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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 naso-gastric (NG) or gastrostomy tube (GT) feeds and do not have other skilled needs.  Home nursing care may be considered medically necessary for these members only 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, Aetna considers home nursing up to 24 hours per day for up to 3 weeks upon an initial discharge from an inpatient setting as a transition to home medically necessary.  Thereafter, up to 16 hours of home nursing per day is considered medically necessary.  Payment for any additional home nursing care is the responsibility of the member/family.

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.



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.

 
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
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
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
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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