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Private Duty Nursing Services (for Florida Only)
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Defines Colorado Rocky Mountain Health Plans medical policy for Private Duty Nursing Services that applies only to members in Florida and references Florida Medicaid clinical criteria and InterQual LOC guidance for hours.
Medical Records Documentation Used for Reviews language was added to clarify documentation requirements to support medical necessity.
Coverage Criteria
Coverage contingent on external Florida Medicaid and InterQual criteria
Covered when ALL of the following are met (per referenced policies/tools):
This policy defers to Florida Medicaid policy and InterQual for specific clinical requirements and hour determinations.
The codes listed in this policy are provided for reference and do not by themselves indicate coverage. Listing of a code in this policy does not imply the service is covered; benefit coverage is determined by applicable federal, state, or contractual requirements and laws, which may mandate coverage for specific services. The inclusion of a code does not guarantee reimbursement or claim payment, and other policies or guidelines may apply.
Coding
| T1000 | Private duty/independent nursing service(s), licensed, up to 15 minutes |
| S9123 | Nursing care, in the home; by registered nurse, per hour |
| S9124 | Nursing care, in the home; by licensed practical nurse, per hour |
| T1001 | Nursing assessment/evaluation |
| 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 |
Provider Actions & Requirements
Prior authorization and external criteria reference
For medical necessity clinical coverage criteria, refer to the Florida Medicaid Private Duty Nursing and Family Home Health Aide Services Coverage Policy; once skilled-care coverage is established, the number of private duty nursing hours is determined using InterQual® LOC: Home Care Q&A, Private Duty Nursing (PDN) Assessment.
Provider must request review using referenced external criteria
Submit prior authorization requests and clinical information consistent with the referenced Florida Medicaid coverage policy and InterQual LOC guidance so medical necessity and hours can be determined.
Medical record documentation expectations
Maintain complete medical records that fully support the medical necessity for requested private duty nursing services, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures; records must be legible and made available upon request.
- Document relevant medical history
- Document physical examination findings
- Include results of pertinent diagnostic tests or procedures
- Ensure documentation is legible and retained in the patient's medical record
- Provide records upon request for review
Denial risk for missing or insufficient documentation
Failure to provide medical record documentation that fully supports the medical necessity for requested services may result in denial of coverage.
Background
This policy delegates the determination of medical necessity clinical coverage criteria to the Florida Medicaid Private Duty Nursing and Family Home Health Aide Services Coverage Policy. In addition, the number of private duty nursing hours is determined using InterQual LOC: Home Care Q&A, Private Duty Nursing Assessment. The policy interprets benefit plans in the context of applicable federal, state, and contractual requirements that govern coverage for members in Florida.
Definitions
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