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Private Duty Nursing Services
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Defines coverage and documentation requirements for private duty nursing (PDN) when provided as Skilled Care for members under Colorado Rocky Mountain Health Plans; applies to states not listed under 'Application' exclusions. Affects providers requesting PDN authorization and claims.
No material clinical or coverage changes in this revision.
Coverage Criteria for Private Duty Nursing (PDN)
Coverage criteria for PDN (initial and ongoing authorization)
Covered when ALL of the following are met:
Skilled Care must be documented in the medical record.
Refer to the InterQual criteria referenced in the policy for hours and level-of-care determinations.
Documentation is required for review and authorization.
This policy does not apply in the states listed under Application. Refer to the state-specific policy or guideline where noted. The states excluded from this Medical Policy are: Florida, Idaho, Indiana, Kansas, Kentucky, Nebraska, New Jersey, New Mexico, North Carolina, Ohio, Pennsylvania, and Tennessee.
Coverage for Private Duty Nursing (PDN) is determined by applicable federal, state, and contractual requirements. Services that lack the required medical record documentation to demonstrate that the member meets clinical criteria for Skilled Care may be denied or determined not medically necessary. Medical records may be requested to assess whether the member meets clinical criteria for coverage but providing documentation does not guarantee that the requested services will be covered.
Applicable Procedure Codes
| T1000 | Private duty/independent nursing service(s), licensed, up to 15 minutes |
| 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 |
| S9124 | Nursing care, in the home; by licensed practical nurse, per hour |
Prior Authorization, Documentation, and Denial Triggers
Prior authorization & InterQual/PDN assessment required
Coverage for Private Duty Nursing (PDN) with Skilled Care requires that services meet the definition of Skilled Care per federal, state, and contractual requirements and that the member meets the InterQual LOC: Home Care Q & A Private Duty Nursing (PDN) Assessment; requests must be documented using the Home Health Certification (CMS-485) including a plan of care signed by an appropriate clinician.
- InterQual LOC (Home Care Q & A, Private Duty Nursing PDN Assessment) determines need and hours.
- Documentation of the request must include Home Health Certification (CMS-485) and a physician- or advanced practitioner-signed plan of care.
Include InterQual assessment and supporting records with request
Ensure the InterQual PDN assessment is completed and available for review; also include any supporting medical records used to demonstrate Skilled Care as part of the authorization submission.
- Submit InterQual LOC results (Home Care PDN Assessment) with the authorization request.
- Attach clinical records that demonstrate Skilled Care per policy and applicable law.
Required documentation: CMS-485 and signed plan of care
Document requests using the Home Health Certification (CMS-485) which must include a plan of care signed by a physician (M.D. or D.O.) or an advanced practitioner (NP, CNS, or PA) where allowed; include supporting medical records used for review.
- CMS-485 (Home Health Certification) must be on file.
- Plan of care must be signed by an M.D. or D.O., or by an NP, CNS, or PA in accordance with applicable law and regulation.
- Provide medical records that demonstrate the member meets clinical criteria for Skilled Care.
Denial triggers for PDN authorization
Services may be denied if documentation does not demonstrate Skilled Care per federal, state, or contractual requirements or if the InterQual LOC (Home Care PDN Assessment) criteria are not met.
- Lack of required documentation (e.g., missing CMS-485 or unsigned plan of care) can lead to denial.
- Failure to meet InterQual PDN Assessment criteria may result in services being denied or deemed not medically necessary.
Definitions
Background and Regulatory Context
Private Duty Nursing is the provision of continuous Skilled Care by registered nurses (RNs) or licensed practical nurses (LPNs) under the direction of the member's physician, consistent with the regulatory definition at CFR § 440.80. Skilled Care refers to care that requires skilled nursing or rehabilitation staff to manage, observe, and evaluate treatment and includes services that can only be performed safely and correctly by a licensed nurse. Coverage for PDN under this policy is contingent on meeting those skilled-care definitions and the InterQual level-of-care assessment referenced in the policy.
Policy Revision History
Policy underwent routine review; no change to coverage guidelines and previous version CS102.U was archived.
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