#reimbursement – Page 2 – KR2 Medical Billing

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Understanding Nursing Home vs PDN Coding-NYS

Posted on January 15, 2026 by KR2Medical Billing

In order for us to understand the coding difference between the nursing home visit codes and PDN (private duty nursing) codes, we need to go back to the basics.

Definitions:

Nursing Home services/visits- the necessary intermittent or part-time nursing care provided for a patient in the patient’s home or home substitute on a per visit basis. These services are usually no more than 2 hours per day and are performed by the Certified Home Health Agency.

Private Duty Nursing services/visits- nursing services that are one on one more personal level, for medical fragile members, that are performed on continuous basis. The purpose of Private Duty Nursing is to assist the caregiver/family members to help the member to remain safely at home. There is a separate code set for PDN services and a corresponding fee schedule.

Reimbursement:

Nursing Home Visits: are reimbursed in the increments of 15 min

PDN services/visits: are reimbursed by hour.

Exception: the following 2 code are reimbursed per diem because they represent the 13-hour shift

T1030- nursing care by RN, per diem, at home- 13 hour shirt

T1031- nursing care by LPN, per diem, at home- 13-hour shift

Coding–

I. Nursing Home Visits/Services:

a. T1002- RN services, up to 15 min

b. T1003- LPN services, up to 15 min

II. PDN services/visits:

a. S9123- RN services, per hour

b. S9124- LPN services, per hour

Please note that when you are billing the T codes you cannot bill them with the “other nursing codes” , listed below, or when the codes listed below better represent the nursing services that are authorized, performed.

Other Nursing Codes:

Need more information about NYS Medicaid Home and Community LTC codes: please visit here

PDN services fee schedule, here.

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NYS Medicaid POC Syphilis testing coverage

Posted on January 9, 2026 by KR2Medical Billing

Effective for any DOS August 2025 and thereafter Point of Care testing for Syphilis is covered for all fee fo service Medicaid and Managed Medicaid Members.

Where is this test covered (POS)?

physician/nurse practitioner/licensed midwife private office setting

What kind of POC is covered and reimbursed?

Currently there is only one FDA approved test -Clinical Laboratory Improvement Amendments-waived, rapid syphilis test, Syphilis Health Check™, for the detection of Treponema pallidum antibodies.

Coding:

86780 – Antibody; Treponema pallidum.

Reimbursement Rates:

Physician- https://www.emedny.org/ProviderManuals/Physician/ – select medicine fee schedule

Midwife- https://www.emedny.org/ProviderManuals/Midwife/ select fee schedule

Nurse Practitioner- https://www.emedny.org/ProviderManuals/NursePractitioner/

For more guidance on which providers are allowed reimbursement please read the NYS PDF file here.

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NYS Medicaid: Bariatric Surgery Medical Policy Update

Posted on January 7, 2026 by KR2Medical Billing

Do you accept NYS Medicaid or Managed Medicaid Plan members? Then this blog post is for you!

Non surgical treatment should be attempted: ex. diet and increased exercise.

Bariatric Surgery Adult Patient: 18 years old and over

BMI index 35 kg/m or greater OR
BMI index 30-34.9 kg/m and a serious weight-related health problem (ex. High blood pressure, type 2 diabetes or severe sleep apnea)

Pediatric patients: 18 years and older – patients that are deemed physically, mentally, and emotionally mature by a team of various providers ex. Pediatric provider, bariatric surgeon, and or other specialty providers.

BMI- more and equal to 35 kg/m or more than 120% of 95th percentile of age and sex, whichever is lower AND with a weight-related health problem: ex. diabetes type 2, obstructive apnea – index or Reapiratory Disturbance Index greater than 5, Blount disease, non alcoholic steatohepatitis, slipped capital femoral epiphanies, GERD, hypertension, insulin resistance; or depressed health-related quality of life
BMI greater than 40 kg/m or greater than 140% of the 95th percentile of age and sex, whichever is lower

Coding:

Most common codes that related to Bariatric Surgery

43644: Laparoscopic Roux-en-Y gastric bypass.

43775: Laparoscopic sleeve gastrectomy.

43770: Laparoscopic placement of an adjustable gastric band

43645: Laparoscopic malabsorptive procedure (e.g., [[Mini-gastric bypass|Mini-gastric bypass]]).

43848: Revision of a gastric restrictive procedure (open).

NYS Medicaid coding and fee resources:

1. Physician Fee schedule- https://view.officeapps.live.com/op/view.aspx?src=https%3A%2F%2Fwww.emedny.org%2FProviderManuals%2FPhysician%2FPDFS%2FPhysician_Manual_Fee_Schedule_Sect5.xls&wdOrigin=BROWSELINK

2. Provider Manual- https://www.emedny.org/ProviderManuals/Physician/PDFS/Physician%20Procedure%20Codes%20Sect5.pdf

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