Private Duty Nursing Services

Description of Procedure or Service

Private duty nursing (PDN) is hourly, skilled nursing care provided in a patient’s home. Private duty nursing provides more individualized skilled care than can be provided in a skilled nurse visit through a home health agency. The intent of private duty nursing is to assist the patient with complex direct skilled nursing care, to develop caregiver competencies through training and education, and to optimize patient health status and outcomes as a ‘bridge to home’ from an acute care hospital. PDN is not intended for ongoing long term permanent care. PDN is intended to be used as, short term temporary assistance. Education and training is expected to begin in the acute care facility prior to discharge home. Private duty nursing is medically necessary, substantial and complex hourly nursing services provided by a licensed nurse in the patient’s home with ongoing collaboration with MD that is documented in the medical records. Examples of private duty nursing services may include, but is not limited to:

• New ventilator dependent patients,
• New tracheotomy patients
• Long term illnesses such as cerebral palsy and traumatic brain injuries that had a recent change in their chronic care.

Related policy:

Skilled Nursing Services

***Note: This Medical Policy is complex and technical. For questions concerning the technical language and/or specific clinical indications for its use, please consult your physician. Policy BCBSNC will provide coverage for Private Duty Nursing when it is determined to be medically necessary and when medical criteria and guidelines shown below are met.

Benefits Application

This medical policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this medical policy. Most plans require prior review for private duty nursing services. 

When Private Duty Nursing Services are covered

Private Duty Nursing Services may be considered medically necessary in patients who meet ALL of the following criteria:

1. The services are ordered by a licensed physician (MD, doctor of medicine; or DO, doctor of osteopathic medicine) as part of a treatment plan for a covered medical condition, and
2. The attending physician must approve a written treatment plan with short and long term goals specified, and
3. The services provided are reasonable and necessary for care of a patient’s illness or injury or particular medical needs, and are within the accepted standards of nursing practice, and
4. Provide care needed by the member when their condition stabilized, and
5. The services are performed by a licensed nurse (i.e., Registered Nurse, RN; or Licensed Practical Nurse, LPN), and
6. The services provided are within the scope of practice of a licensed nurse (RN or LPN), and 
7. The services require the professional proficiency and skills of a licensed nurse (RN or LPN), and
8. The services are provided in the patient’s private residence, and 9
9. The patient’s condition is such that a licensed professional is required to reinforce/educate and teach the caregiver the technical as well as basic care needs of the member.
10. The length and duration of skilled nursing services in the home is considered intermittent and temporary in nature and not intended to be provided on a permanent ongoing basis.
11. The member’s condition requires frequent nursing assessments and changes in the plan of care with MD collaboration.
12. The member/caregiver must complete an assessment with the Blue Cross and Blue Shield of North Carolina case management team to evaluate for current and ongoing needs.

When Private Duty Nursing Services are not covered

When the conditions above are not met

The nurse providing care must not be the patient’s spouse, natural or adoptive child, parent, or sibling, grandparent or grandchild. This also includes any person with an equivalent step or in-law relationship to the patient.

PDN is not considered medically necessary if a caregiver is unavailable to assume the care needs of the member.

PDN is not covered if the patient is in an acute inpatient hospital, inpatient rehabilitation hospital, skilled nursing facility, intermediate care facility or a resident of a licensed residential care facility.

PDN is not covered for the convenience of the member/caregiver or to allow respite/sleep for caregivers or patient’s family.

PDN is not covered to allow the patient’s family or caregiver to work or go to school.

The time the nurse spends traveling to and from a patient’s home is included in the cost for providing the service. It is not covered separately.

Maintenance care or custodial care is not considered PDN. (See Policy Guidelines below.)

PDN in the home is not covered when provided at the same time as other home healthcare nursing services. 

Policy Guidelines

All PDN cases will be referred to Case Management and members/caregivers are expected to enroll in the Case Management Program to assist members with community resources, alternate coverage options and benefits.

All PDN cases require prior authorization and will be reviewed with member’s medical records for determination of medical necessity.

The goal of PDN as a transition to home from the hospital for patients is to complete training and provide oversight of the family/caregiver for the patients care. Hours of approved PDN coverage is based on a schedule that will terminate in a discreet period of time.

The patient and family should be made aware prior to the authorization of services that PDN is a limited benefit and to expect that the number of PDN hours approved to decrease in a discreet time period with termination of services. Alternate care needs will need to be in place at that time as extension of covered services will not be considered for ‘lack of a caregiver.’

To qualify for private duty nursing, the member must have at least one caregiver who is capable and available to be trained while the nurse is on duty and to provide care for the member when the nurse is not available. If the caregiver is unable to or unavailable to train to provide this care, private duty nursing will be considered not medically necessary as the home care plan is considered unsafe absent a trained caregiver.

