Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Private Duty Nursing
Policy #:MA02.002

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

Private duty nursing (PDN) is not covered by the Company because it is a service not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.
Policy Guidelines

This policy is consistent with Medicare’s coverage determination.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, private duty nursing (PDN) is not eligible for payment under the medical benefits of the Company’s Medicare Advantage products because the service is not covered by Medicare.

Description

Private duty nursing (PDN) is defined as medically appropriate, complex skilled nursing care in the individual's private residence by a registered nurse (RN) or a licensed practical (vocational) nurse (LPN). The purpose of PDN is to provide continuous monitoring and observation of an individual who requires frequent skilled nursing care on an hourly basis.
References

Centers for Medicare and Medicaid Services (CMS).CMS Manual System. Medicare Claims Processing. Transmittal 1838. [CMS Web site]. 08/06/2001. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1838A3.pdf. Accessed November 21, 2019.


Evidence of Coverage.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)



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



Revenue Code Number(s)



0989 Private duty nurse

Coding and Billing Requirements


Cross References




Policy History

MA02.002
12/18/2019The policy has been reviewed and reissued to communicate the Company’s continuing position on Private Duty Nursing.
07/03/2018Effective 07/03/2018, this policy has undergone a routine review, and no revisions have been made.
01/04/2017The policy has been reviewed and reissued to communicate the Company’s continuing position on Private Duty Nursing.
01/06/2016The policy has been reviewed and reissued to communicate the Company’s continuing position on Private Duty Nursing.
01/07/2015The policy has been reviewed and reissued to communicate the Company’s continuing position on Private Duty Nursing.
01/01/2015This is a new policy.




Version Effective Date: 01/01/2015
Version Issued Date: 01/01/2015
Version Reissued Date: 12/18/2019