CurrentBlue Cross Blue Shield - MichiganPolicy N/A

Private Duty Nursing

Defines Medicare Plus Blue coverage, payment conditions, clinical criteria, billing and documentation requirements for private duty nursing (PDN) provided in the home for Medicare Advantage members.

Policy Summary

PayerBlue Cross Blue Shield - Michigan

PolicyPrivate Duty Nursing

Policy CodePolicy N/A

Change TypeNo material change

Effective Date01/01/2026

Next Review DateN/A

Key ActionVerify coverage, allowed amounts and member cost share via Availity and follow Blue Cross reimbursement policies before billing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24max continuous care hrs

8daily hrs generally required

S9123,S9124CPT/HCPCS codes

q3 monthsphysician certification freq

0clinical/benefit changes

Coverage Criteria for Private Duty Nursing

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

inv-01: General criteria

Covered when ALL of the following are met

General criteria: Member must be homebound as certified by the attending physician; absences from home, if any, are infrequent/short and require considerable effort or assistance; member is clinically and physiologically stable for discharge and all reasonably anticipated medical needs can be met in the home with private duty nursing support; comorbidities and combination of technologies indicate a need for continuous skilled services (up to 24 hours) though payment for 24 hours is not required; at least two trained caregivers must be available and competent to provide care when the nurse is not present; PDN services must be ordered by an M.D. or D.O. involved in the patient’s ongoing care.

inv-02: Specific clinical criteria

AND all of the following specific clinical/documentation criteria are met

Documentation and frequency: A physician certification letter explaining medical necessity must be submitted every three months and must indicate the condition may require up to 24 hours per day of LPN or RN care; continuous assessment/observation with hourly documentation (or shift notes if hourly notes not provided) is required; training and teaching activities by the skilled nurse to patient/family/caregivers are required until caregivers are competent or training is no longer appropriate.

Clinical intervention requirements: Continuous assessment and monitoring of complex or fragile clinical conditions are required; when present, tracheostomy suctioning for secretion control must occur at least twice per 8-hour shift; ventilator patients require recording of initial ventilator settings (mode, tidal volume, respiratory rate, wave form modifications, PEEP, FIO2), continuous oxygen saturation monitoring, and hourly observations with documentation of changes; complex or frequent medication administration (including IV drugs or nutrition) with potential for serious side effects requires documentation and monitoring; management of tube drainage (including replacement every two hours when required), complex wounds, cavities and irrigations require documentation; tube feedings with frequent changes in formulation or rate or increased aspiration risk require documentation; payable skilled procedures that require an RN or LPN/LVN include dressing application with prescribed medications and aseptic technique, frequent removal of nasopharyngeal and tracheotomy secretions, initial medical gas administration phases, insertion/placement of catheters with sterile irrigation, insertion/placement of catheters associated with active urinary tract treatment, insertion of Levin tube and initial feedings, post-operative management after gastrostomy tube insertion, respirator/ventilator treatment, and treatment of extensive decubitus ulcers or other widespread skin disorders.

The following services are explicitly excluded from coverage: care provided by the patient’s relative, care provided by a hospital employee, housekeeping, laundry, respite care, services not medically necessary, taxes, and travel expenses.

These Medicare Advantage Enhanced Benefit policies describe the criteria BCBSM/BCN use to determine reasonable and necessary services when Medicare rules are not fully developed. They are not an authorization, certification, explanation of benefits, or a contract and do not guarantee payment. Providers must review member benefit documents and applicable reimbursement and provider manual guidance before billing; enhanced benefit policies do not replace independent clinical judgment.

Services that are not medically necessary are excluded from coverage. Claims for such services will not be covered under this PDN benefit.

Coding and Utilization Details

CPT/HCPCS CodesHCPCSCovered

S9123	Nursing care, in the home; by registered nurse, per hour (use for general nursing care only, not to be used when CPT codes 99500-99602 can be used).
S9124	Nursing care, in the home; by licensed practical nurse, per hour

ICD-10 CodesICD-10

No codes listed

Daily hours generally required

Daily hours generally required8 hours per day are generally required to meet the needs of the patient.

Payable provider typesRN, LPN, LVN (LVN not in Michigan).

