, if applicable, or is the first date of an interim bill.

"Through" date is the actual discharge date, or final date of an interim bill.

"From" and "Through" dates cannot exceed a calendar month (e.g., bill 01/15/10 thru 01/31/10 and 02/01/10 thru 02/15/10, not 01/15/10 thru 02/15/10).

Dates must match the prior authorization if applicable. If member is admitted and discharged the same date, that date must appear in both fields.

Detail dates of service must be within the "Statement Covers Period" dates.
8a. Patient Identifier Text Enter the Health First Colorado ID number for the member.
8b. Patient Name Up to 25 characters, letters & spaces Required
Enter the member's last name, first name and middle initial.
9a. Patient Address - Street Characters Letters & numbers Required
Enter the member's street/post office box as determined at the time of admission.
9b. Patient Address - City Text Required
Enter the member's city as determined at the time of admission
9c. Patient Address - State Text Required
Enter the member's state as determined at the time of admission.
9d. Patient Address - ZIP Digits Required
Enter the member's zip code as determined at the time of admission.
9e. Patient Address - Country Code Digits Optional
10. Birthdate 8 digits (MMDDCCYY) Required
Enter the member's birthdate using two digits for the month, two digits for the date, and four digits for the year (MMDDCCYY format). Example: 01012010 for January 1, 2010.
11. Patient Sex 1 letter Required
Enter an M (male) or F (female) to indicate the member's sex.
12. Admission Date 6 digits Required
Enter the date care originally started from any funding source (e.g., Medicare, Health First Colorado, Third Party Resource, etc.).
13. Admission Hour 6 digits Not required
14. Admission Type 1 digit Not Required
15. Source of Admission 1 digit Required

Complete if the member has been admitted or readmitted during the billing period.
16. Discharge Hour 2 digits Not Required
17. Patient Discharge Status 2 digits Required
Enter member status as ongoing member (code 30) or as of discharge date. Agencies are limited to the following codes:
01 Discharged to Home
03 Discharged/Transferred to SNF
04 Discharged/Transferred to ICF
05 Discharged/Transferred to Another type of institution
06 Discharged/Transferred to organized Home Health Care Program (HCBS)
07 Left Against Medical Advice
20 Deceased/Expired (not for Hospice user)
30 Still a member
40 Expired at Home
41 Expired in hospital, SNF, ICF, or free-standing hospice
42 Expired - Place unknown
50 Hospice - Home
51 Hospice - Medical Facility
18-28. Conditions Codes 2 digits Conditional
Use condition code A1 to bill PDN hours greater than 16 for children.
29. Accident State 2 digits Optional
31 - 34. Occurrence Code/Date 2 digits & 6 digits Required

use occurrence code 27 and enter the Plan of care start date. Enter the date using MMDDYY format.
35-36. Occurrence Span Code From/ Through Digits Leave blank
38. Responsible Party Name/Address None Leave blank
39 - 41. Value Codes and Amounts 2 characters and up to 9 digits Conditional
Enter appropriate codes and related dollar amounts to identify monetary data or number of days using whole numbers, necessary for the processing of this claim. Never enter negative amounts. Codes must be in ascending order. If a value code is entered, a dollar amount or numeric value related to the code must always be entered.
Most Common Codes:
01 semiprivate rate (Accommodation Rate)
06 Medicare blood deductible
14 No fault including auto/other
15 Worker's Compensation
31 Member Liability Amount*
32 Multiple Member Ambulance Transport
37 Pints of Blood Furnished
38 Blood Deductible Pints
40 New Coverage Not Implemented by HMO
45 Accident Hour
Enter the hour when the accident occurred that necessitated medical treatment. Use the same coding used in FL 18 (Admission Hour).
49 Hematocrit Reading - EPO Related
58 Arterial Blood Gas (PO2/PA2)
68 EPO-Drug
80 Covered Days
81 Non-Covered Days
Enter the amount paid by indicated payer:
A3 Estimated Responsibility Payer A
B3 Estimated Responsibility Payer B
C3 Estimated Responsibility Payer C

For Rancho Coma Score bill with appropriate diagnosis for head injury.
42. Revenue Code 4 digits Required
Enter the revenue code that identifies the specific accommodation or ancillary service provided. List revenue codes in ascending order.

