CurrentmedstarfamilychoicedistrictofcolumbiaPolicy N/A

Private Duty Nursing and Skilled Nursing Services - Prepayment Review Edits

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Defines billing, unit limits, and prepayment review edits for Private Duty Nursing (PDN) and Skilled Nursing services for MedStar Family Choice District of Columbia; affects providers submitting claims to MedStar Family Choice DC for dates of service on or after November 25, 2025.

Policy Summary

Payermedstarfamilychoicedistrictofcolumbia

PolicyPrivate Duty Nursing and Skilled Nursing Services - Prepayment Review Edits

Policy CodePolicy N/A

Change TypeExpanded prepayment (prospective) reviewsbilling/unit edit additions

Effective DateNov 25, 2025

Next Review DateN/A

Key ActionSubmit claims knowing that claims received on or after November 25, 2025 are subject to expanded prepayment reviews by AMPS per DHCF guidance.

SourceLink

POLICY UPDATE CHANGES

Prospective (prepayment) reviews are expanded to include additional edits based on DHCF guidance and in partnership with AMPS.

Specific billing/unit limits and denial rules for PDN and Skilled Nursing services (per-day and per-60-day limits, concurrent billing restrictions, place-of-service requirement) are specified.

24SN per-day unit threshold

48PDN per-day unit threshold

8Reassess/supervisory 60-day threshold

Nov 25, 2025Edits effective for claims received

Billing, Adjustment, and Denial Rules

PDN and Skilled Nursing billing and denial criteria

Claims adjudication rules and denial/adjustment criteria:

ALL of the following

Reassessment and supervisory visit limits
- Reassessment or supervisory visits (e.g., T1001-U2, T1001-U3) billed with units greater than eight (8) in sixty (60) days will have the additional units adjusted.
- If the PDN initial assessment, reassessment, or supervisory services are billed more than once in sixty (60) days, the units will be adjusted.
- Reassessment service will be denied if there is no initial assessment within the required sixty (60) day period.
Concurrent billing and place-of-service restrictions
- Private Duty Nursing services billed concurrently with skilled nursing codes are not allowed; PDN procedures billed concurrently with skilled nursing will be denied as inappropriately coded.
- Private duty services billed without a place of service that represents home, or any setting where normal activities occur, will be denied.
Per-day unit limits (adjustments)
- If Skilled Nursing services are billed with more than twenty-four (24) units per day, the additional units will be adjusted.
- If Private Duty Nursing services are billed with more than forty-eight (48) units per day, the additional units will be adjusted.

Operational note: These edits will be applied as prepayment (prospective) reviews for claims received on or after November 25, 2025 per DHCF/AMPS guidance.

Claims received on or after Nov 25, 2025 are subject to expanded prepayment reviews (see provider actions).

Codes, Unit Thresholds, and Assessment Requirements

Reassessment and supervisory visit codesCPTCovered

T1001-U2	Private Duty Nursing reassessment visit (example code referenced)
T1001-U3	Private Duty Nursing supervisory visit (example code referenced)

Reassessment/supervisory units per 60 days — adjustments and limits

Reassessment/supervisory frequency limitIf reassessment or supervisory visits (T1001-U2, T1001-U3) are billed with units greater than eight (8) in sixty (60) days, additional units will be adjusted.

Concurrent billing restrictionPrivate Duty Nursing services billed concurrently with skilled nursing codes are not allowed; PDN procedures will be denied as inappropriately coded.

Duplicate billing within 60 daysIf PDN initial assessment, reassessment, or supervisory services are billed more than once in sixty (60) days, the units will be adjusted.

Skilled Nursing units per day — adjustment threshold

Skilled Nursing per-day unit thresholdIf Skilled Nursing Services are billed more than twenty-four (24) units per day, additional units will be adjusted.

Adjustment actionUnits billed in excess of 24 per day will be adjusted rather than paid at the billed quantity.

Related concurrent rulePDN billed concurrently with skilled nursing codes remains not allowed and subject to denial.

Private Duty Nursing units per day — adjustment threshold

Private Duty Nursing per-day unit thresholdIf Private Duty Nursing Services are billed more than forty-eight (48) units per day, additional units will be adjusted.

Place-of-service requirementPDN services billed without a place of service representing home or a normal-activity setting will be denied.

Concurrent billing prohibitionPDN billed concurrently with skilled nursing codes is not allowed and will be denied as inappropriately coded.

Initial assessment requirement for reassessment

Initial assessment requirementReassessment service will be denied if there is no initial assessment within the required sixty (60) day period.

Effect of missing initial assessmentAbsence of a prior initial assessment within 60 days is a denial reason for reassessment claims.

Related frequency ruleIf initial assessment, reassessment, or supervisory services are billed more than once in 60 days, units will be adjusted.

Prepayment Reviews and Provider Impact

Prior Authorization

Prepayment review expansion effective Nov 25, 2025

Claims received on or after November 25, 2025 will be subject to expanded prospective (prepayment) reviews conducted by Advanced Medical Pricing Solutions (AMPS) in accordance with DHCF guidance. Providers should expect additional prepayment edits to be applied to submitted claims on or after that receipt date.

Term Definitions

Reassessment — definition and payment conditions

DefinitionReassessment — a follow-up assessment service; subject to frequency and documentation requirements for payment; billed reassessments exceeding eight (8) units in a sixty (60) day period will have additional units adjusted.