PDN services are considered maintenance and custodial care when any one of the following situations occur:

• Medical and nursing documentation supports that the condition of the client is at their new baseline, medically stable and predictable; or
• The plan of care does not require a licensed professional to perform the services; or
• The patient, family, or caregivers have been taught how to provide the care needed by the member and have demonstrated the skills and ability to carry out the plan of care.
• Care provided by family members, health aids or other unlicensed individuals after an acute medical event when an individual has reached the maximum level of physical or mental function and is not likely to make further significant improvement.

In determining whether an individual is receiving custodial care, the factors considered are the level of care and medical supervision required and furnished. The decision is not based on diagnosis, type of condition, and degree of functional limitation or rehabilitation potential.

Billing/Coding/Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Applicable service codes: S9123, S9124, G0299, G0300

BCBSNC will request medical records for determination of medical necessity.

Medical Term Definitions

Custodial and Maintenance Care

Care comprised of services and supplies, including room and board and other facility services, which are provided to the patient, whether disabled or not, primarily to assist him or her in the activities of daily living. Custodial/maintenance care includes, but is not limited to, routine equipment use (ventilators), non oral feedings (peg tube, total parenteral nutrition or TPN), exercises, help in walking, bathing, dressing, feeding, preparation of special diets and supervision over self administration of medications. Such services and supplies are custodial as determined by BCBSNC without regard to the place of service or the provider prescribing or providing the services.

Respite

Short-term care provided to the member only when necessary to relieve the family member or other persons caring for the individual ("Inpatient respite care" is addressed in the "Hospice Services" section in the member benefits booklet.)

Scientific Background and Reference Sources

North Carolina Division of Medical Assistance. Medicaid Clinical Coverage Policies and Provider Manuals. Community Care Provider Manual, Section 9. Private Duty Nursing (PDN) retrieved on September 6, 2005 from http://www.dhhs.state.nc.us/dma/cc/9.pdf

Oregon Department of Human Services. Health Services. Office of Medical Assistance Programs (OMAP). Rule Book for Private Duty Nursing Services Program retrieved on September 6, 2005 from http:// www.dhs.state.or.us/policy/healthplan/guides/pdn/132_rb_080104.pdf

State of Nevada. Department of Health and Human Services. Division of Health Care Financing and Policy. Medicaid Services Manual. Private Duty Nursing retrieved on September 6, 2005 from http:// dhcfp.state.nv.us/MSM/Ch%20900%2007-23-03%20FINAL.pdf

North Carolina Division of Medical Assistance. Medicaid Clinical Coverage Policies and Provider Manuals. Community Care Provider Manual, Section 9. Private Duty Nursing (PDN) retrieved on 1/31/13 from http://www.dhhs.state.nc.us/dma/cc/9.pdf

Specialty Matched Consultant Advisory Panel- 2/2013

Specialty Matched Consultant Advisory Panel- 2/2014

Specialty Matched Consultant Advisory Panel- 2/2015

Specialty Matched Consultant Advisory Panel- 2/2016

Specialty Matched Consultant Advisory Panel review 2/2020

Specialty Matched Consultant Advisory Panel review 2/2021

Specialty Matched Consultant Advisory Panel review 2/2022

Medical Director Review 5/2022

Specialty Matched Consultant Advisory Panel review 2/2023

Medical Director Review 2/2023 

Medical Director Review 9/2023

Specialty Matched Consultant Advisory Panel review 2/2024

Medical Director Review 2/2024

Policy Implementation/Update Information

11/3/05 Original policy issued.

5/8/06 Medical Policy Advisory Group review 3/24/06. No change to policy.

10/22/07 Added statement to Description section: "The frequency and duration of private duty nursing services is intermittent and temporary in nature and is not intended to be provided on a permanent ongoing basis." Added items to the When PDN is Covered section: "The attending physician must approve a written treatment plan with short and long term goals specified" and "The patient’s condition is unstable and requires frequent nursing assessments and changes in the plan of care. It must be determined that the patient’s needs could not be met through a skilled nursing visit, but only through private duty nursing services." The statements "The frequency and duration of approved services will be determined on a case-by-case basis" and "All private duty nursing requests will be referred to and discussed with the Regional Medical Director" were moved from the Description section to the Policy Guidelines section. Also noted in the Policy Guidelines, "If there is no caregiver available to assume this role, private duty nursing is NOT appropriate." Definitions of Custodial Care and Unstable Medical Condition added to medical terms section. Specialty Matched Consultant Advisory Panel review meeting 9/20/07. No change to policy statement. (adn)

11/23/09 The following statement was added to the Policy Guidelines section: "The patient’s condition must be unstable, requiring frequent nursing assessments and changes in the plan of care. The nursing and other adjunctive therapy progress notes must indicate that such interventions or adjustments have been made and are necessary. Also, the physician’s orders dealing with the patient’s unstable condition must reflect that changes or adjustments have been made at least monthly." Definition for Custodial Care was revised. New definition for Respite was added along with the statement, "Inpatient respite care" is addressed in the "Hospice Services" section in the member benefits booklet. Specialty Matched Consultant Advisory Panel review meeting 9/28/09. No change to policy coverage criteria. (adn)

