Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Private Duty Nursing

Policy #:02.01.02c

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


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. 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.

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 Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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

MEDICALLY NECESSARY PRIVATE DUTY NURSING

Private duty nursing (PDN) on a short-term basis, with the intent of having a caregiver assume the role of caring for the individual, is considered medically necessary and, therefore, covered when ALL of the following criteria are met:
  • The PDN has been ordered by a professional provider (in accordance with his or her scope of practice) who is involved in the oversight of the individual's care and is included as part of a written treatment plan for a covered medical condition.
    • The written treatment plan must include short- and long-term goals regarding the purpose and outcome of the PDN
    • The written treatment plan must be periodically reviewed and updated at least every 30 days by the professional provider to determine the effectiveness of and the need for the PDN service.
  • The PDN must be for services that meet the definition of skilled nursing services and are within the scope of practice of the registered nurse (RN) or a licensed practical (vocational) nurse (LPN).
    • A skilled nursing service requires the knowledge, expertise, and skills provided by an RN or an LPN that does not require the supervision of an RN to be safe and effective.
  • The PDN services are required to meet the skilled needs of the member only, not for the convenience of the family caregiver
  • In most cases, PDN services would generally consist of eight or more continuous hours, but typically not more than 16 hours per day of nursing care, with the following exceptions:
    • For those individuals who are determined to be technology dependent (e.g., ventilator dependent), consideration may be given for up to 24 hours a day of PDN for a two week period for the teaching and training of a caregiver, with the plan to transition the individual to no more than 16 hours a day of PDN following the two week period.
    • For those individuals who become acutely ill and the additional PDN will prevent an immediate hospital admission, consideration may be given for up to 24 hours a day of PDN for a three day period.
  • The individual's medical condition requires frequent nursing assessments and nursing monitoring with changes made to the plan of care and treatment goals in accordance with the individual's medical condition.
  • The individual's medical needs could not be met through a skilled nursing visit or a home health aide visit, but only through PDN services.
  • The PDN services are being provided by an actively practicing RN or LPN nurse who is not a member of the individual's immediate family and does not reside in the individual's private residence (e.g., private residence/domicile, independent-living facility, or a facility setting at a custodial level of care).
  • The PDN services are deemed medically necessary and appropriate for the individual's illness, injury, or particular medical needs.
  • The PDN services are provided in the individual's private residence (e.g., private residence/domicile, independent-living facilities, or a facility setting at a custodial level of care), and the individual is considered to be homebound as defined by meeting one of the following criteria:
    • The individual is unable to leave home due to severe restrictions on mobility; it would be a considerable and taxing effort for the individual to leave home; and the individual is unable to use transportation without assistance.
    • The individual's absences from the home are infrequent, for periods of relatively short duration, attributable to obtaining health care treatment, or for occasional nonmedical purposes such as, but not limited to:
      • A trip to the barber
      • A walk around the block or a drive
      • Other infrequent or unique events (e.g., attendance at a funeral)

For many of the Company's products, when the above criteria are met, coverage for PDN may be eligible for up to a maximum of 360 In-Network/Out-of-Network hours; however, individual member benefits must be verified.

NOT MEDICALLY NECESSARY PRIVATE DUTY NURSING

If the above criteria are not met, then PDN is considered not medically necessary and, therefore, not covered.

The following are examples of, but are not limited to, situations when PDN would be considered not medically necessary and, therefore, not covered.
  • A caregiver is not available for training or is unwilling or too anxious to assume care for the individual.
  • Routine services directed toward the prevention of injury or illness.
  • Administration and/or set-up of oral (PO) medication.
  • Periodic turning and repositioning.
  • Application of eye drops or ointments and topical medications.
  • Routine administration of maintenance medications, including insulin. This applies to oral, subcutaneous, intramuscular, and intravenous administration of medications.
  • Administration of chronic uncomplicated tube/enteral feedings.
  • Routine ostomy care.
  • Ongoing intermittent straight catheterization for chronic conditions.
  • Suctioning of the nasopharynx or nasotrachea.
  • Monitoring for aspiration.
  • Any duplication of care already being provided to the individual.
  • Monitoring or observing for seizures.
  • Services for more than 16 hours per day, unless the exception criteria above are met.
  • A stable medical condition not meeting skilled nursing requirements.
  • Services that do not meet medical necessity or are beyond the medically appropriate PDN hours.
  • Services are solely to provide respite and/or allow or accommodate the member's caregiver’s schedule, such as, but not limited to, work or school.

The following are examples of, but are not limited to, situations when PDN is not covered by the Company because they are benefit contract exclusions and, therefore, not eligible for reimbursement consideration.
  • Custodial services
  • The hours exceed the benefit limits, if any
  • Services provided in a setting other than the individual's private residence or when nursing care is already being provided (e.g., hospice, acute/inpatient setting).
  • Services that are provided at a school, whether or not as a part of an individualized education program (IEP), are not eligible for coverage by the Company.

For most of the Company's products, PDN has hourly limitations. Individual member benefits must be verified.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

The medical record must include the plan of care that has been written and developed by the professional provider. The plan of care must be established prior to the initiation of the PDN and signed by the professional provider.

The documentation in the medical record must illustrate the complexity of the unskilled services that are a necessary part of the medical treatment and which require the involvement of skilled nursing personnel to promote the individual's recovery and medical safety in view of the individual's overall condition.