A revenue code must appear only once per date of service. If more than one of the same service is provided on the same day, combine the units and charges on one line accordingly.

Enter the appropriate Revenue code. Private Duty Nursing services cannot be provided to Nursing Facility residents.
43. Revenue code Description Text Required
Enter the revenue code description or abbreviated description.
44. HCPCS/Rates/ HIPPS Rate Codes 5 digits Required for the following:
  • Private Duty Nursing RN visit: Use only HCPCS code T1000 with modifier TD for revenue code 552.
  • Private Duty Nursing LPN visit: Use only HCPCS code T1000 with modifier TE for revenue code 559.
  • Private Duty Nursing private duty nursing RN group visit: Use only HCPCS code T1000 with modifiers HQ and TD for revenue code 580.
  • Private Duty Nursing private duty nursing LPN group visit: Use only HCPCS code T1000 with modifiers HQ and TE for revenue code 581.
When billing HCPCS codes, the appropriate revenue code must also be billed.
45. Service Date 6 digits Conditional
Enter the date of service using MMDDYY format foe each detail line completed.
46. Service Units 3 digits Required
Enter a unit value on each line completed. Use whole numbers only. Do not enter fractions or decimals and do not show a decimal point followed by a 0 to designate whole numbers (e.g., Do not enter 1.0 to signify one unit)
47. Total Charges 9 digits Required

Enter the total charge for each line item. Calculate the total charge as the number of units multiplied by the unit charge. Do not subtract Medicare or third-party payments from line charge entries. Do not enter negative amounts.
A grand total on line 23 is required for all charges.
48. Non-covered Charges Up to 9 digits Conditional

Enter incurred charges that are not payable by Health First Colorado.

Non-covered charges must be entered in both FL 47 (Total Charges) and FL 48 (Non-Covered Charges.)

Each column requires a grand total.
50. Payer Name 1 letter and text Enter the payment source code followed by name of each payer organization from which the provider might expect payment.
At least one line must indicate Health First Colorado.
Source Payment Codes
B Workmen's Compensation
C Medicare
D Health First Colorado
E Other Federal Program
F Insurance Company
G Blue Cross, including Federal Employee Program
H Other - Inpatient (Part B Only)
I Other
Line A Primary Payer
Line B Secondary Payer
Line C Tertiary Payer
51. Health Plan ID 8 digits Required
Enter the provider's Health Plan ID for each payer name.
Enter the NPI number assigned to the billing provider. Payment is made to the enrolled provider or agency that is assigned this number.
52. Release of Information N/A Submitted information is not entered into the claim processing system.
53. Assignment of Benefits N/A Submitted information is not entered into the claim processing system.
54. Prior Payments Up to 9 digits Conditional
Complete when there are Medicare or third-party payments.
Enter third party and/or Medicare payments.
55. Estimated Amount Due Up to 9 digits Conditional
Complete when there are Medicare or third-party payments.
Enter the net amount due from Health First Colorado after provider has received other third party, Medicare or member liability amount.
Medicare Crossovers
Enter the sum of the Medicare coinsurance plus Medicare deductible less third-party payments and member payments.
56. National Provider Identifier (NPI) 10 digits Required
Enter the billing provider's 10-digit National Provider Identifier (NPI).
57. Other Provider ID   Optional
Submitted information is not entered into the claim processing system.
58. Insured's Name Up to 30 characters Required
Enter the member's name on the Health First Colorado line.
Other Insurance/Medicare
Complete additional lines when there is third party coverage. Enter the policyholder's last name, first name, and middle initial.
60. Insured's Unique ID Up to 20 characters Required
Enter the insured's unique identification number assigned by the payer organization exactly as it appears on the health insurance card. Include letter prefixes or suffixes shown on the card.
61. Insurance Group Name 14 letters Conditional
Complete when there is third party coverage.

Enter the name of the group or plan providing the insurance to the insured exactly as it appears on the health insurance card.
62. Insurance Group Number 17 digits Conditional
Complete when there is third party coverage.

