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Private Duty Nursing Services (for Kansas Only)
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Defines coverage requirements for Private Duty Nursing (PDN) services with Skilled Care for UnitedHealthcare Community Plan members in the state of Kansas, including documentation and coding guidance.
Added detailed language in 'Medical Records Documentation Used for Reviews' clarifying that benefit coverage is determined by federal, state, or contractual requirements and that documentation may be required to assess clinical criteria but does not guarantee coverage.
Coverage Criteria
Covered PDN with Skilled Care
Covered when ALL of the following are met
Use InterQual LOC: Home Care PDN Assessment to establish number of PDN hours.
Benefit coverage is determined by federal, state, and contractual requirements.
The list of procedure and diagnosis codes included in this policy is provided for reference only. Listing 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 laws; other policies or guidelines may also apply.
Services that are not supported by medical record documentation of medical necessity may be denied. The patient’s medical record must fully support the medical necessity for the requested services and include, at minimum, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Documentation used for reviews may be required to determine whether the member meets clinical criteria, but the presence of documentation does not guarantee coverage. Supporting records must be legible, maintained in the patient’s medical record, and made available upon request.
Coding
| T1000 | Private duty/independent nursing service(s), licensed, up to 15 minutes |
| S9123 | Nursing care, in the home; by registered nurse, per hour (use for general nursing care only, not to be used when CPT codes 99500-99602 can be used) |
| S9124 | Nursing care, in the home; by licensed practical nurse, per hour |
| 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 |
Provider Actions & Documentation Requirements
Use InterQual PDN assessment and submit CMS-485 for coverage
Coverage for Private Duty Nursing with Skilled Care is determined using the InterQual LOC: Home Care PDN Assessment; providers must document requests via the Home Health Certification (CMS-485) including a signed plan of care to support prior authorization and coverage determinations.
- Prior authorization and PDN hours determination follow InterQual LOC: Home Care PDN Assessment.
- Use CMS-485 to submit the plan of care signed by an MD/DO or an advanced practitioner per law.
Step therapy: none specified
No step therapy requirements are specified in this policy.
Document on CMS-485 with signed plan of care and supportive medical record
Requests must be documented using the Home Health Certification (CMS-485); the CMS-485 must include the plan of care signed by a physician (MD/DO) or by an advanced practitioner (NP, CNS, or PA) in accordance with applicable law and regulation. The patient medical record must include relevant history, physical exam, and pertinent diagnostic test results to fully support medical necessity.
- CMS-485 with physician or authorized advanced practitioner signature is required.
- Medical record must contain relevant history, physical exam, and diagnostic results to support medical necessity.
Denial risk if supporting records are not provided or available
Failure to provide medical record documentation that fully supports medical necessity, or failure to make documentation available upon request, may result in denial of the requested services.
- Documentation must be legible, maintained in the patient's record, and made available upon request.
- Medical records may be requested to assess whether the member meets clinical criteria and lack of adequate records does not guarantee coverage.
Background
Private Duty Nursing (PDN) refers to the provision of continuous Skilled Care by registered nurses (RNs) or licensed practical nurses (LPNs) under the direction of the member’s physician in accordance with CFR §440.80. Skilled Care denotes services that require licensed nursing or rehabilitation staff to manage, observe, and evaluate care — including procedures that only a licensed nurse can perform safely.
Coverage for PDN services with skilled care is determined using clinical criteria (see InterQual LOC: Home Care PDN Assessment) and requires documentation such as a Home Health Certification (CMS‑485) and a physician‑ or authorized practitioner‑signed plan of care to demonstrate that the member meets the applicable federal, state, or contractual requirements.
Definitions
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