Skilled Home Private Duty Nursing Care
Number: 0136
(Replaces CPB 139)
Table Of Contents
PolicyApplicable CPT / HCPCS / ICD-10 Codes
Background
References
Policy
Scope of Policy
This Clinical Policy Bulletin addresses skilled home private duty nursing care and medically fragile day care. Skilled home private duty nursing care (PDN) involves performance of skilled services by a licensed nursing professional (RN/LPN) in the member's home, typically to take the place of continued inpatient treatment.
Note: This policy only applies to plans with private duty nursing benefits. Please check benefit plan descriptions for details.
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Medical Necessity
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Private Duty Home Nursing
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.
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 all of the following criteria are met:
- The member has skilled needsFootnote1*; and
- The member is homebound; and
- The member needs skilled care that exceeds the scope of intermittent care; and
- 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; and
- Home nursing care is provided as part of a written short term, home care plan leading to the training of the primary care giver(s) to deliver those services once the member’s condition is stabilized; and
- Home nursing is not meant to replace a parent or caregiver, but to provide skilled support to the member; and
- Services are provided at home when such services are medically necessary to properly attend the member; and
- The member is participating/engaged in case management with an Aetna case manager.
Note: For Medicare Advantage members, the terms of Medicare Local Coverage Determinations (LCDs) on PDN would apply where applicable. PDN services must be ordered by the member’s primary care and/or treatment physician following a face-to-face visit; with recertification every 60 day by the ordering provider; and the agency/provider must participate with traditional Medicare and be licensed to perform the PDN services ordered in the home.
Footnote1* Services that can safety and effectively be provided by a nonclinical person do not become skilled needs solely because a caregiver/family member is unavailable. To qualify for private duty nursing, the member must have one caregiver willing and able to accept responsibility for the member's care when the nurse is not available; If the caregiver/family member cannot or will not accept responsibility for the care, private duty nursing will be considered not medically necessary as this is considered an unsafe environment. This includes situations where no person is available to assume the role of a caregiver, as well as situations where a family member or other potential caregiver is available but is not willing to assume the caregiver role.
Private duty nursing is not considered medically necessary if the nurse is placed in the home solely for the convenience of the family member or caregiver, including placement of the nurse in the home to allow the family member or caregiver to go to work or school.
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 member's stability and the number of skilled needs that the member has. 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.
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Home Nursing for Patients on Ventilators
Aetna considers initial stabilization 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.
For members on a ventilator at home, Aetna considers continuous home nursing medically necessary 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, the amount of home nursing per day that is medically necessary will decline as the member is stabilized and the family member/caregiver is instructed on routine ventilator care.
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Medically Fragile Day Care
Aetna considers medically fragile day care medically necessary when all of the following criteria are met:
- Care is not custodial; and
- It has been recommended following medical review; and
- It is in lieu of private duty nursing care that Aetna would routinely approve.
Note: Transportation to and from the day care facility will be the family's responsibility.
Note: Coverage of medically fragile daycare is available to persons with a private duty nursing benefit. Please check benefit plan descriptions. One day of medically fragile daycare is considered equivalent to 8 hours of private duty nursing. If the member who is participating in such a program can not attend medically fragile day care due to an acute illness, Aetna considers medically necessary up to 8 hours of nursing per day in the home after the member has been ill for 72 hours.
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Policy Limitations and Exclusions
- Electrical generators do not meet Aetna's definition of DME because they are not primarily medical in nature.
- Aetna standard benefit plans exclude coverage of custodial care. Please check benefit plan documents.
- Custodial care is defined as services 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.
- Private duty nursing services become custodial care when any one of the following situations occur:
- The member’s condition is stable such that a licensed nurse is not required to monitor the condition; or
- Continuous attendance by a licensed nurse is not necessary; or
- Hands-on nursing interventions are not necessary.
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Examples of custodial care include:
- Routine patient care such as changing dressings, periodic turning and positioning in bed, and administering medications that can be self-administered or given by trained non-medical persons;
- 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 (examples include but not limited to pulse oximetry monitoring, monitoring of respiratory status, and seizure monitoring and observation in a person who is stable without cardiorespiratory compromise);
- 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.
Coverage of private duty nursing is limited to persons who are homebound. CMS states that, for a beneficiary to be certified by a doctor as homebound, it requires a considerable and taxing effort to leave the home because of reliance on a mobility aid (e.g. cane, wheelchair or walker), special transportation, or the assistance of another person to do so. An individual does not have to be bedridden to be considered homebound and can still qualify even if they are able to leave home for medical treatments, adult day care, and short, infrequent nonmedical outings, such as religious services and family gatherings. According to CMS policy: "Any absence of an individual from the home attributable to the need to receive health care treatment, including regular absences for the purpose of participating in therapeutic, psychosocial, or medical treatment in an adult day-care program that is licensed or certified by a State, or accredited, to furnish adult day-care services in the State shall not disqualify an individual from being considered to be confined to his home. Any other absence of an individual from the home shall not so disqualify an individual if the absence is of infrequent or of relatively short duration. For purposes of the preceding sentence, any absence for the purpose of attending a religious service shall be deemed to be an absence of infrequent or short duration."