Denial conditionA reassessment will be denied if there is no initial assessment within the required prior sixty (60) day period.

Frequency adjustmentReassessment billed more than once in sixty (60) days triggers unit adjustments.

Supervisory visit — definition and payment conditions

DefinitionSupervisory visit — a PDN supervisory service (example code T1001-U3); if billed with units greater than eight (8) in sixty (60) days, additional units will be adjusted.

Frequency ruleSupervisory visits billed more than once in sixty (60) days will have units adjusted.

Concurrent/service restrictionsSupervisory visits are subject to the same concurrent billing and place-of-service requirements as other PDN services.

Policy Summary

Payermedstarfamilychoicedistrictofcolumbia

PolicyPrivate Duty Nursing and Skilled Nursing Services - Prepayment Review Edits

Policy CodePolicy N/A

Change TypeExpanded prepayment (prospective) reviewsbilling/unit edit additions

Effective DateNov 25, 2025

Next Review DateN/A

Key ActionSubmit claims knowing that claims received on or after November 25, 2025 are subject to expanded prepayment reviews by AMPS per DHCF guidance.

SourceLink

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Private Duty Nursing and Skilled Nursing Services - Prepayment Review Edits

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Sign up for all medstarfamilychoicedistrictofcolumbia policy alerts

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Billing, Adjustment, and Denial Rules

PDN and Skilled Nursing billing and denial criteria

Claims adjudication rules and denial/adjustment criteria:

ALL of the following

Reassessment and supervisory visit limits
- Reassessment or supervisory visits (e.g., T1001-U2, T1001-U3) billed with units greater than eight (8) in sixty (60) days will have the additional units adjusted.
- If the PDN initial assessment, reassessment, or supervisory services are billed more than once in sixty (60) days, the units will be adjusted.
- Reassessment service will be denied if there is no initial assessment within the required sixty (60) day period.
Concurrent billing and place-of-service restrictions
- Private Duty Nursing services billed concurrently with skilled nursing codes are not allowed; PDN procedures billed concurrently with skilled nursing will be denied as inappropriately coded.
- Private duty services billed without a place of service that represents home, or any setting where normal activities occur, will be denied.
Per-day unit limits (adjustments)
- If Skilled Nursing services are billed with more than twenty-four (24) units per day, the additional units will be adjusted.
- If Private Duty Nursing services are billed with more than forty-eight (48) units per day, the additional units will be adjusted.

Operational note: These edits will be applied as prepayment (prospective) reviews for claims received on or after November 25, 2025 per DHCF/AMPS guidance.

Claims received on or after Nov 25, 2025 are subject to expanded prepayment reviews (see provider actions).

Codes, Unit Thresholds, and Assessment Requirements

Reassessment and supervisory visit codesCPTCovered

T1001-U2	Private Duty Nursing reassessment visit (example code referenced)
T1001-U3	Private Duty Nursing supervisory visit (example code referenced)

Reassessment/supervisory units per 60 days — adjustments and limits

Reassessment/supervisory frequency limitIf reassessment or supervisory visits (T1001-U2, T1001-U3) are billed with units greater than eight (8) in sixty (60) days, additional units will be adjusted.

Concurrent billing restrictionPrivate Duty Nursing services billed concurrently with skilled nursing codes are not allowed; PDN procedures will be denied as inappropriately coded.

Duplicate billing within 60 daysIf PDN initial assessment, reassessment, or supervisory services are billed more than once in sixty (60) days, the units will be adjusted.

Skilled Nursing units per day — adjustment threshold

Skilled Nursing per-day unit thresholdIf Skilled Nursing Services are billed more than twenty-four (24) units per day, additional units will be adjusted.

Adjustment actionUnits billed in excess of 24 per day will be adjusted rather than paid at the billed quantity.

Related concurrent rulePDN billed concurrently with skilled nursing codes remains not allowed and subject to denial.

Private Duty Nursing units per day — adjustment threshold

Private Duty Nursing per-day unit thresholdIf Private Duty Nursing Services are billed more than forty-eight (48) units per day, additional units will be adjusted.

Place-of-service requirementPDN services billed without a place of service representing home or a normal-activity setting will be denied.

Concurrent billing prohibitionPDN billed concurrently with skilled nursing codes is not allowed and will be denied as inappropriately coded.

Initial assessment requirement for reassessment

Initial assessment requirementReassessment service will be denied if there is no initial assessment within the required sixty (60) day period.

Effect of missing initial assessmentAbsence of a prior initial assessment within 60 days is a denial reason for reassessment claims.

Related frequency ruleIf initial assessment, reassessment, or supervisory services are billed more than once in 60 days, units will be adjusted.

Prepayment Reviews and Provider Impact

Prior Authorization

Prepayment review expansion effective Nov 25, 2025

Term Definitions

Reassessment — definition and payment conditions

Denial conditionA reassessment will be denied if there is no initial assessment within the required prior sixty (60) day period.

Frequency adjustmentReassessment billed more than once in sixty (60) days triggers unit adjustments.

Supervisory visit — definition and payment conditions

DefinitionSupervisory visit — a PDN supervisory service (example code T1001-U3); if billed with units greater than eight (8) in sixty (60) days, additional units will be adjusted.

Frequency ruleSupervisory visits billed more than once in sixty (60) days will have units adjusted.

Concurrent/service restrictionsSupervisory visits are subject to the same concurrent billing and place-of-service requirements as other PDN services.