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Aetna Aetna
Clinical Policy Bulletin:
Skilled Home Private Duty Nursing Care
Number: 0136
(Replaces CPB 139)

Policy

Note: This policy only applies to plans with private duty nursing benefits.  Please check benefit plan descriptions for details.

Aetna considers private duty home nursing for members other than those on a ventilator (see separate section below for special coverage rules for members on ventilators) medically necessary as set forth below.

  1. Subject to applicable benefit plan terms and limitations, Aetna considers home nursing care medically necessary when recommended by the member's primary care and/or treating physician and both of the following circumstances are met:

    1. Member has skilled needs; and
    2. Placement of the nurse in the home is done to meet the skilled needs of the member only; not for the convenience of the family caregiver.

  2. In most cases, more than 12 hours per day of skilled nursing care is not considered medically necessary.  However, more than 12 hours per day of skilled nursing care may be considered medically necessary in any of the following circumstances:

    1. Member is being transitioned from an inpatient setting to home; or
    2. Member becomes acutely ill and the additional skilled nursing care will prevent a hospital admission; or
    3. Member meets the clinical criteria for confinement in a skilled nursing facility (SNF), but a SNF bed is not available.  In this situation additional skilled nursing may be provided until a SNF bed becomes available.

Ongoing skilled home nursing care is not considered medically necessary for members who are on continuous or bolus nasogastric (NG) or gastrostomy tube (GT) feedings and do not have other skilled needs.  Intermittent home nursing care may be considered medically necessary for these members as a transition from an inpatient setting to the home.

Note: Aetna Case Managers should gather the input from the hospital staff, nursing agency, and primary and/or specialist physicians when deciding upon the medically necessary number of 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 family 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 or family prior to the initiation of home services.

Home Nursing for Patients on Ventilators:

Aetna considers home nursing medically necessary for members who are on ventilators or continuous positive airway pressure (CPAP) for respiratory insufficiency at home when the primary care physician or specialist has agreed to the home care plan and all of the following criteria are met:

  1. Member is on either a pressure or volume ventilator or CPAP; and
  2. Member meets the medical necessity criteria for confinement in a SNF; and
  3. Placement of the nurse is for the care and benefit of the member with a skilled need only.

Note: For members on a ventilator at home, Aetna considers home nursing medically necessary for up to 24 hours per day for up to 3 weeks upon an initial discharge from an inpatient setting as a transition to home, as long as the member requires continuous skilled care to manage the ventilator.  Thereafter, up to 16 hours of home nursing per day is considered medically necessary if the member requires continuous skilled care to manage the ventilator.  Payment for any additional home nursing care is the responsibility of the member/family.

Aetna considers initial stabiliation of a member on a ventilator at home after discharge to be a skilled need requiring home nursing care. Once the member is stabilized at home, Aetna does not consider continued ventilator management a skilled need requiring home nursing unless the member is unstable and needs close monitoring and frequent ventilator adjustments. This instability may be the result of an acute event (e.g., respiratory infection or exacerbation of chronic obstructive pulmonary disease (COPD)) or weaning from a ventilator.

Note: Electrical generators do not meet Aetna's definition of DME because they are not primarily medical in nature.

If 24 hours per day of nursing care is being requested for an indefinite period of time, the case manager may offer a SNF placement as the alternative.  If the family agrees and a SNF bed is not available, Aetna considers home nursing for up to 24 hours medically necessary until a SNF bed is available.

Note: Aetna standard benefit plans exclude coverage of custodial care. Please check benefit plan documents.

Custodial care is defined as services and supplies that are primarily intended to help members meet personal needs. Custodial care can be prescribed by a physician or given by trained medical personnel. It may involve artificial methods such as feeding tubes, ventilators or catheters. Examples of custodial care include:

  • Routine patient care such as changing dressings, periodic turning and positioning in bed, administering oral medications;
  • Care of a stable tracheostomy (including intermittent suctioning);
  • Care of a stable colostomy/ileostomy;
  • Care of stable gastrostomy/jejunostomy/nasogastric tube (intermittent or continuous) feedings;
  • Care of a stable indwelling bladder catheter (including emptying/changing containers and clamping tubing);
  • Watching or protecting a member;
  • Respite care, adult (or child) day care, or convalescent care;
  • Institutional care, including room and board for rest cures, adult day care and convalescent care;
  • Help with the daily living activities, such as walking, grooming, bathing, dressing, getting in or out of bed, toileting, eating or preparing foods;
  • Any services that a person without medical or paramedical training could be trained to perform; and
  • Any service that can be performed by a person without any medical or paramedical training.


Background

Private duty nursing refers to provision of continuous skilled 1-on-1 nursing care in the home from registered nurses (RNs) or licensed practical nurses (LPNs).

