Private Duty Nursing Billing Manual

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Private Duty Nursing

Providers must be enrolled as a Health First Colorado (Colorado's Medicaid program) provider in order to:

  • Treat a Health First Colorado member
  • Submit claims for payment to Health First Colorado

The Private Duty Nursing (PDN) program provides skilled nursing services on a continuous basis to Health First Colorado members in their place of residence. A plan of care as ordered by the attending physician is developed by the Home Health agency. The plan of care is reviewed periodically by the physician. All plan of care services are subject to post-payment review for medical necessity and regulation compliance.

Providers should refer to the Code of Colorado Regulations, Program Rules (10 C.C.R. 2505-10), for specific information when providing PDN services.


Billing Information

Refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down menu for general billing information.

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Ordering, Prescribing and Referring (OPR) Providers 

Effective July 1, 2022, the Department of Health Care Policy & Financing (the Department) began enforcing the federal requirement 42 CFR § 455.440, which requires that all claims for Home Health services include the National Provider Identifier (NPI) of the provider who ordered the service and 42 CFR 455.440, that requires the NPI is associated with an actively enrolled with Health First Colorado Provider.
Providers are required to enter the NPI of the ordering provider into the following locations for claim submission. In the Provider Web Portal, this field may be labeled "Referring Provider". 

Institutional claims

  • The Attending Provider field (#76) or the Other ID fields (#78 or #79) for both paper and electronic claims
  • Providers should refer to their applicable UB-04 billing manuals for guidance on how each field is used.

Private Duty Nursing services can be ordered by either a physician or an allowed practitioner. Allowed practitioners are defined in accordance with State law as physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS). The ordering provider must also be actively enrolled [Health First Colorado. If these conditions are not met, the claim will be denied.

Visit the OPR Claim Identifier Project web page or refer to Program Rule 10 CCR 2505-10 8.125.8.A for further information.


General Prior Authorization Requirements

All PDN Prior Authorization Requests (PARs) must be submitted via the ColoradoPAR web page. The additional forms necessary for PDN PAR submission are located on the Provider Forms web page or from the authorizing agency. PAR forms must be completed and sent to the authorizing agency before services can be billed. Instructions for completing the PAR form are included in this manual. Refer to Appendix C and Appendix D located on the Billing Manuals web page under the Appendices drop-down for authorizing agency information.

Health First Colorado requires the completion of a PAR form for:

  • All PDN services prior to starting services.
  • Orders must specify how often treatment or visits will be and the length of visit.
  • Time submitted that is outside of or different from the orders will be deducted and the units adjusted accordingly.
  • Do not submit claims before a copy of the PAR is received or made available unless submission is necessary to meet timely filing requirements. Refer to the Department Program Rules - Code of Colorado Regulations for required attachments.

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General Prior Authorization Request Instructions

Submit all appropriate documentation to support your PDN request including detailed demographics, diagnosis, physician's orders, treatment plans, nursing summaries, nurse aide assignment sheets, medications, etc. via the ColoradoPAR web page.

Revision must also be submitted via the ColoradoPAR web page and must be completed in a timely manner prior to the expiration of the PAR Revenue Coding.

The following table identifies the only valid revenue codes for billing Private Duty Nursing to Health First Colorado. Valid revenue codes are not always a Health First Colorado benefit. When valid non- benefit revenue codes are used, the claim must be completed according to the billing instructions for non-covered charges.

PDN providers billing on the UB-04 claim form for services provided to authorized members must use the appropriate condition code in form locators 18 through 28 (Condition Codes) and use the revenue codes listed below. Claims submitted with revenue codes that are not listed below are denied.

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UB-04 Paper Claim Reference Table

The information in the following table provides instructions for completing form locators (FL) as they appear on the paper UB-04 claim form. Instructions for completing the UB-04 claim form are based on the current National Uniform Billing Committee (NUBC) UB-04 Reference Manual. Unless otherwise noted, all data form locators on the UB-04 have the same attributes (specifications) for Health First Colorado as those indicated in the NUBC UB-04 Reference Manual.

All code values listed in the NUBC UB-04 Reference Manual for each form locator may not be used for submitting paper claims to Health First Colorado. The appropriate code values listed in this manual must be used when billing Health First Colorado.

