Clinical UM Guideline


Subject:   Private Duty Nursing in the Home Setting
Guideline #:   CG-REHAB-08Current Effective Date:   07/07/2015
Status:   RevisedLast Review Date:   05/07/2015

Description

This document defines private duty nursing (PDN) in the home and the conditions under which it would be considered medically necessary. PDN refers to intermittent and temporary, complex skilled nursing care on an hourly basis in the home by a Registered Nurse (RN) or a Licensed Practical Nurse (LPN)/Licensed Vocational Nurse (LVN). PDN care includes assessment, monitoring, skilled nursing care, and caregiver/family training to assist with transition of care from a more acute setting to home.

Note: Please see the following related documents for additional information:

Note: Benefit language supersedes this document. PDN service is not a covered benefit under all member contracts/certificates. Please see the text in the footnote of this document regarding Federal and State mandates and contract language, as these requirements or documents may specifically address the topic of PDN.

Clinical Indications

Medically Necessary:

Private Duty Nursing

PDN in the home is considered medically necessary when ALL of the following criteria are met:

  1. Intensity of Care
    1. The services must be skilled and not custodial in nature [See CG-REHAB-07 Skilled Nursing and Skilled Rehabilitation Services (Outpatient) and CG-MED-19 Custodial Care]; AND
    2. The attending physician must certify the medical necessity of PDN; AND
    3. The attending physician must approve a written treatment plan with short and long term goals specified; AND
    4. Services must require the professional proficiency and skills of an RN or LPN/LVN. The decision to use an RN or LPN/LVN is dependent on the type of services required and must be consistent with the scope of nursing practice under applicable state licensure regulations. PDN performed by an LPN/LVN must be under the supervision of an RN following a plan of care developed by the physician in collaboration with the individual, family/caregiver and PDN; AND
    5. Services must be performed on a part-time or intermittent visiting basis, according to the defined treatment plan and under the direction of a physician in order to ensure the safety of the individual and to achieve the medically desired result; AND
    6. The service must be appropriate with regard to standards of good medical practice and not solely for convenience.
  2. Availability of Caregiver
    1. PDN is appropriate for short-term training with the intent of having caregivers assume this role when the individual's medical condition becomes stable; AND
    2. The primary caregiver accepts ongoing 24-hour responsibility for the health and welfare of the member.
  3. Unstable Condition
    1. The individual's condition must be unstable and require frequent nursing assessments and changes in the plan of care. Instability of the individual's condition means that an individual's condition changes frequently or rapidly, so that constant monitoring or frequent adjustments of treatment regimens are required. It must be determined that these needs could not be met through a skilled nursing visit, but could be met though PDN; AND
    2. The individual requires treatment or complex skilled nursing care of an unstable medical condition, including but not limited to treatment of at least one of the following:
      1. Dependence on mechanical ventilation;
      2. Gastrostomy feeding complicated by frequent regurgitation, with or without aspiration;
      3. Tracheostomy care requiring deep suctioning at least every 4 hours;
      4. Seizure disorder manifested by prolonged seizures, requiring emergent administration of anticonvulsant medication; AND
    3. An individual is considered to have an unstable medical condition when both of the following are met:
      1. The physician has ordered that the nurse constantly monitor and evaluate the individual's condition on an ongoing basis and make any necessary adjustments to the treatment regimen; AND
      2. The nursing and other adjunctive therapy progress notes indicate that such interventions or adjustments have been made at least monthly and are necessary.
  4. Regular Progress Summaries
    1. Initially, written weekly progress summaries are required for assessing the need to extend a PDN service, in order to determine if the individual has reached his/her optimal level of recovery and that a caregiver has been taught to assume care.
    2. For continued requests for PDN, a written progress summary with measurable long and short-term goals and a plan of care are required. The frequency of these updates should be at the discretion of the case manager, but at least monthly. Theses updates may be done telephonically at the discretion of the case manager.

Not Medically Necessary:

  1. PDN in the home is considered not medically necessary when it is provided for one or more of the following:
    1. Solely for convenience;
    2. Stable medical condition;
    3. Services to allow the individual's family to work or to provide respite for the family;
    4. Custodial care (See CG-MED 19 – Custodial Care).
  2. The following services are examples that do not require the skills of a licensed nurse and therefore are considered to be not medically necessary in the home setting, unless there is documentation of comorbidities and complications that require individual consideration.
    1. Routine services directed toward the prevention of injury or illness.
    2. Administration or set-up of oral (PO) medications or both.
    3. Application of eye drops or ointments and topical medications.
    4. Routine administration of maintenance medications, including insulin. This applies to PO, subcutaneous (SQ), intramuscular (IM) and intravenous (IV) medications.
    5. Routine enteral feedings (for example, continuous or bolus nasogastric (NG) or gastrostomy tube (GT) feedings).
    6. Routine colostomy care.
    7. Ongoing intermittent straight catheterization for chronic conditions.
    8. Custodial care by an LPN/LVN or RN.
    9. Emotional support, counseling or both.
    10. Suctioning of the nasopharynx or nasotrachea.
    11. Any duplication of care which is already provided by supply or infusion companies.
Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