6/22/10 Policy Number(s) removed (amw)

2/1/11 Policy status changed to “Active policy, no longer scheduled for routine literature review.” Approved by medical director in 2010. (lpr)

3/12/13 Specialty Matched Consultant Advisory panel review meeting 2/20/2013 . No change to policy statement. References updated. Converted policy to active status from active archive status. Medical director review. (lpr)

3/11/14 Specialty Matched Consultant Advisory panel review meeting 2/25/2014. No change to policy statement. (lpr)

3/10/15 Specialty matched consultant advisory panel review meeting 2/25/2015. No change to policy statement. (lpr)

4/1/16 Specialty Matched Consultant Advisory Panel review 2/24/2016. No change to policy. -an

3/31/17 Specialty Matched Consultant Advisory Panel review 2/22/2017. No change to policy. (an)

3/29/18 Specialty Matched Consultant Advisory Panel review 2/28/2018. No change to policy. (an)

3/12/19 Added the following statement to the “When Not Covered” section: “PDN in the home is not covered when provided at the same time as home healthcare nursing services”. Updated Policy Guidelines section to include list of examples of services that typically do not require PDN services. Added additional statement to define “maintenance”. Also added statement to read: “In determining whether an individual is receiving custodial care, the factors considered are the level of care and medical supervision required and furnished. The decision is not based on diagnosis, type of condition, and degree of functional limitation or rehabilitation potential.” Specialty Matched Consultant Advisory Panel review 2/20/2019. (an)

3/10/20 Specialty Matched Consultant Advisory Panel review 2/19/2020. No change to policy. (eel)

3/31/21 Specialty Matched Consultant Advisory Panel review 2/17/2021. No change to policy statement. (bb).

6/30/22 Description updated. When Private Duty Nursing services are covered updated to reflect: “The services are ordered by a licensed physician (MD, doctor of medicine; or DO, doctor of osteopathic medicine) as part of a treatment plan for a covered medical condition, and The attending physician must approve a written treatment plan with short and long term goals specified, and The services provided are reasonable and necessary for care of a patient’s illness or injury or particular medical needs, and are within the accepted standards of nursing practice, and Provide care needed by the member when their condition stabilized.and The services are performed by a licensed nurse (i.e., Registered Nurse, RN; or Licensed Practical Nurse, LPN), and The services provided are within the scope of practice of a licensed nurse (RN or LPN), and The services require the professional proficiency and skills of a licensed nurse (RN or LPN), and The services are provided in the patient’s private residence, and The patient’s condition is such that a licensed professional is required to reinforce/educate and teach the caregiver the technical as well as basic care needs of the member. The length and duration of skilled nursing services in the home is considered intermittent and temporary in nature and not intended to be provided on a permanent ongoing basis. The member’s condition requires frequent nursing assessments and changes in the plan of care with MD collaboration. The member and caregivers must accept and be engaged in the Blue Cross Blue Shield of North Carolina Case Management process.” When Private Duty Nursing Services are not covered updated to reflect: “When the conditions above are not met.The nurse providing care must not be the patient’s spouse, natural or adoptive child, parent, or sibling, grandparent or grandchild. This also includes any person with an equivalent step or in-law relationship to the patient. PDN is not considered medically necessary if a caregiver is unavailable to assume the care needs of the member. PDN is not covered if the patient is in an acute inpatient hospital, inpatient rehabilitation hospital, skilled nursing facility, intermediate care facility or a resident of a licensed residential care facility. PDN is not covered for the convenience of the member/caregiver or to allow respite/sleep for caregivers or patient’s family. PDN is not covered to allow the patient’s family or caregiver to work or go to school. The time the nurse spends traveling to and from a patient’s home is included in the cost for providing the service. It is not covered separately. Maintenance care or custodial care is not considered PDN. (See Policy Guidelines below.) PDN in the home is not covered when provided at the same time as other home healthcare nursing services. Policy Guidelines and Medical Definitions updated for clarity. Specialty Matched Consultant Advisory Panel review 2/2022. Medical Director review 5/2022. Notification given on 7/1/22 for effective date 1/1/2023. (tt)

3/7/23 References updated. Specialty Matched Consultant Advisory Panel review 2/2023. Removed the following statement from Policy Guidelines: “All PDN requests will be discussed with a Medical Director.” Medical Director review 2/2023. No change to policy statement. (tt)

10/10/23 Updated #12 under When Covered to read as follows: “The member/caregiver must complete an assessment with the Blue Cross and Blue Shield of North Carolina case management team to evaluate for current and ongoing needs.” Medical Director review 10/2023. (tt)

4/1/24 References updated. Specialty Matched Consultant Advisory Panel review 2/2024. Medical Director review 2/2024. No change to policy statement. (tt)