Skip to Main Content

Effective November 1, 2025: Private Duty Nursing Modifiers

Date: 10/02/25

Please Note: This article has been updated as of 10/31/2025.

Effective November 1, 2025, Private Duty Nursing (PDN) Modifier UA must be Prior Authorized for Medicaid (STAR Kids, STAR Health, STAR) and CHIP members.

What Is New: PDN providers that request prior authorization for PDN specialized care (procedure code T1000 with modifier UA) must submit all clinical documentation required for PDN services as well as a physician’s order that include the clinical indications that justify PDN services with UA. PDN specialized care (T1000 with UA modifier) is exclusive to members who are dependent on invasive mechanical ventilation or have a functioning tracheostomy that requires suctioning or specialized nursing care. Members receiving non-invasive ventilation do not qualify for the UA modifier. Non-invasive ventilation methods include ventilator used as a respiratory assistance device (RAD), continuous positive airway pressure (CPAP), auto-titrating positive airway pressure (APAP), bilevel positive airway pressure (BPAP or BiPAP), and adaptive servo-ventilation (ASV).

  • Procedure code T1000 AND Modifier (UA), if applicable, must be Included on the Prior Authorization Request and include a brief description of the requested services:

Medical necessity must also be included in the Home Health Plan of Care (POC), the Nursing Addendum to Plan of Care for Private Duty Nursing and/or Prescribed Pediatric Extended Care Centers forms. The criteria for medical necessity is included in the Clinical Policy (TX.CP.MP.520 Private Duty Nursing – Medicaid and TX.CP.MP.521 Private Duty Nursing – CHIP)

  • Documentation for T1000 AND modifier UA must include:
    • The primary care provider must include the settings or modes for required equipment (e.g., ventilator, oxygen) in the physician-recommended plan of care (POC).

When This Applies: Prior Authorization Requests submitted on or after November 1, 2025

Prior Authorization Requests:

Superior ensures medical necessity review criteria is current and appropriate for members and the scope of services provided. Below are the Current Procedural Terminology (CPT) codes and modifiers included in this change to the prior authorization requirements.

Procedure Code

Applicable Products

Criteria

T1000 - Private duty / independent nursing service(s) - licensed, up to 15 minutes

 

Medicaid (STAR, STAR Health, STAR Kids), CHIP

Updated Clinical Policies:

Medicaid:

TX.CP.MP.520 Private Duty Nursing - Medicaid

CHIP:

TX.CP.MP.521 Private Duty Nursing – CHIP

 

 

Modifiers for T1000:

      UA - Specialized services

     

To review prior authorization requirements, please visit Superior’s Prior Authorization webpage.

For questions or additional information, contact Superior’s Prior Authorization department at 1-800-218-7508.