Private Duty Nursing (PDN) — Coverage Criteria
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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.
No material clinical or coverage changes in this revision.
Coverage Criteria for Private Duty Nursing (PDN)
General criteria
Covered when ALL of the following general criteria are met
From General criteria
From General criteria
From General criteria
Specific clinical criteria
Covered when ALL of the following specific clinical criteria are met in addition to general criteria
From Specific clinical criteria
List of payable skilled services requiring RN/LPN
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.
Coding and Payment Units
Provider Responsibilities, Documentation, and 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.
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.
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).
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.
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.
Background
Private duty nursing (PDN) provides individualized, continuous skilled nursing care in the home for patients who require more intense and frequent skilled services than those available under the standard home health benefit. PDN is intended for clinically complex or fragile members who need ongoing nursing observation, monitoring and skilled procedures in the home setting, and it is not intended to substitute for family caregiving.
Key Definitions
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