BILLING REQUIREMENTS

All traveling expenses to and from the individual's private residence by the private duty nurse are included in the costs of services and are not eligible for separate reimbursement.

Providers must report the number of units of care for each date of service. If a service spans two consecutive dates (e.g., overnight care), hours must be reported for each date of service.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, private duty nursing (PDN) is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as not medically necessary are not eligible for coverage or reimbursement by the Company.
Description

Private duty nursing (PDN) is defined as medically appropriate, complex skilled nursing care in the
individual's private residence (e.g., private residence/domicile, independent-living facility, or a facility setting at a custodial level of care) by a registered nurse (RN) or a licensed practical (vocational) nurse (LPN). The purpose of PDN is to provide one-on-one continuous monitoring and observation of an individual's condition that requires skilled nursing care on an hourly basis with frequent changes made to the plan of care as necessary. It is determined that these needs will not be met through a skilled, intermittent nursing visit, but could be met through PDN where the RN or LPN stays for an extended length of time to care for an individual with a continuous need for skilled services. Skilled nursing care requires the knowledge, expertise, and skills provided by a RN, or a LPN, to be safe and effective. Some services are classified as a skilled nursing service on the basis of complexity alone (e.g., intravenous and intramuscular injections, insertion of catheters).While an individual's particular medical condition is a valid factor in deciding if skilled services are needed, an individual's diagnosis or prognosis should never be the sole factor in deciding that a service is not skilled. However, in some cases the condition of the individual may cause a service that would ordinarily be considered unskilled (i.e., supportive in nature), to be considered a skilled nursing service. This would occur when the individual's condition is such that services are of such complexity that they can only be safely and effectively provided by a nurse (i.e., RN, LPN). However, a service may not necessarily be considered a skilled nursing service merely because it is performed by or under the supervision of a nurse. The unavailability of a competent person to provide a non-skilled service, regardless of the importance of the service to the individual, does not make it a skilled service.

A PDN may assist in the transition of care from a more acute setting to home and teach competent caregivers how to assume this care when the condition of the member is stabilized. The length and duration of PDN is not intended to be provided on a permanent, ongoing basis. PDN comprises those services provided in the individual's private residence that have been ordered by a professional provider (in accordance with his or her scope of practice) who is involved in the oversight of the individual's care.

PDN is not custodial care. Custodial care (domiciliary care) is care that is provided primarily for the maintenance of the individual; designed essentially to assist the individual in meeting his or her activities of daily living; and not primarily provided for its therapeutic value in the treatment of an illness, disease, bodily injury, or condition. Custodial care includes, but is not limited to, help in walking, exercising, bathing, dressing, positioning for the prevention of wounds, feeding, preparing special diets, and supervising the individual's self-administration of medications that do not require the technical skills or professional training of medical or nursing personnel in order to be performed safely and effectively.
References

American Thoracic Society. Statement on home care for patients with respiratory disorders. Am J Respir Crit Care Med.2005;171(12):1443-1464.


Benefit Contracts.

Berry JG, Hall M, Dumas H, et al. Pediatric hospital discharges to home health and postacute facility care: a national study. JAMA Pediatr. 2016;170(4):326-33.

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 May 23, 2018.

Centers for Medicare and Medicaid Services (CMS).CMS Manual System. Pub. 100-04: Medicare Claims Processing. Transmittal 179. [CMS Web site]. 01/14/2014. Available at: https://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r179bp.pdf. Accessed May 23, 2018.

Centers for Medicare & Medicaid Services (CMS). Jimmo versus Sebelius Settlement Agreement Fact Sheet. [Medicare Web site]. N.D. Available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/Jimmo-FactSheet.pdf.
Accessed May 23, 2018.

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 7: Home health services. [CMS Web site]. Original: 10/01/03. (Revised: 02/24/17). Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c07.pdf. Accessed May 23, 2018.

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 8: Coverage of extended care (SNF) services under hospital insurance. [CMS Web site]. 10/13/2016. Available at:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c08.pdf. Accessed May 23, 2018.

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15: Covered medical and other health services. [CMS Web site]. 02/02/18.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf. Accessed May 23, 2018.

Centers for Medicare & Medicaid Services (CMS). Medicare and home health care. [Medicare Web site]. October 2017. Available at: https://www.medicare.gov/Pubs/pdf/10969-Medicare-and-Home-Health-Care.pdf. Accessed May 23, 2018.

Elias ER, Murphy NA, Council on Children with Disabilities. Home care of children and youth with complex health care needs and technology dependencies. Pediatrics. 2012;129;996-1005.

Fields AI, Rosenblatt A, Pollack MM, et al. Home care cost-effectiveness for respiratory technology-dependent children. AM J Dis Child. 1991;145(7):729-733.

Panitch HB, Downes JJ, Kennedy JS. Guidelines for home care of children with chronic respiratory insufficiency. Pediatr Pulmonol. 1996;21(1):52-56.


Townsend M, Pasek F, Prophet C, et al. Pediatric home nursing and ancillary programs. In: Libby RC, Imaizumi, SO, eds. Guidelines for Pediatric Home Health Care. 2n ded. Elk Grove Village, IL: American Academy of Pediatrics; 2009: 87-89.




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

Effective 07/03/2018, this policy has been reviewed and reissued to communicate the Company’s continuing position on Private Duty Nursing.
Version Effective Date: 06/07/2016
Version Issued Date: 06/07/2016
Version Reissued Date: 07/03/2018

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2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.