Enter the identification number, control number, or code assigned by the carrier or fund administrator identifying the group under which the individual is carried.
63. Treatment Authorization Code Up to 18 characters Conditional
Complete when the service requires a PAR.
Enter the authorization number in this FL if a PAR is required and has been approved for services.
64. Document Control Number none Enter Previous ICN in field 64a
65. Employer Name Text Conditional
Complete when there is third party coverage.
Enter the name of the employer that provides health care coverage for the individual identified in FL 58 (Insured Name).
66. Diagnosis Version Qualifier   Submitted information is not entered into the claim processing system.
Enter applicable ICD indicator to identify which version of ICD codes is being reported.
0ICD-10-CM (DOS 10/1/15 and after)
67. Principal Diagnosis Code Up to 6 digits Required
Enter the exact diagnosis code describing the principal diagnosis that exists at the time of admission or develops subsequently and affects the length of stay. Do not add extra zeros to the diagnosis code.
67A. - 67Q. - Other Diagnosis 6 digits Optional
Enter the exact diagnosis code corresponding to additional conditions that co-exist at the time of admission or develop subsequently and which effect the treatment received or the length of stay. Do not add extra zeros to the diagnosis code.
Enter applicable ICD indicator to identify which version of ICD codes is being reported.
69. Admitting Diagnosis Code 6 digits Not Required

Enter the diagnosis code as stated by the physician at the time of admission.
70. Patient Reason Diagnosis   Submitted information is not entered into the claim processing system.
71. PPS Code   Submitted information is not entered into the claim processing system.
72. External Cause of Injury code (E-Code) 6 digits Optional
Enter the diagnosis code for the external cause of an injury, poisoning, or adverse effect. This code must begin with an "E".
74. Principal Procedure Code/Date 7 characters and 6 digits Not Required
74A. Other Procedure Code/Date 7 characters and 6 digits Not Required
76. Attending NPI - Required NPI - 10 digits Health First Colorado ID Required
NPI - Enter the 10-digit NPI number assigned to the physician having primary responsibility for the member's medical care and treatment. This number is obtained from the physician and cannot be a clinic or group number.
(If the attending physician is not enrolled in the Health First Colorado or if the member leaves the ER before being seen by a physician, the hospital may enter their individual numbers.)
Hospitals and FQHCs may enter the member's regular physician's 10- digit NPI in the Attending Physician ID form locator if the locum tenens physician is not enrolled in the Health First Colorado.
QUAL - Enter "1D" for Health First Colorado
Enter the attending physician's last and first name.
This form locator must be completed for all services.
77. Operating NPI   Optional
Submitted information is not entered into the claim processing system.
78 - 79. Other ID NPI - 10 digits Required

Complete when attending physician is not the PCP or to identify additional physicians.

Ordering, Prescribing, or Referring NPI

NPI - Enter up to two 10-digit NPI numbers, when applicable. This form locator identifies physicians other than the attending physician. If the attending physician is not the PCP or if a clinic is a PCP agent, enter the PCP NPI number as the referring physician. The name of the Health First Colorado member's PCP appears on the eligibility verification. Review either for eligibility and PCP. Health First Colorado does not require that the PCP number appear more than once on each claim submitted.

The attending physician's last and first name are optional.
80. Remarks Text Enter specific additional information necessary to process the claim or fulfill reporting requirements.
81. Code - QUAL/CODE/VALUE (a-d) Qualifier: 2 digits
Taxonomy Code: 10 digits		 Optional
Complete both the qualifier and the taxonomy code for the billing provider in field 81CC-a.
Field 81CC-a must be billed with qualifier B3 for the taxonomy code to be captured in the claims processing system. If B3 is missing, no taxonomy code will be captured in the claims processing system.
Only one taxonomy code can be captured from field 81CC. If more than one taxonomy code is provided, only the first instance of B3 and taxonomy code will be captured in the claims processing system.

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Private Duty Nursing Claim Example

Note: Medicare crossover claims are valid only with Medicare claims for visits rather than episodes. LUPA payments not episode case mix payment.
PDN Claim example

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Timely Filing

For more information on timely filing policy, including the resubmission rules for denied claims, refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down menu.

