Private Duty Nursing Form

500 EXCHANGE STREET, P ROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 09|01|2020 POLICY LAST REVIEWED: 07|16|2025 OVERVIEW Private duty nursing (PDN) is considered substantial, complex, and continuous service that requires more individual and continuous care than is available from a visiting nurse or skilled nursing home care visit and which would require frequent nursing interventions in the home.
MEDICAL CRITERIA Medicare Advantage Plans Refer to Policy Statement section of policy. Commercial Products Private duty nursing services received in the home may be medically necessary when ordered by a physician, and the services are performed by a certified home healthcare agency.
PRIOR AUTHORIZATION Prior authorization review is recommended for Commercial Products. POLICY STATEMENT Medicare Advantage Plans Private duty and full-time nursing services are not covered for Medicare Advantage Plans members. Commercial Products Private duty nursing services are covered when the patient requires continuous skilled nursing observation and intervention in the home. Services of a private duty nurse are considered not covered in the following instances: • Services of a nurse's aide. • Services of a private duty nurse: o when the primary duties are limited to bathing, feeding, exercising, homemaking, giving oral medications or acting as companion or sitter; o after the caregiver or patient have demonstrated the ability to carry out the plan of care; o provided outside the home. Examples include at school, or in a nursing or assisted living facility; o that are duplication or overlap of services. Examples include when a person is receiving hospice care services or for the same hours of a skilled nursing home care visit; o that are for observation only; and o provided as part-time/intermittent and not continuous care. • Maintenance care when the condition has stabilized including routine ostomy care or tube feeding administration or if the anticipated need is indefinite. • Twenty-four (24) hour private duty nursing care for a person without an available caregiver in the home. • Respite care (e.g., care during a caregiver vacation) or private duty nursing so that the caregiver may attend work or school COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable “Private Duty Nursing” coverage/benefits. Medical Coverage Policy | Private Duty Nursing

500 EXCHANGE STREET, P ROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

BACKGROUND Private duty nursing is considered substantial, complex, and continuous service that requires more individual and continuous care than is available from a visiting nurse or skilled nursing home care visit and which would require frequent nursing interventions in the home. PDN services are provided under the direction of a written individualized plan of care signed by the member’s attending physician. Care is managed by a certified home health care agency or certified community home health care agency. Nursing services are rendered by a licensed registered nurse (RN) or licensed practical nurse (LPN) and employed by the home care agency.

Examples of private duty nursing services include the following types of care (list is not all inclusive):
• Chronically ill patients who require greater than 8 hours of continuous skilled nursing care to remain at home • New ventilator dependent patients
• New tracheotomy patients
• Patients dependent on other device-based respiratory support, including tracheostomy care, suctioning, and oxygen support

CODING Commercial Products Preauthorization is recommended for private duty nursing services for all Commercial products. To report private duty nursing services, use the following HCPCS codes: T1000 Private duty/independent nursing service(s), licensed, up to 15 minutes

RELATED POLICIES None

PUBLISHED Provider Update, September 2025 Provider Update, October 2024 Provider Update, September 2023 Provider Update, September 2022 Provider Update August 2021

REFERENCES None

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This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessa ry (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your p articipation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, te chnology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.
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