The UB-04 Certification document must be completed and attached to all claims submitted on the paper UB-04. Completed UB-04 paper Health First Colorado claims, including hardcopy Medicare claims, should be mailed to the correct fiscal agent address listed in Appendix A, located on the Billing Manuals web page under the Appendices drop-down.

Do not submit "continuation" claims. Each claim form has a set number of billing lines available for completion. Do not crowd more lines on the form.

Billing lines in excess of the designated number are not processed or acknowledged. Claims with more than one page may be submitted through the Provider Web Portal.

Bill with a date span (From and To dates of service) only if the service was provided every consecutive day within the span. The From and To dates must be in the same month.

The Paper Claim Reference Table below lists the required, optional and/or conditional form locators for submitting the paper UB-04 claim form to Health First Colorado for nursing facility services.

Form Locator and LabelsCompletion FormatInstructions
1. Billing Provider Name, Address, Telephone NumberText

Enter the provider or agency name and complete mailing address of the provider who is billing for the services:

  • Street
  • City
  • State
  • Zip Code

Abbreviate the state using standard post office abbreviations. Enter the telephone number.

2. Pay-to Name, Address, City, StateText

Required only if different from FL 1.
Enter the provider or agency name and complete mailing address of the provider who will receive payment for the services:

  • Street/Post Office box City
  • State Zip Code
  • Abbreviate the state using standard post office abbreviations. Enter the telephone number.
3a. Patient Control NumberUp to 20 characters: Letters, numbers or hyphensOptional
Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).
3b. Medical Record Number17 digitsOptional
Enter the number assigned to the member to assist in retrieval of medical records.
4. Type of Bill3 digits

Private Duty Nursing
Effective 3/1/2017, use 32X for Home Health/Private Duty Nursing services. 33X is no longer valid.
(These instructions supersede all prior publications)

Use 321-324 or 341-344 for Medicare crossover claims.

Enter the three-digit number indicating the specific type of bill. The three-digit code requires one digit each in the following sequences (Type of facility, Bill classification, and Frequency):

Digit 1Type of Facility
2Skilled Nursing
3Home Health Services
4Religious Non-Medical Health Care Institution
6Intermediate Care
7Clinic (Rural Health/FQHC/Dialysis Center)
8Special Facility (Hospice, RTCs)
Digit 2Bill Classification (Except clinics and special facilities):
1Inpatient (Including Medicare Part A)
2Inpatient (Medicare Part B only)
4Other (for hospital referenced diagnostic services or home health not under a plan of treatment)
5Intermediate Care Level I
6Intermediate Care Level II
7Sub-Acute Inpatient (Revenue Code 019X required with this bill type)
8Swing Beds
Digit 2Bill Classification (Clinics Only):
1Rural Health/FQHC
2Hospital Based or Independent Renal Dialysis Center
4Outpatient Rehabilitation Facility (ORF)
5Comprehensive Outpatient Rehabilitation Facilities (CORFs)
6Community Mental Health Center
Digit 3Frequency:
0Non-Payment/Zero Claim
1Admit through discharge claim
2Interim - First claim
3Interim - Continuous claim
4Interim - Last claim
7Replacement of prior claim
8Void of prior claim
5. Federal Tax NumberNoneSubmitted information is not entered into the claim processing system.
6. Statement covers period From/ThroughFrom: 6 digits MMDDYY
Through: 6 digits MMDDYY
Private Duty Nursing
"From" date is the actual start date of services.

"From" date cannot be prior to the start date reported on the initial prior authorization, if applicable, or is the first date of an interim bill.

"Through" date is the actual discharge date, or final date of an interim bill.

"From" and "Through" dates cannot exceed a calendar month (e.g., bill 01/15/10 thru 01/31/10 and 02/01/10 thru 02/15/10, not 01/15/10 thru 02/15/10).

Dates must match the prior authorization if applicable. If member is admitted and discharged the same date, that date must appear in both fields.

Detail dates of service must be within the "Statement Covers Period" dates.
8a. Patient IdentifierTextEnter the Health First Colorado ID number for the member.
8b. Patient NameUp to 25 characters, letters and spacesRequired
Enter the member's last name, first name and middle initial.
9a. Patient Address - StreetCharacters Letters and numbersRequired
Enter the member's street/post office box as determined at the time of admission.
9b. Patient Address - CityTextRequired
Enter the member's city as determined at the time of admission
9c. Patient Address - StateTextRequired
Enter the member's state as determined at the time of admission.
9d. Patient Address - ZIPDigitsRequired
Enter the member's zip code as determined at the time of admission.
9e. Patient Address - Country CodeDigitsOptional
10. Birthdate8 digits (MMDDCCYY)

Enter the member's birthdate using two digits for the month, two digits for the date, and four digits for the year (MMDDCCYY format).