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Institutional Provider Certification

The Institutional Provider Certification form is located under the Claim Forms and Attachments drop-down section on the Provider Forms web page.

This document is an addendum to the UB-04 claim form and is required per 42 C.F.R. 445.18 (a)(1-2) to be attached to paper claims submitted on the UB-04.

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Early and Periodic Screening, Diagnostic, and Treatment 

Hospice benefits are provided in accordance with Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) requirements as listed in 8.280.4.E: “Other EPSDT Benefits” 8.280.4.E reads as follows: 

Other health care services may include other EPSDT benefits if the need for such services is identified. The services are a benefit when they meet the following requirements:

  1. All goods and services described in Section 1905(a) of the Social Security Act are a covered benefit under EPSDT when medically necessary as defined at 10 C.C.R. 2505-10, Section 8.076.1.8, regardless of whether such goods and services are covered under the Colorado Medicaid State Plan.
  2. For the purposes of EPSDT, medical necessity includes a good or service that will, or is reasonably expected to, assist the client to achieve or maintain maximum functional capacity in performing one or more Activities of Daily Living; and meets the criteria set forth at Section 8.076.1.8.b - g.
  3. The service provides a safe environment or situation for the child.
  4. The service is not for the convenience of the caregiver.
  5. The service is medically necessary.
  6. The service is not experimental or investigational and is generally accepted by the medical community for the purpose stated.
  7. The service is the least costly.

Providers can ask for these additional services by following the PAR process as outlined for this benefit.

More information regarding EPSDT may be found on the EPSDT web page.

Questions about EPSDT may be directed to gina.robinson@state.co.us

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Electronic Visit Verification 

Federal guidance requires Electronic Visit Verification (EVV) for Home and Community Based Services (HCBS) that include an element of Personal Care Services and State Plan Home Health Care Services. Colorado requires the use of EVV for several other services that are similar in nature and delivery to the federally mandated services. These additional services are included to enhance care coordination, promote quality outcomes for members, and to streamline requirements for providers. 

All Private Duty Nursing services require EVV. 

Further information regarding the EVV program is available at the EVV web page and the EVV Program Manual. EVV questions may be directed to EVV@state.co.us.

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Private Duty Nursing Revisions Log

Revision Date Section/Action Made by
12/01/2016 Manual revised for interChange implementation. Form annual revisions prior to 12/01/2016 Please refer to Archive. HPE (now DXC)
12/27/2016 Updates based on Colorado iC Stage II Provider Billing Manual Comment Log v0_2.xlsx HPE (now DXC)
1/10/2017 Updates based on Colorado iC Stage II Provider Billing Manual Comment Log v0_3.xlsx HPE (now DXC)
1/19/2017 Updates based on Colorado iC Stage II Provider Billing Manual Comment Log v0_4.xlsx HPE (now DXC)
1/26/2017 Updates based on Department 1/20/2017 approval email HPE (now DXC)
3/8/2017 Added Type of Bill 32x to row 4 of the Private Duty Nursing Claim example table. HCPF
3/13/2017 Updated the Type of Bill section in the Paper Claims Table to reflect the NUBC manual. HCPF
3/14/2017 Updated the type of bill in the paper claim example. HCPF
5/26/2017 Updates based on Fiscal Agent name change from HPE to DXC DXC
6/15/2018 Updated timely filing information and removed references to LBOD, removed general billing information already available in the General Provider Information manual. DXC
6/13/2019 Updated Appendices' links and verbiage. Updated Institutional Provider Certification form information. DXC
12/9/2019 Converted to web page. HCPF
8/7/2020 Updated item 81 of the Paper Claim Reference Table for taxonomy code billing. DXC
9/17/2021 Updated Billing manual with existing guidance regarding EPSDT and EVV. HCPF
7/22/2022 Changed definition of PDN program to read continuous instead of intermittent. HCPF
9/11/2023 Added Ordering, Prescribing, Referring (OPR) Policy. Updated Field #78-79 on claim reference table. HCPF

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