CurrentBlue Cross Blue Shield - MichiganPolicy N/A

Private Duty Nursing (PDN) — Coverage Criteria

Defines coverage, clinical criteria, billing and payment rules for private duty nursing (PDN) for Medicare Plus Blue Group PPO members; describes provider, documentation and member responsibilities for PDN services delivered at home.

Policy Summary

PayerBlue Cross Blue Shield - Michigan

PolicyPrivate Duty Nursing (PDN) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit physician certification every three months and provide hourly clinical documentation for continuous monitoring.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

S9123, S9124Covered codes

15-minPayment unit

8–16Daily hours

q3 monthsPhysician recertify

HourlyDocumentation

Coverage Criteria for Private Duty Nursing (PDN)

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General criteria

Covered when ALL of the following general criteria are met

General PDN eligibility: The member must be homebound: attending physician certifies the member is confined to the home or is immobile due to illness, injury or surgery; if the member leaves home, absences are infrequent or short and require considerable effort or assistance; member need not be bedbound but services are provided only in the home.none

From General criteria

Stability and in-home care: Member is medically stable for discharge and all reasonably anticipated medical needs can be met in the home with private duty nursing support.none

From General criteria

Clinical complexity and staffing: Co-morbidities and combination of technologies indicate need for continuous 24-hour skilled services in the home (payment for 24 hours not required); at least two trained caregivers must be trained and competent to give care when the nurse is not in attendance.none

From General criteria

Specific clinical criteria

Covered when ALL of the following specific clinical criteria are met in addition to general criteria

Certification and monitoring: A physician certification letter explaining medical necessity must be submitted every three months and must indicate the need for up to 24 hours/day care by an LPN or RN; continuous assessment, observation, and monitoring of a complex or fragile clinical condition are required with hourly documentation of clinical information and services performed; training/teaching of patient, family or caregivers by the skilled nurse is required until competent.recertify q3 months

From Specific clinical criteria

High-acuity skilled tasks: Presence of one or more of the following payable skilled services requiring RN/LPN/LVN: tracheostomy tube suctioning at least twice per 8-hour shift; ventilator management with recording of initial settings (mode, tidal volume, respiratory rate, wave form modifications, PEEP, FIO2), continuous oxygen saturation measurement and hourly observations; complex or frequent medication administration (including IV drugs or nutrition) with monitoring; management of tube drainage with replacement every two hours; complex wound care, cavities and irrigations; tube feedings that require frequent changes in formulation or administration rate or increase aspiration risk; insertion/placement of catheters and sterile irrigations (including catheter associated with active treatment of urinary tract disease); insertion of Levin tube and initial feedings; post‑operative management following initial gastrostomy tube insertion; respirator/ventilator treatment; treatment of extensive decubitus ulcers or other widespread skin disorders.

The following services are excluded from coverage and may be denied when billed under Private Duty Nursing (PDN): care provided by the member's relative; care provided by a hospital employee; housekeeping and laundry services; respite care; taxes; and travel expenses. These items are not covered as PDN services and should not be submitted for PDN reimbursement.

Services that are determined to be not medically necessary are excluded from PDN coverage and will not be reimbursed.

Provider Responsibilities, Documentation, and Authorization

Prior Authorization

Prior authorization and coding

Prior authorization is not required for PDN when Conditions for payment are met; the provider must still meet all medical necessity criteria (general and specific) and have a physician order. Use HCPCS codes S9123 and S9124 and bill in 15-minute increments per the Conditions for payment.

Prior authorization: Not required when Conditions for payment are met.
Required physician order and fulfillment of all general and specific medical necessity criteria.
Bill using S9123 (RN) or S9124 (LPN/LVN) in 15-minute increments.

Step Therapy

Step therapy requirements

There are no step therapy requirements specified in the policy. PDN is intended for patients whose needs exceed what the home health care benefit provides.

No prerequisite home health services or step therapy are required by policy.

Documentation Required

Member claims documentation requirements

Members must submit identifying and clinical claim documentation for PDN payment, including nurse identification, hours/dates of service, attending physician information, and detailed certification.

Nurse's name, degree, address, professional license number, and driver’s license with photo ID and number.
Hours worked and dates of service; name of member receiving care; attending physician's name and degree.
Complete physician certification: diagnosis, plan of treatment, specific nursing duties, explanation of medical necessity, service dates with week ending dates, and estimated length of time care will be required.
Medical documentation of hour-by-hour description of services performed (or nurse shift notes if hourly notes unavailable).

Documentation Required

Ongoing physician certification and hourly documentation

Ongoing clinical documentation must include a physician certification letter every three months and hourly documentation of clinical information for continuous assessment and monitoring.

Physician certification letter explaining medical necessity must be submitted every three months and certify need for up to 24-hour/day RN or LPN care.
Continuous assessment, observation, and monitoring are required with hourly documentation of clinical information and services performed.

Denial Risk

Excluded services that may be denied

Services listed as excluded or not medically necessary may be denied if billed for PDN.

Care provided by the patient's relative.
Care provided by a hospital employee.
Housekeeping and laundry.
Respite care.
Services determined to be not medically necessary.
Taxes and travel expenses.

Key Definitions

Private duty nursing (PDN) — definition

DefinitionSkilled nursing provided in the member's home requiring individualized and continuous 24-hour nursing care more intense than home health care; excludes care by non-nurse caregivers and is not intended to substitute family caregiving.

Provider typesEligible providers include RN and LPN/LVN (per Conditions for payment).

SettingServices are provided in the member's home; PDN is not intended to be provided in institutional settings.

Homebound — definition and brief criteria

Homebound definitionMember is confined to the home or is immobile due to illness, injury or surgery, as certified by the attending physician; absences are infrequent or of short duration and require considerable effort or assistance.

Bedbound not requiredMember does not have to be bed bound to be considered homebound, but services will only be provided in the home.

Certification requirementAttending physician must certify homebound status.

OpenPayer

Private Duty Nursing (PDN) — Coverage Criteria

Coverage Criteria for Private Duty Nursing (PDN)

Coding and Payment Units

Provider Responsibilities, Documentation, and Authorization

Background

Key Definitions

S9123	Private duty nursing, RN, per hour (as listed)
S9124	Private duty nursing, LPN/LVN, per hour (as listed)