Clinical UM Guideline |
Subject: Private Duty Nursing in the Home Setting | |
Guideline #: CG-REHAB-08 | Publish Date: 09/27/2023 |
Status: Reviewed | Last Review Date: 08/10/2023 |
Description |
This document defines private duty nursing (PDN) in the home and the conditions under which it would be considered medically necessary. PDN refers to intermittent and temporary, complex skilled nursing care on an hourly basis in the home by a Registered Nurse (RN) or a Licensed Practical Nurse (LPN)/Licensed Vocational Nurse (LVN). PDN care includes assessment, monitoring, skilled nursing care, and caregiver/family training to assist with transition of care from a more acute setting to home.
Note: Please see the following related documents for additional information:
Note: Benefit language supersedes this document. PDN service is not a covered benefit under all member contracts/certificates. Please see the text in the footnote of this document regarding Federal and State mandates and contract language, as these requirements or documents may specifically address the topic of PDN.
Clinical Indications |
Medically Necessary:
Private Duty Nursing
General Criteria
Not Medically Necessary:
Coding |
The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
When services may be Medically Necessary when criteria are met:
HCPCS |
|
S9123 | Nursing care, in the home; by registered nurse, per hour |
S9124 | Nursing care, in the home; by licensed |
T1000 | Private duty/independent nursing service(s), licensed, up to 15 minutes |
T1002 | RN services, up to 15 minutes |
T1003 | LPN/LVN services, up to 15 minutes |
T1030 | Nursing care, in the home, by registered nurse, per diem |
T1031 | Nursing care, in the home, by licensed practical nurse, per diem |
| |
ICD-10 Diagnosis |
|
All diagnoses |
When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for situations designated in the Clinical Indications section as not medically necessary.
Discussion/General Information |
PDN is defined as the provision of medically necessary, complex skilled nursing care in the home by an RN or an LPN/LVN. The purpose of PDN is to assess, monitor and provide more individualized and continuous skilled nursing care in the home on an hourly basis; to assist in the transition of care from a more acute setting to home; and to teach competent caregivers the assumption of this care when the condition of the individual is stabilized. The length and duration of PDN services is intermittent and temporary in nature and not intended to be provided on a permanent ongoing basis. Such services are normally billed at an hourly or shift rate. The PDN cannot be a member of the individual’s immediate family or anyone living in the home.
Definitions |
Prolonged seizures: Continuous seizure activity that lasts 5 minutes or longer, or repetitive seizures lasting fifteen minutes.
References |
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
Index |
Private Duty Nursing
History |
Status | Date | Action |
Reviewed | 08/10/2023 | Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References section. |
Reviewed | 08/11/2022 | MPTAC review. Updated References sections. |
Revised | 08/12/2021 | MPTAC review. Updated formatting in MN clinical indication section. Updated Discussion and References sections. |
Revised | 08/13/2020 | Medical Policy & Technology Assessment Committee (MPTAC) review. Clarified wording in clinical indications not medically necessary section, removed reference to “licensed” nurse. Updated References section. Reformatted Coding section. |
Revised | 08/22/2019 | MPTAC review. Clarified wording in NMN clinical indications for private duty nursing in the home setting. Updated References section. |
Revised | 03/21/2019 | MPTAC review. Clarified wording in clinical indications for private duty nursing general criteria section, changed respiratory distress to disorder. Updated References section. |
Revised | 09/13/2018 | MPTAC review. Clarified wording in clinical indications for private duty nursing, removing scope of nursing practice under applicable state licensure regulations. Updated Description and References sections. |
Reviewed | 07/26/2018 | MPTAC review. Updated Description and References sections. |
Revised | 08/03/2017 | MPTAC review. Revised MN criteria for initial and continuation of private duty nursing services. Updated References section. |
Reviewed | 05/04/2017 | MPTAC review. Updated formatting in clinical indications section. Updated References. |
Revised | 05/05/2016 | MPTAC review. Revised MN unstable condition criteria to address enteral feeding. Clarified NMN criteria for enteral feeding. Updated Reference section. Added Definition section. Removed ICD-9 codes from Coding section |
Revised | 05/07/2015 | MPTAC review. Revised medically necessary criteria for unstable conditions. Clarified not medically necessary criteria. Description, Discussion and Reference sections updated. |
Reviewed | 02/05/2015 | MPTAC review. Updated Coding and References sections. |
Reviewed | 02/13/2014 | MPTAC review. Updated Websites. |
Reviewed | 02/14/2013 | MPTAC review. Coding and Websites updated. |
Reviewed | 02/16/2012 | MPTAC review. Updated websites. |
Reviewed | 02/17/2011 | MPTAC review. Related guidelines cross referenced in clinical indication section. Description, Discussion, Coding, References and Websites updated. |
Reviewed | 02/25/2010 | MPTAC review. References updated. |
Reviewed | 02/26/2009 | MPTAC review. References updated. Removed Place of Service section and Case Management section. |
Reviewed | 02/21/2008 | MPTAC review. References updated. Related documents noted. |
Reviewed | 03/08/2007 | MPTAC review. References updated. |
New | 03/23/2006 | MPTAC initial guideline development. |
Pre-Merger Organizations | Last Review Date | Document Number | Title |
Anthem, Inc. |
|
| No Document |
Anthem MW | 05/27/2005 | MA-019 | Private Duty Nursing |
WellPoint Health Networks, Inc. |
|
| No Document |
This Clinical UM Guideline is intended to provide assistance in interpreting Healthy Blue’s standard Medicaid benefit plan. When evaluating insurance coverage for the provision of medical care, federal, state and/or contractual requirements must be referenced, since these may limit or differ from the standard benefit plan. In the event of a conflict, the federal, state and/or contractual requirements for the applicable benefit plan coverage will govern. Healthy Blue reserves the right to modify its Policies and Guidelines as necessary and in accordance with legal and contractual requirements. This Clinical UM Guideline is provided for informational purposes. It does not constitute medical advice. Healthy Blue may also use tools and criteria developed by third parties, to assist us in administering health benefits. Healthy Blue’s Policies and Guidelines are intended to be used in accordance with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.