Private duty nursing is typically prescribed on an hourly basis for tasks that require continuous nursing care, and is distinguished from skilled nursing care provided by home care agencies that is prescribed on an intermittent (per visit) basis.  See CPB 0201 - Skilled Home Health Care Nursing Services

Private duty nursing is distinguished from caregivers who are not nurses (often called "sitters") who provide non-skilled care (bathing and other hygiene assistance, assistance with eating, etc.) and companionship to patients.  Such sitters often do minor housekeeping chores for patients, but they are neither educated nor qualified to provide skilled nursing care. 

Appendix

Documentation Requirements:

Private Duty Nursing (PDN) Services are considered medically necessary for members who meet all of the following criteria:

  1. The services are ordered by a licensed physician (MD or DO) 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 medically necessary for the member's disease, illness or injury, and are within the accepted standards of nursing practice, and
  4. The services are performed by a licensed nurse (i.e., Registered Nurse or Licensed Practical Nurse), and
  5. The services provided are within the scope of practice of a licensed nurse (RN or LPN), and
  6. The services require the professional proficiency and skills of a licensed nurse (RN or LPN), and
  7. The services are provided in the member's private residence, and
  8. The member's condition is unstable and requires frequent nursing assessments and changes in the plan of care. It must be determined that the member’s needs could not be met through a skilled nursing visit, but only through private duty nursing services.

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

PDN is not covered solely to allow respite for caregivers or member’s family.

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

PDN is not covered for maintenance or custodial care.

PDN services become maintenance or custodial care when any one of the following situations occur:

  • Medical and nursing documentation supports that the condition of the client is stable/predictable; or
  • The plan of care does not require a Licensed Nurse to be in continuous attendance; or
  • The member, family, or caregivers have been taught the nursing services and have demonstrated the skills and ability to carry out the plan of care.

PDN is not considered medically necessary solely because there is no caregiver available to assume this rolee.

A member who needs PDN is normally unable to leave home without being accompanied by a licensed nurse. Note that the need for nursing care solely to participate in activities outside of the home is not a basis for authorizing PDN services or expanding the hours needed for PDN services.

A nurse may accompany the member when the member’s normal life activities (such as a child attending school) take the member outside of the home. The medical needs of the child must meet the criteria requiring PDN. The term "normal life activities" does not include coverage of PDN when the member is receiving medical care in an inpatient facility, outpatient facility, hospital, physician’s office or other medical care setting.

To qualify for PDN, the member’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 member’s unstable condition must reflect that changes or adjustments have been made at least monthly.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
Other CPT codes related to the CPB:
99500
99501
99502
99503
99504
99505
99506
99507
99509
99511
99512
99601
+ 99602
HCPCS codes covered if selection criteria are met:
T1000 Private duty/independent nursing service(s) - licensed, up to 15 minutes
Other HCPCS codes related to the CPB:
G0154 Direct skilled nursing services of a licensed nurse (LPN or RN) in the home health or hospice setting, each 15 minutes
G0156 Services of home health/hospice aide in home health or hospice settings, each 15 minutes [custodial care]
G0162 Skilled services by a registered nurse (RN) in the delivery of management & evaluation of the plan of care; each 15 minutes (the patient's underlying condition or complication requires an RN to ensure that essential non-skilled care achieve its purpose in the home health or hospice setting)
G0163 Skilled services of a licensed nurse (LPN or RN) in the delivery of observation & assessment of the patient's condition, each 15 minutes (when the likelihood of change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment in the home health or hospice setting)
G0164 Skilled services of a licensed nurse, in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes
Q5001 Hospice or home health care provided in patient's home / residence
S9122 Home health aide or certified nurse assistant, providing care in the home; per hour [custodial care]
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
S9126 Hospice care, in the home, per diem
S5497 - S5502, S5517 - S5523, S9061, S9098, S9208, S9379, S9490 - S9810 Home therapy
T1001 Nursing assessment/evaluation
T1002 RN Services, up to 15 minutes
T1003 LPN/LVN services, up to 15 minutes
T1004 Services of a qualified nursing aide, up to 15 minutes [custodial care]
T1019 Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, icf/mr or imd, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant) [custodial care]
T1020 Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, icf/mr or imd, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant) [custodial care]
T1021 Home health aide or certified nurse assistant, per visit [custodial care]
T1030 Nursing care, in the home, by registered nurse, per diem
T1031 Nursing care, in the home, by licensed practical nurse, per diem
Other ICD-9 codes related to the CPB:
V44.1 Gastrostomy status
V46.0 - V46.9 Other dependence on machines


The above policy is based on the following references:
  1. Bailey KL. Establishing private duty in a Medicare world. Caring. 1998;17(9):24-25, 27, 29-31.
  2. Lulavage A. RN-LPN teams: Toward unit nursing case management. Nurs Manage. 1991;22(3):58-61.
  3. Creighton H. Private duty nursing: Part I - Reimbursement issues. Nurs Manage. 1988;19(6):22, 26.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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