Private Duty Nursing Care (PDN) — Coverage and Prior Authorization
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Defines MedStar Family Choice District of Columbia criteria and procedures for prior authorization, coverage, and limitations of hourly RN and LPN private duty nursing (PDN) services for members.
New Policy
Medical Necessity & Coverage Criteria
Medical Necessity and Prior Authorization Criteria
Covered when ALL of the following are met:
ALL of the following
- Member has a medically fragile or technologically dependent condition requiring continuous, direct skilled nursing care that cannot be met by an unlicensed caregiver.
- Skilled care is required to sustain life, prevent deterioration, or respond to life‑threatening changes in condition.
ONE OR MORE of the following clinical indications:
- Dependence on mechanical ventilation or tracheostomy care.
- Requirement for continuous skilled assessment and interventions (e.g., unstable seizure disorders; complex medication administration such as IV therapy, TPN, or infusion pumps).
- Frequent skilled interventions to maintain airway patency, manage respiratory status, or prevent life‑threatening complications.
- Medically fragile conditions with ongoing instability (e.g., severe neuromuscular disorders, advanced genetic or metabolic conditions).
- Infants or children with congenital or chronic conditions requiring continuous monitoring and skilled care beyond intermittent skilled nursing visits.
- Duration/intensity: requires prolonged or continuous nursing care that exceeds intermittent skilled nursing (example threshold: 4+ hours/day); complexity exceeds scope of intermittent home health nursing.
- Home setting feasibility: the home environment supports provision of skilled nursing and required equipment, and a trained/responsible caregiver is available to provide care when PDN staff are not present.
- Prior authorization and documentation: a physician order and RN initial assessment with plan of care are submitted; physician review/signature within 30 days for new requests; for continuing requests, treating practitioner documentation and orders within 60 days and nursing documentation from services within 30 days of renewal demonstrating ongoing need.
Billing Codes and Limits
| T1000 TD | Private Duty RN Visit; Private duty independent nursing services- licensed, up to 15 minutes |
| T1000 TE | Private Duty LPN Visit; 15 minutes Private duty independent nursing services- licensed, up to 15 minutes |
| T1001 U1 | Private Duty Initial Assessment; Private duty initial assessment visit |
| T1001 U2 | Private Duty Reassessment; Private duty reassessment visit |
| T1001 U3 | Private Duty Supervisory Visit; Private duty supervisory visit by RN |
Prior Authorization, Approvals & Documentation
Prior Authorization and Renewal Requirements
New and renewal PDN requests must include a physician order and an RN-conducted initial assessment with a plan of care; the plan of care must be submitted to the physician and the physician must review and sign the plan within 30 days. For continuing requests, treating practitioner documentation and an order must be no older than 60 days from the anticipated renewal date, and nursing documentation from services within 30 days of renewal must be submitted to demonstrate continuing need.
- Physician order required for new requests; include face-to-face encounter documentation as applicable.
- RN initial assessment and plan of care required for new requests; submit plan to physician and obtain physician signature within 30 days of plan development.
- Submit updated physician orders and plan of care every 60 days.
- For renewals: treating practitioner documentation and order within 60 days of anticipated renewal; nursing documentation from services within 30 days of renewal.
Approval Limits and Caregiver Requirement
PDN will not be approved if there is not at least one caregiver willing and able to accept responsibility for the member's care when the nurse is not available. MFC will not authorize ongoing 24/7 PDN; 24 hours may be authorized short-term for up to one week to help caregiver adjustment, after which services are reduced to a maximum of 12 hours per day.
- At least one responsible caregiver must be available and willing to provide care when nurse not present; absence of such caregiver precludes approval.
- Ongoing continuous 24/7 PDN is not authorized; short-term authorization of up to 24 hours is permitted for a maximum of one week to assist caregiver adjustment.
- After short-term period, nursing services limited to a maximum of 12 hours per day, 7 days per week.
Documentation Requirements
Documentation must include the plan of care, physician orders, and comprehensive nursing notes that demonstrate services provided and caregiver involvement; nursing notes for renewals must be complete and submitted from services within 30 days of renewal.
- Plan of care submitted to physician initially and every 60 days; physician review/signature within 30 days.
- Physician orders obtained or revised as needed and every 60 days.
- Nursing notes must include notes from each prior date of service, time in/time out, thorough description of services rendered, presence/absence of primary caregiver and other household members, goals set and progress toward goals, and a new nursing plan of care with goals for the newly requested timeframe.
- Nursing documentation from services provided within 30 days of anticipated renewal must be submitted to demonstrate continuing need.
Key Definitions
Policy Changes
Policy established as a new MedStar Family Choice District of Columbia Private Duty Nursing policy (policy number 1426.DC).
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