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Private Duty Nursing Services (for New Mexico Only)
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Defines coverage and clinical/documentation requirements for private duty nursing (PDN) services for UnitedHealthcare Community Plan members in New Mexico, and identifies use of InterQual LOC for PDN hours determination.
Medical Records Documentation Used for Reviews section added language clarifying documentation required to support medical necessity and that documentation may be requested.
References section updated to reflect the most current information and links.
Archived previous policy version CS102NM.C.
Coverage Criteria
Medical necessity and hours determination
Covered when ALL of the following are met per applicable federal/state/contractual requirements:
Provider must supply CMS-485 with a signed plan of care and make supporting medical record documentation (relevant history, physical exam, diagnostic test results) available upon request.
Listing of a procedure or diagnosis code in this policy is for reference only and does not imply the service described by the code is covered. Benefit coverage for health services is determined by applicable federal, state, or contractual requirements and laws; inclusion of a code does not guarantee reimbursement or payment and other policies or guidelines may apply.
Services for which the medical record lacks documentation that fully supports medical necessity are not eligible for coverage. The patient's medical record must include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures, be legible, maintained in the record, and made available upon request to support any request for Private Duty Nursing services.
Applicable Procedure Codes
| T1000 | Private duty/independent nursing service(s), licensed, up to 15 minutes. |
| S9124 | Nursing care, in the home; by registered 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 and Documentation Requirements
InterQual hours determination and CMS‑485 required
Private Duty Nursing (PDN) services require documentation that the care is Skilled Care per federal/state/contractual requirements, and the number of PDN hours must be determined using the InterQual LOC: Home Care Q & A, Private Duty Nursing (PDN) Assessment. Use CMS‑485 when requesting services/establishing the plan of care.
- InterQual LOC determines number of PDN hours.
- CMS‑485 (Home Health Certification) required for requests and includes the signed plan of care.
Billing and submission must reference CMS‑485 and applicable PDN codes
Ensure billing reflects the appropriate PDN procedure codes and that requests include the CMS‑485 plan of care and supporting medical record documentation; failure to include required documentation may affect payment or authorization processing.
Use CMS‑485 with signed plan of care and maintain supporting medical records
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 as allowed by law; the patient's medical record must contain legible documentation supporting medical necessity and be made available upon request.
- CMS‑485 must include the physician/authorized practitioner signature and the plan of care.
- Medical record must contain relevant history, physical exam, and results of pertinent diagnostic tests or procedures.
- Documentation must be legible, maintained in the medical record, and provided upon request.
Insufficient medical record documentation may lead to denial
Lack of medical record documentation that fully supports medical necessity — including relevant history, physical exam, and diagnostic test results — may result in denial or non‑coverage; documentation may be requested to assess whether clinical criteria are met.
- Incomplete or illegible medical records increase the risk of denial.
- Documentation requested for review does not guarantee coverage even if provided.
Definitions
Background
Private Duty Nursing (PDN) is the provision of continuous Skilled Care by Registered Nurses (RNs) or Licensed Practical Nurses (LPNs) under the direction of the member’s physician. PDN provides continuous skilled nursing services that require the knowledge and abilities of licensed nursing staff. The policy references the federal regulatory definition and location for these services at CFR §440.80.
Revision History
Medical Records Documentation Used for Reviews section added clarifying required documentation to support medical necessity and that records may be requested.
References section updated to reflect the most current information.
Previous policy version CS102NM.C archived.
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