T1000 — Private duty / independent nursing service(s) - licensed, up to 15 minutes
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Requests should be documented using Home Health Certification (CMS-485) which includes the plan of care signed by a physician (M.D. or D.O.) or signed by an advanced practitioner (NP, CNS, or PA) in accordance with applicable law and regulation.
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage; refer to the protocol titled Medical Records Documentation Used for Reviews.
- Once coverage for Skilled Care is established, determination of the number of private duty nursing hours should reference InterQual ® LOC: Home Care Q & A, Private Duty Nursing (PDN) Assessment.
- Documentation that the child meets an eligible condition per state-defined criteria for developmental delay (medical/diagnostic documentation of developmental delay or high risk).
Key Coverage Criteria
- Private duty nursing services with Skilled Care are covered in certain circumstances.
- These services are covered according to the member specific benefit plan document and only when meeting the definition of Skilled Care below.
- Once the coverage for Skilled Care has been established, for the number of private duty nursing hours, refer to the InterQual ® LOC: Home Care Q & A, Private Duty Nursing (PDN) Assessment.
- Skilled Care: Skilled nursing, skilled teaching, skilled habilitation, and skilled rehabilitation services when all of the following are true: Must be delivered or supervised by licensed technical or professional medical personnel in order to obtain the specified medical outcome, and provide for the safety of the patient; Ordered by a physician; Not delivered for the purpose of helping with activities of daily living, including dressing, feeding, bathing, or transferring from a bed to a chair; R [...]
- Examples of services which require the skills of qualified technical or professional personnel include: Intravenous injections; Intravenous feeding; Nasopharyngeal and tracheostomy aspiration; Insertion and sterile irrigation and replacement of suprapubic catheters; Treatment of extensive decubitus ulcers or other widespread skin disorder; Initial phases of a regimen involving administration of medical gases; Rehabilitation nursing procedures, including the related teaching and adaptive aspects [...]
- Early intervention programs (coordinated multidisciplinary care) for children from infancy to 3 years of age who have developmental delays or have a high potential for developmental delay.
7 Active Policies
AETNA-CPB-0201 — Skilled Home Health Care Nursing Services
AETNA-CPB-0329 — Home Births
AETNA-CPB-0444 — Early Intervention Programs
UHC-POL-private-duty-nursing-services — Private Duty Nursing Services
ANTHEM-CG-REHAB-08 — CG-REHAB-08 Private Duty Nursing in the Home Setting
Related Codes
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