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Private Duty Nursing Services (for Kentucky Only)
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Policy governing coverage and requirements for Private Duty Nursing (PDN) services for UnitedHealthcare Community Plan members in Kentucky, including criteria for Skilled Care and documentation/prior authorization processes.
No material clinical or coverage changes in this revision.
Coverage Criteria for Private Duty Nursing
Coverage criteria for Private Duty Nursing
Covered when ALL of the following are met
Refer to state-specific coverage provisions and requirements.
Includes skilled interventions provided directly by a licensed nurse (e.g., bowel/bladder care; medication or oxygen administration; infusion therapy; medication setups; wound care; ventilation).
InterQual referenced for level-of-care and hours determination.
Lack of adequate documentation may result in denial or inability to approve services.
The list of procedure codes in this policy is provided for reference only. Listing of a code does not imply that the service described by the code is a covered or non‑covered health service, nor does inclusion guarantee reimbursement or claim payment. Benefit coverage is determined by applicable federal, state, or contractual requirements and other plan terms.
Medical record documentation may be required to evaluate whether the member meets clinical criteria for coverage, but submission of documentation alone does not guarantee coverage. The patient’s medical record must contain legible documentation that fully supports the medical necessity for the requested services, including relevant history, physical exam, and pertinent diagnostic test results, and must be made available upon request.
Procedure Codes and Billing References
| T1000 | Private duty/independent nursing service(s), licensed, up to 15 minutes |
Prior Authorization, Documentation, and Provider Requirements
Prior authorization and hours determination
Coverage for the number of Private Duty Nursing (PDN) hours is determined using InterQual LOC: Home Care Q&A, Private Duty Nursing (PDN) Assessment; requests should use the CMS-485 Home Health Certification with an appropriate signed plan of care.
- Use InterQual LOC: Home Care Q&A, Private Duty Nursing for hours determination.
- Submit CMS-485 Home Health Certification including the plan of care signed by an authorized provider.
Required documentation: CMS-485 with signed plan of care
Requests must be documented using the Home Health Certification (CMS-485), which includes a plan of care signed by a physician (MD or DO) or an advanced practitioner (NP, CNS, or PA) in accordance with applicable law and regulation.
- Include CMS-485 with the plan of care signed by MD/DO or authorized advanced practitioner.
- Ensure signatures comply with applicable law and regulation.
Documentation insufficiency may lead to denial
The patient's medical record must contain documentation that fully supports the medical necessity for the requested services; insufficient or missing documentation may result in denial or inability to approve services.
- Documentation must include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- Records must be legible, maintained in the patient's medical record, and made available upon request.
Background
Private Duty Nursing (PDN) refers to the delivery of Skilled Nursing Services as defined by Kentucky Administrative Regulations and the policy’s clinical criteria. Skilled care includes nursing interventions that exceed routine monitoring, are clinically appropriate, and are provided continuously or part‑time/short‑term to manage, observe, and evaluate the member’s condition.
Documentation requirements for PDN follow usual home health standards: services must be supported by the medical record and a plan of care (see policy for requirements such as the CMS‑485). PDN services are subject to state regulatory definitions and must meet the criteria in this policy to be eligible for coverage.
Definitions
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