HCPCS 
S9123Nursing care, in the home; by registered nurse, per hour
S9124Nursing care, in the home; by licensed practical nurse, per hour
T1000Private duty/independent nursing service(s), licensed, up to 15 minutes
T1002RN services, up to 15 minutes
T1003LPN/LVN services, up to 15 minutes
T1030Nursing care, in the home, by registered nurse, per diem
T1031Nursing care, in the home, by licensed practical nurse, per diem
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
 All diagnoses
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2015]
 All diagnoses
  
Discussion/General Information

PDN is defined as the provision of medically necessary, complex skilled nursing care in the home on a fee-for service basis by a RN or a LPN/LVN. The purpose of PDN is to assess, monitor and provide skilled nursing care in the home on an hourly basis; to assist in the transition of care from a more acute setting to home; and to teach competent caregivers the assumption of this care when the condition of the individual is stabilized. The length and duration of PDN services is intermittent and temporary in nature and not intended to be provided on a permanent ongoing basis. Such services are normally billed at an hourly or shift rate. The PDN cannot be a member of the individual's immediate family or anyone living in the home.

References

Peer Reviewed Publications:

  1. Borchers EL. Improving nursing documentation for private-duty home health care. J Nurs Care Qual. 1999; 13(5):24-43.
  2. Donaghy B, Writght AJ. New home care choices for children with special needs. Caring. 1993; 12(12):47-50.
  3. Duncan BW, Howell LJ, deLorimier AA, et al. Tracheostomy in children with emphasis on home care. J Pediatr Surg. 1992; 27(4):432-435.
  4. Jessop DJ, Stein RE. Providing comprehensive health care to children with chronic illness. Pediatrics. 1994; 93(4):602-607.
  5. Roemer NR. The tracheotomized child. Private duty nursing at home. Home Healthc Nurse. 1992; 10(4):28-32.
  6. Sperling RL. New OSHA standards managers must know. Home Healthc Nurse Manag. 2000; 4(4):11-16.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Academy of Pediatrics Committee on Children with Disabilities. Guidelines for home care on infants, children, and adolescents with chronic disease. Pediatrics. 1995; 96(1 Pt 1):161-164.
  2. American Academy of Pediatrics Section on Home Health Care. Guideline for pediatric home health care, 2nd edition. Libby RC, Imaizumi SO Editors. 2009. pp87-88.
  3. Centers for Medicare and Medicaid Services. Manual. Available at: http://www.cms.hhs.gov/Manuals/PBM/list.asp. Accessed on March 3, 2015.
    • Home Health Agency Manual. Pub 11. Last updated September 8, 2005.
    • Skilled Nursing Facility. Pub 12. Last updated September 8, 2005.
  4. State of Nevada. Department of Health and Human Services. Division of Health Care Financing and Policy. Medicaid Services Manual. Private duty nursing. Available at: http://www.dhcfp.state.nv.us/MSM%20Table%20of%20Contents.htm. Accessed on March 3, 2015.
  5. State of New York. Department of Health and Human Services. Division of Health Care Financing and Policy. New York State Medicaid Program private duty nursing manual policy guideline. Available at: https://www.emedny.org/ProviderManuals/NursingServices/PDFS/archive/Private_Duty_Nursing_Policy_2006-2.pdf. Accessed on May 18, 2015.
Index

Private Duty Nursing

History

Status

Date

Action

Revised05/07/2015Medical Policy & Technology Assessment Committee (MPTAC) review. Revised medically necessary criteria for unstable conditions. Clarified not medically necessary criteria. Description, Discussion and Reference sections updated.
Reviewed02/05/2015MPTAC review. Updated Coding and References sections.
Reviewed02/13/2014MPTAC review. Updated Websites.
Reviewed02/14/2013MPTAC review. Coding and Websites updated.
Reviewed02/16/2012MPTAC review. Updated websites.
Reviewed02/17/2011MPTAC review. Related guidelines cross referenced in clinical indication section. Description, Discussion, Coding, References and Websites updated.
Reviewed02/25/2010MPTAC review. References updated.
Reviewed02/26/2009MPTAC review.  References updated. Removed Place of Service section and Case Management section.
Reviewed02/21/2008MPTAC review. References updated. Related documents noted.
Reviewed03/08/2007MPTAC review. References updated.
New03/23/2006MPTAC initial guideline development.
Pre-Merger OrganizationsLast Review DateDocument NumberTitle
Anthem, Inc.  No Document
Anthem MW05/27/2005MA-019Private Duty Nursing
WellPoint Health Networks, Inc.  No Document