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Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-99500-02

Original Effective Date: 09/15/09

Reviewed: 06/23/11

Revised: 05/11/14

Subject: Private Duty Nursing Care in the Home

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

NOTE: Coverage for private duty nursing care in the home is subject to the member’s benefit terms, limitations and maximums. Some plans specifically exclude coverage for private duty nursing care. Refer to specific contract language regarding private duty nursing care in the home.

DESCRIPTION:

Private duty nursing is hourly skilled nursing care provided in the home by a Registered Nurse (RN) or a Licensed Practical Nurse (LPN). Private duty nursing provides continuous skilled care that can be provided in a home health care nursing visit.

The private duty nurse:

The frequency of private duty nursing care in the home is based on supporting medical documentation that describes the complexity and intensity of the member’s care. Private duty nursing care in the home is intended to support the transition of care in the home to the caregiver and not intended to be provided on a permanent basis by the private duty nurse.

POSITION STATEMENT:

NOTE: Coverage for private duty nursing care in the home is subject to the member’s benefit terms, limitations and maximums. Some plans specifically exclude coverage for private duty nursing care. Refer to specific contract language regarding private duty nursing care in the home.

Medical Director review is required for all requests for private duty nursing care in the home.

If coverage is available for private duty nursing care in the home, the following criteria for coverage apply.

Private duty nursing care in the home is considered medically necessary when ALL of the following criteria are met:

Availability of Caregiver
Private duty nursing is appropriate for short-term care with the intent of having the caregiver assume the role of providing care for the member when the member's medical condition becomes stable. If there is no caregiver available to assume the role or caregiver, private duty nursing is not appropriate.

Unstable Condition

NOTE: Case Managers should gather input from the physician, hospital staff and licensed health care agency when deciding upon the medically necessary hours of skilled nursing care. Case managers should consider the number of skilled needs the member has and how stable the member is. Other considerations include the caregiver's abilities, and the nature of the member's illness. The goal should be to make the caregiver as independent as possible and to wean nursing care away as the member's medical condition improves. Expectations about regression of nursing hours and eventual termination of these services should be conveyed to the member and caregiver prior to the initiation of home services.

The following are examples (not all inclusive) of services prescribed by a physician that may be performed in the home by a private duty nurse (RN or LPN) when ALL of the above criteria are met:

Non-Covered Services

Services That Do Not Require Private Duty Nursing Care

The following are examples (not all inclusive) of services that do not require private duty nursing care in the home by a RN or LPN, and therefore are considered not medically necessity in the home setting, unless there is documentation of comorbidities and complications.

Private duty nursing care in the home is considered not medically necessity when provided for the following:

Custodial Care

Care that does not meet the criteria for private duty nursing care in the home is considered custodial and is not covered.

Custodial care is:

NOTE: 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.

Private duty nursing care in the home provided at the same time as home health care nursing services is not covered.

Private duty nursing care rendered at other locations (e.g., hospital, skilled nursing facility, assisted living facility) is covered according to the member’s benefit terms, limitations and maximums.

BILLING/CODING INFORMATION:

The following HCPCS codes may be used to report private duty nursing care by a registered nurse (RN) or licensed practical nurse (LPN) in the home.

HCPCS Coding:

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

REIMBURSEMENT INFORMATION:

Refer to member’s benefit plan limitations and maximums for private duty nursing in the home.

The frequency of private duty nursing care in the home is based on supporting medical documentation that describes the complexity and intensity of the member’s care and treatment plan.

LOINC Codes:

The following information may be required documentation to support medical necessity: physician history and physical, physician progress notes, plan of treatment and reason for private duty nursing care in the home.

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Plan of treatment

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

PROGRAM EXCEPTIONS:

Federal Employee Plan (FEP): Follow FEP guidelines.

State Account Organization: Follow SAO guidelines.

Medicare Advantage products:

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

DEFINITIONS:

Respite care: temporary relief for caregivers and families who care for those with disabilities, chronic or terminal illness and the elderly.

Skilled services (as related to this guideline): services provided in accordance to physician orders that require the skills of professional personnel such as a registered nurse or licensed practical nurse.

Therapeutic treatment: services that require the continuing attention or supervision of trained, licensed medical or paramedical personnel.

RELATED GUIDELINES:

Home Health Care, 01-99500-01

OTHER:

The following are examples (not all inclusive) of complex medical cases and complex health care needs and technology dependent cases:

Complex medical cases – (e.g., end-stage renal disease, diabetes, heart condition, congestive heart failure (CHF), brain injury, spinal injury, multiple trauma, stroke, neurological disorders, motor disorders, severe burns, respiratory failure)

Complex health care needs – (e.g., intravenous medication, wound care)

Technology dependent – (e.g., mechanical ventilation).

Complex Medical Cases and Complex Health Care Needs and Technology Dependent Cases:

Complex medical cases, complex health care needs and technology dependent cases should be referred for case management. A case management plan of care should be developed with input from the physician, hospital staff, licensed health care agency and caregiver.

REFERENCES:

  1. American Association for Respiratory Care Clinical Practice Guideline-Long-Term Invasive Mechanical Ventilation in the Home Revision & Update, 2007.
  2. Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual Chapter 7-Home Health Services [Skilled Nursing Care 30.4, 40.1], 10/01/03.
  3. Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual Chapter 16-General Exclusions from Coverage. 110-Custodial Care, 10/01/03.
  4. Code of Federal Regulations-Private duty nursing services 440.80, 2009.
  5. Florida Agency for Health Care Administration (ACHA) – Home Health Agencies, 2009.
  6. Florida Statutes-Nurse Practice Act, 2008.
  7. National Respite Network-Respite, 2009.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 06/20/11.

GUIDELINE UPDATE INFORMATION:

09/15/09

New Medical Coverage Guideline.

07/15/11

Scheduled review; no change in position statement. Updated S9123 code descriptor. Updated references.

10/01/11

Revision; formatting changes.

05/11/14

Revision: Program Exceptions section updated.

Date Printed: August 18, 2017: 10:26 AM