Here’s what you need to know about the Private Duty Nursing Program

Blue Cross Blue Shield of Michigan has created a Private Duty Nursing document to help you understand if you qualify as a private duty nursing provider and how the program works.

The Private Duty Nursing document is available on web-DENIS. Here’s how to find it:

• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters & Resources.
• Click on Clinical Criteria & Resources in the left-hand column.

The document is also linked from our online provider manual for home health agencies in the “Home Health Care Services” chapter, as well as from our hospital outpatient manual in the “Hospital Services” chapter.

Private duty nursing doesn’t cover services provided by, or within the scope of practice of, a medical assistant, nurse’s aide, home health aide or other non-nurse caregivers.

Private duty nursing can be provided to individuals who have this benefit and who have a skilled care need as identified by “InterQual Skilled Nursing” criteria. (Custodial care doesn’t qualify for PDN.) As always, you can check a member’s benefits through Benefit Explainer on web-DENIS.
Private duty nursing is considered medically necessary when specific criteria are met. Criteria include the following:

• The member’s condition requires intense, individualized, continual 24-hour on-site services extending beyond the basic home health care benefit.
• At least eight hours of PDN are required to meet the needs of the patient. (During transition from inpatient to home care, up to 16 hours per day of private duty nursing may be required.)
• At least two trained caregivers (family or friend, etc.) must be trained and competent to give care when the nurse isn’t in attendance.
• The family caregivers must provide at least eight hours of skilled care per day.
• The PDN services must be ordered by an M.D. or D.O. who is involved in the ongoing care of the patient, inclusive of home health certification with the plan of care or treatment plan.
• Private duty nursing services don’t require Blue Cross preauthorization or Blue Cross precertification.
• Continual assessment, observation and monitoring of a complex or fragile clinical condition and hourly documentation of the clinical information and services performed is required.
• Training and teaching activities by the skilled nurse to teach the patient, family or caregivers how to manage the treatment regimen is required and considered a skilled nursing service.
• Criteria and documentation requirements for specific conditions, if present, in addition to the medically complex or fragile condition of the patient, may include:
• Tracheostomy tube suctioning
• Ventilator management and oxygen saturation measuring with hourly observations
• Management of tube drainage, complex wounds and cavities
• Complex medication administration
• Tube feedings that require frequent changes in formulation or administration rate

Refer to the Private Duty Nursing document to view the full set of criteria and rules.

Required billing documentation submission rules
Invoicing and documentation for new private duty nursing patients** is required after the first seven to 10 days of services to ensure that PDN criteria is met. After that, billing should be monthly. Here are other rules:

• Don’t overlap months on the invoice.
• An invoice and notes must be included for the service dates billed.
• Each agency must submit an invoice and notes separately (don’t combine agencies).
• Invoices and medical records or documentation must be submitted in the following order:
• The Private duty nursing submission form must be completed and used as a cover sheet with each monthly invoice. The form is posted on the new Forms page on web-DENIS.
• Invoice — The invoice should include the following:
• Nurse’s name, level of degree and license number. (If not included on the invoice, it should be on a typed form following the invoice.)
• Tax ID and contract number
• Total hours or units for each level of care for each date billed (S9123 for an R.N. and S9124 for an L.P.N. Indicate charge per hour or unit (1 unit = 1 hour) and total charges for each date.
• Current home health certification with plan of care or treatment plan
• Physician’s letter of medical necessity or prescription
• Daily nursing notes with nursing flow sheets (date the notes and place in consecutive order)
• Additional documentation supporting services rendered

Refer to the Private Duty Nursing document for a full list of the criteria. Invoices and records should be mailed to the following address, with the Private duty nursing submission form included as a cover sheet:

Blue Cross Blue Shield of Michigan
P.O. Box 32597
Private Duty Nursing
Detroit, MI 48232-0597

Note: Mailing this information to any other address or omitting any required documentation will result in processing delays (returned invoices) or claim rejections.

** This is a pay-subscriber benefit, which means that benefits are paid directly to the subscriber by Blue Cross. If there are any invoicing or medical record issues, the member will need to assign permission for you to speak to Customer Service on their behalf. Otherwise, the member can call Customer Service directly, using the appropriate number on the back of their Blue Cross ID card.