Clinical UM Guideline |
Subject: Private Duty Nursing in the Home Setting | |
Guideline #: CG-REHAB-08 | Publish Date: 10/01/2024 |
Status: Revised | Last Review Date: 08/08/2024 |
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:
I. Initial private duty nursing services are medically necessary when both (section A and section B below) are demonstrated in the clinical record:
Section A (Criteria A.1-A.6 must all be met):
Section B (Criterion B.1 and at least one of criteria B.2, B.3, or B.4 below must be met):
II. Continuation of private duty nursing services are considered medically necessary when the following criteria are met:
III. Private duty nursing for the purpose of caregiver training is considered medically necessary when the following criteria are met:
Not Medically Necessary:
Private duty nursing in the home is considered not medically necessary when it is provided for one or more of the following:
The following are examples of services that do not require the skills of a nurse and therefore are considered to be not medically necessary in the home setting unless there is documentation of comorbidities and complications that require individual consideration.
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.
Gay and colleagues (2016) reported the results of a retrospective matched cohort study of 2783 hospitalized children receiving post discharge home health services across 19 states and 7361 matched individuals discharged without home health services between 2004-2012. The outcomes measured were subsequent hospitalizations, hospital days, and readmissions. Although the individuals that received home health services had a higher rate of complex chronic conditions, technology assistance, and neurologic impairment than the control group, 30-day readmission rates were lower in the home health group (18.3% versus 21.5%, p=0.001). At 12 months after the index admission, the home health group averaged fewer admissions (0.8 versus 1.0, p=0.001) and fewer days in the hospital (6.4 versus 6.6, p<0.001) compared with the control group. The authors concluded that children discharged with home health care experienced less hospital utilization than those with similar characteristics who did not use home health care.
The Hospital at Home model (HAH) is a primary means for treating acutely ill patients in many regions of the world, however the HAH model in the USA is not yet mainstream. In November 2020, due to the COVID-19 pandemic, Medicare issued a temporary CMS waiver that allows hospital-level reimbursement for the HAH model. Helberg and colleagues (2023) published a non-randomised, prospective, case-controlled study of 60 individuals with heart failure (HF) enrolled in HAH (n=40) versus admission to the hospital (n=20). Inclusion criteria were individuals aged 18 years or older with known HF (systolic or diastolic) that presented to their community providers or emergency departments with acute decompensated HF requiring inpatient admission. Acute decompensated HF was defined as worsening of specific HF signs including peripheral edema, pulmonary rales, increased abdominal girth, and symptoms such as dyspnea and fatigue caused by abnormal cardiac function, and supported by documentation including electrocardiography, chest X- ray, laboratory tests, or echocardiography. No participants admitted to the HF HAH program required inotropes or oxygen at the time of admission. The study results demonstrate that HAH participants had slightly longer lengths of stay (6.3 days versus 4.7 days), however, fewer adverse events (12.5% versus 35%) compared with the admission group. Participants in the HAH program were less likely to be discharged with post-acute services. Secondary outcomes of 30-day readmission and emergency department usage were similar between the groups. The authors concluded that the HAH pilot program is a safe and effective alternative to hospitalization for appropriately selected individuals presenting with acute on chronic HF.
Definitions |
Bi-level positive airway pressure (BPAP): A mechanical ventilation technique that keeps the airways open by delivering pressurized air at two different pressure levels. When an individual breathes in the machines deliver higher air pressure, when the individual breathes out the machine reduces the air pressure.
Continuous positive airway pressure (CPAP): A mechanical ventilation technique that keeps the airways open by delivering continuous pressurized air through an invasive or noninvasive interface.
Intubation: A surgical procedure in which a tube is placed in the trachea (airway) to keep it open so air can get to the lungs. A nasotracheal tube is inserted through the nares into the trachea. An orotracheal tube is passed through the mouth into the trachea. A tracheostomy tube is inserted through a tracheostomy.
Mechanical Ventilation: A form of life support in which a machine (ventilator) supports the work of breathing when an individual is not able to breathe enough independently.
Prolonged seizures: Continuous seizure activity that lasts 5 minutes or longer, or repetitive seizures lasting fifteen minutes.
Tracheostomy: A surgical procedure in which a hole is created in the trachea through which a tube is inserted to exchange respiratory gasses with the lungs. A tracheostomy may be temporary or permanent.
Ventilation: The process of moving respiratory gasses into and out of the lungs; also called breathing.
Ventilator: A mechanical device capable of providing pressurized air with or without supplemental oxygen and two or more of the following features: pressure support, rate support, volume support or various combinations of pressure, rate, and volume support.
References |
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
Websites for Additional Information |
Index |
Private Duty Nursing
History |
Status | Date | Action |
Revised | 08/08/2024 | Medical Policy & Technology Assessment Committee (MPTAC) review. Revised MN Criteria section. Revised formatting in MN and NMN sections. Updated Discussion, Definitions, and References sections, and added Websites section. |
Reviewed | 08/10/2023 | 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 |
Federal and State law, as well as contract language including definitions and specific coverage provisions/exclusions, and Medical Policy take precedence over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Clinical UM Guidelines, which address medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically. Clinical UM guidelines are used when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether or not to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the back of the member's card.
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.
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