A medically fragile day care facility is a licensed facility staffed and equipped to provide ambulatory care for people with skilled nursing needs. Medically fragile day care offers an alternative to private duty nursing care provided in the home.
Glossary of Terms
| Term | Definition |
|---|---|
| Custodial care | Services that are primarily intended to help members meet personal needs |
Appendix
Documentation Requirements
Private Duty Nursing (PDN) Services are considered medically necessary for members who meet all of the following criteria:
- The services are ordered by a licensed physician (MD or DO) 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 medically necessary for the member's disease, illness or injury, and are within the accepted standards of nursing practice, and
- The services are performed by a licensed nurse (i.e., Registered Nurse or Licensed Practical Nurse), 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 member's private residence, and
- 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.
References
The above policy is based on the following references:
- Bailey KL. Establishing private duty in a Medicare world. Caring. 1998;17(9):24-25, 27, 29-31.
- Beale H. Respite care for technology-dependent children and their families. Paediatr Nurs. 2002;14(7):18-19.
- Briggs NJ. Day care for medically fragile children. Pediatr Nurs. 1987;13(2):120-121.
- Brodaty H, Green A, Koschera A. Meta-analysis of psychosocial interventions for caregivers of people with dementia. J Am Geriatr Soc. 2003;51(5):657-664.
- Centers for Medicare & Medicaid Services (CMS). Coverage of extended care (SNF) services under hospital insurance. Medicare Benefit Policy Manual, Chapter 8. Rev. 198. Baltimore, MD: CMS; revised October 4, 2019. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c08pdf.pdf. Accessed April 15, 2021.
- Centers for Medicare & Medicaid Services (CMS). Custodial care vs. skilled care. Infograph. Medicaid Integrity Program Resource Library. Baltimore, MD: CMS; March 2016. Available at:
https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/infograph-CustodialCarevsSkilledCare-%5BMarch-2016%5D.pdf. Accessed April 15, 2021. - Centers for Medicare & Medicaid Services (CMS). General exclusions from coverage. Medicare Benefit Policy Manual, Chapter 16. Rev. 198. Baltimore, MD: CMS; revised November 6, 2014. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c16.pdf. Accessed April 15, 2021.
- Centers for Medicare & Medicaid Services (CMS). Home health services. Medicare Benefit Policy Manual, Chapter 7. Rev. 10438. Baltimore, MD: CMS; revised November 6, 2020. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c07.pdf. Accessed April 15, 2021.
- Centers for Medicare & Medicaid Services (CMS). 30.1.1 - Patient confined to the home. Medicare Benefit Policy Manual, Chapter 7. Rev. 10438. Baltimore, MD: CMS; revised November 6, 2020. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf. Accessed June 24, 2021.
- Creighton H. Private duty nursing: Part I - Reimbursement issues. Nurs Manage. 1988;19(6):22, 26.
- Harding R, Higginson IJ. What is the best way to help caregivers in cancer and palliative care? A systematic literature review of interventions and their effectiveness. Palliat Med. 2003;17(1):63-74.
- Harrigan RC, Ratliffe C, Patrinos ME, Tse A. Medically fragile children: An integrative review of the literature and recommendations for future research. Issues Compr Pediatr Nurs. 2002;25(1):1-20.
- Health Council of the Netherlands, Gezondheidsraad (GR). Day care for persons with profound multiple disabilities. Den Haag, The Netherlands: GR; 1999.
- Holmes AM, Deb P. The effect of chronic illness on the psychological health of family members. J Ment Health Policy Econ. 2003;6(1):13-22.
- Ingleton C, Payne S, Nolan M, Carey I. Respite in palliative care: A review and discussion of the literature. Palliat Med. 2003;17(7):567-575.
- Lulavage A. RN-LPN teams: Toward unit nursing case management. Nurs Manage. 1991;22(3):58-61.
- Miller S. Respite care for children who have complex healthcare needs. Paediatr Nurs. 2002;14(5):33-37.
- Neufeld SM, Query B, Drummond JE. Respite care users who have children with chronic conditions: Are they getting a break? J Pediatr Nurs. 2001;16(4):234-244.
- Porter SA. Infant medical day care. A natural extension of home care. Caring. 1992;11(9):90-92, 94.
- Private duty nursing services. 42 CFR § 440.80.