Payable locationHome.

Transition approval maximum

Transition approval maximumUp to 16 hours per day of PDN may be approved during transition from inpatient setting to home.

ContextApproval applies specifically during transition from inpatient to home to support increased needs temporarily.

Related CPT/HCPCSS9123, S9124 (used for PDN billing).

Provider Actions, Documentation & Billing

Prior Authorization

Verify coverage, authorizations and payment

Coverage/payment is determined by the member's plan and fee schedule. Providers must verify authorization, coverage and the plan’s maximum payment amount through the BCBSM/BCN provider portals before delivering or billing services.

Verify Medicare Plus Blue PPO Enhanced Benefit Fee Schedule via Availity Essentials™ (Secure Provider Resources → Fee Schedules).
Payment = lesser of allowed amount or provider charge, minus member cost share; providers may not balance-bill the member.

Billing Rule

Review reimbursement policies before billing

All providers are required to review applicable BCBSM reimbursement policies and the provider manual before submitting claims. Failure to follow BCBSM/BCN reimbursement policies or provider manual requirements may result in unpaid or denied claims.

Review BCBSM reimbursement policies relevant to Private Duty Nursing prior to claim submission.
Contracted providers: review the BCBSM/BCN Medicare Advantage provider manual for additional claim submission requirements.
Non‑contracted providers: be prepared to submit supporting documentation (including medical records) if requested.

Denial Risk

Excluded services may be denied

Do not submit claims for excluded services. Claims for care provided by a patient’s relative, hospital employee, housekeeping, laundry, respite care, services not medically necessary, taxes, or travel expenses may be denied.

Excluded services include: care by patient’s relative; care by hospital employee; housekeeping; laundry; respite care; non‑medically necessary services; taxes; travel expenses.

Documentation Required

Ordering and caregiver training requirements

Private duty nursing services must be ordered by an MD or DO and the care plan must document training of caregivers. At least two caregivers (family member, friend, etc.) must be trained and competent to provide care when the nurse is not present.

Order must be from the attending physician (M.D. or D.O.) involved in ongoing care.
Document caregiver training and competency for at least two caregivers.
Services are intended to be temporary with the goal of training caregivers to assume care as appropriate.

Documentation Required

Required documentation and physician certification

Providers must maintain and submit the required documentation and periodic physician certification. Submit a physician certification letter every three months and include hourly medical documentation or nurse shift notes, physician certification statement (diagnosis, plan of treatment, specific nursing duties, explanation of medical necessity), and all supporting items listed below.

Physician certification every 3 months indicating need for up to 24‑hour LPN/RN care and estimated length of care.
Hourly clinical documentation of services and observations; if hourly notes are not available, submit nurse shift notes.
Complete certification statement must include: member diagnosis; plan of treatment; specific nursing duties; explanation of medical necessity; service dates with week ending dates; attending physician name and degree.
Include nurse identification details and hours worked: nurse name/degree/address; professional license number; driver’s license with photo ID and number; hours worked and dates of service; member name; attending physician’s name and degree.
Send all supporting documentation to: Blue Cross Blue Shield of Michigan Imaging and Support Services, Attention: Medicare Advantage Private Duty Nursing, P.O. Box 32593, Detroit, MI 48232-0593.

Definitions

Private Duty Nursing (PDN) definition

DefinitionIndividualized, continuous 24-hour nursing care in the home by an RN or LPN when skilled care needs exceed home health services.

Scope exclusionsDoes not cover services provided by or within scope of medical assistants, nurse's aides, home health aides or other non-nurse level caregivers.

PurposeIntended for patients needing more intense skilled nursing than home health and not to supplement family caregiving responsibilities.

Homebound

Homebound certificationAttending physician certifies the member is confined to the home or is immobile due to illness, injury or surgery.

Absence allowanceIf the member leaves home, absences must be infrequent or short, and require considerable effort, supportive devices, special transportation, or assistance of another person.

Not strictly bed‑boundMember need not be bed-bound to be considered homebound; services are provided only in the home.

OpenPayer

Private Duty Nursing

Coverage Criteria for Private Duty Nursing

Coding and Utilization Details

Provider Actions, Documentation & Billing

Definitions

Background