CurrentColorado Rocky Mountain Health PlansPolicy CS102OH.F

Private Duty Nursing Services (for Ohio Only)

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This policy governs private duty nursing services provided to members in Ohio, including coverage rationale, documentation used for reviews, definitions, and applicable billing codes.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrivate Duty Nursing Services (for Ohio Only)

Policy CodePolicy CS102OH.F

Change TypeNo material clinical or coverage changes

Effective DateNov 1, 2026

Next Review DateN/A

Key ActionMaintain legible medical record documentation that supports medical necessity and make it available upon request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

OhioApplicable state

2Licensed nursing professional types

4HCPCS codes listed

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CurrentColorado Rocky Mountain Health PlansPolicy CS102OH.F

Private Duty Nursing Services (for Ohio Only)

Customize your policy alerts

Sign up for Colorado Rocky Mountain Health Plans Policy CS102OH.F alerts

Get alerted when Policy CS102OH.F changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This policy governs private duty nursing services provided to members in Ohio, including coverage rationale, documentation used for reviews, definitions, and applicable billing codes.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrivate Duty Nursing Services (for Ohio Only)

Policy CodePolicy CS102OH.F

Change TypeNo material clinical or coverage changes

Effective DateNov 1, 2026

Next Review DateN/A

Key ActionMaintain legible medical record documentation that supports medical necessity and make it available upon request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

OhioApplicable state

2Licensed nursing professional types

4HCPCS codes listed

Ohio Private Duty Nursing Coverage and Hours

Coverage for Private Duty Nursing services is based on the Ohio Administrative Code. Once coverage for Skilled Care has been established, the number of Private Duty Nursing hours is guided by the InterQual® LOC: Home Care Q & A, Private Duty Nursing (PDN) Assessment.

ALL of the following

Medical necessity, coverage, and service specifications for Private Duty Nursing services are established under Ohio Administrative Code Rule 5160-12-02: Private Duty Nursing Services: Provision Requirements, Coverage and Service Specification.
Coverage for Skilled Care has been established before determining the number of Private Duty Nursing hours.
The number of Private Duty Nursing hours needed by the member is determined using the InterQual® LOC: Home Care Q & A, Private Duty Nursing (PDN) Assessment as a guideline.

HCPCS Codes

HCPCS CodesHCPCS

S9123	Nursing care, in the Home; by registered nurse, per hour.
S9124	Nursing care, in the Home; by licensed practical nurse, per hour.
T1000	Private duty/independent nursing service(s) - licensed, up to 15 minutes.
T1001	Nursing assessment/evaluation.

Documentation Requirements

Documentation Required

Submit medical necessity documentation

Ensure the patient's medical record contains legible documentation that fully supports the medical necessity for the requested private duty nursing services. Maintain the documentation in the medical record and make it available upon request; supporting documentation does not guarantee coverage of the requested services.

Include relevant medical history, as applicable.
Include physical examination findings, as applicable.
Include results of pertinent diagnostic tests or procedures, as applicable.

Private Duty Nursing Overview

Private duty nursing provides continuous skilled care in the home by a registered nurse or licensed practical nurse under the direction of the member’s physician.

Key Terms

Private Duty Nursing

DefinitionProvision of continuous skilled care from registered nurses (RNs) or licensed practical nurses (LPNs) under the direction of the member's physician.

Skilled Care

DefinitionA type of health care given when skilled nursing or rehabilitation staff are needed to manage, observe, and evaluate care.

Skilled Nursing Care

DefinitionA level of care that includes services that can only be performed safely and correctly by a licensed nurse, either a registered nurse or a licensed practical nurse.