Private duty nursing (PDN)

Federal Medicaid rules define private duty nursing as nursing for people who need more individual and continuous care than a visiting nurse, or the nursing staff of a hospital or skilled nursing facility, routinely provides. A registered nurse or licensed practical nurse delivers it under the direction of the patient’s physician, in one or more settings the state chooses: the patient’s own home, a hospital or a skilled nursing facility. It sits on Medicaid’s list of optional benefits, under section 1905(a)(8) of the Social Security Act, so each state decides how it covers the service². In Iowa, for example, private duty nursing is part of the Early and Periodic Screening, Diagnostic, and Treatment program and is available to children up to age 21³.

It is not Medicare home health. Medicare lists private-duty nursing among the things it does not cover in a hospital stay. It does not cover 24-hour-a-day care at home either, and its part-time or intermittent home health benefit typically allows skilled nursing and home health aide services of up to 8 hours a day combined, with a maximum of 28 hours a week⁴. A patient who needs a nurse at the bedside for whole shifts sits outside that benefit.

Billing is hour-based and authorization-driven. Iowa requires prior authorization, with its request form and a plan of care, and lists its PDN code, T1000, in 15-minute units³. The billing risks follow from that structure: shifts billed past the authorized hours, units rounded inconsistently from one claim to the next, an authorization that lapsed before the renewal was filed, or nursing notes that do not support the hours on the claim. Match every shift to the authorization and the notes before the claim goes out.