Example: 01012010 for January 1, 2010.

11. Patient Sex1 letterRequired
Enter an M (male) or F (female) to indicate the member's sex.
12. Admission Date6 digitsRequired
Enter the date care originally started from any funding source (e.g., Medicare, Health First Colorado, Third Party Resource, etc.).
13. Admission Hour6 digitsNot required
14. Admission Type1 digitNot Required
15. Source of Admission1 digitRequired

Complete if the member has been admitted or readmitted during the billing period.
16. Discharge Hour2 digitsNot Required
17. Patient Discharge Status2 digits

Enter member status as ongoing member (code 30) or as of discharge date. Agencies are limited to the following codes:

01Discharged to Home
03Discharged/Transferred to SNF
04Discharged/Transferred to ICF
05Discharged/Transferred to Another type of institution
06Discharged/Transferred to organized Home Health Care Program (HCBS)
07Left Against Medical Advice
20Deceased/Expired (not for Hospice user)
30Still a member
40Expired at Home
41Expired in hospital, SNF, ICF, or free-standing hospice
42Expired - Place unknown
50Hospice - Home
51Hospice - Medical Facility
18-28. Conditions Codes2 digitsConditional
Use condition code A1 to bill PDN hours greater than 16 for children.
29. Accident State2 digitsOptional
31 - 34. Occurrence Code/Date2 digits and 6 digitsRequired

use occurrence code 27 and enter the Plan of care start date. Enter the date using MMDDYY format.
35-36. Occurrence Span Code From/ ThroughDigitsLeave blank
38. Responsible Party Name/AddressNoneLeave blank
39 - 41. Value Codes and Amounts2 characters and up to 9 digits

Enter appropriate codes and related dollar amounts to identify monetary data or number of days using whole numbers, necessary for the processing of this claim. Never enter negative amounts. Codes must be in ascending order. If a value code is entered, a dollar amount or numeric value related to the code must always be entered.
Most Common Codes:

01semiprivate rate (Accommodation Rate)
06Medicare blood deductible
14No fault including auto/other
15Worker's Compensation
31Member Liability Amount*
32Multiple Member Ambulance Transport
37Pints of Blood Furnished
38Blood Deductible Pints
40New Coverage Not Implemented by HMO
45Accident Hour
Enter the hour when the accident occurred that necessitated medical treatment. Use the same coding used in FL 18 (Admission Hour).
49Hematocrit Reading - EPO Related
58Arterial Blood Gas (PO2/PA2)
80Covered Days
81Non-Covered Days
Enter the amount paid by indicated payer:
A3 Estimated Responsibility Payer A
B3 Estimated Responsibility Payer B
C3 Estimated Responsibility Payer C

For Rancho Coma Score bill with appropriate diagnosis for head injury.

42. Revenue Code4 digitsRequired
Enter the revenue code that identifies the specific accommodation or ancillary service provided. List revenue codes in ascending order.

A revenue code must appear only once per date of service. If more than one of the same service is provided on the same day, combine the units and charges on one line accordingly.

Enter the appropriate Revenue code. Private Duty Nursing services cannot be provided to Nursing Facility residents.
43. Revenue code DescriptionTextRequired
Enter the revenue code description or abbreviated description.
44. HCPCS/Rates/ HIPPS Rate Codes5 digits

Required for the following:

  • Private Duty Nursing RN visit: Use only HCPCS code T1000 with modifier TD for revenue code 552.
  • Private Duty Nursing LPN visit: Use only HCPCS code T1000 with modifier TE for revenue code 559.
  • Private Duty Nursing private duty nursing RN group visit: Use only HCPCS code T1000 with modifiers HQ and TD for revenue code 580.
  • Private Duty Nursing private duty nursing LPN group visit: Use only HCPCS code T1000 with modifiers HQ and TE for revenue code 581.

When billing HCPCS codes, the appropriate revenue code must also be billed.

45. Service Date6 digitsConditional
Enter the date of service using MMDDYY format for each detail line completed.
46. Service Units3 digitsRequired
Enter a unit value on each line completed. Use whole numbers only. Do not enter fractions or decimals and do not show a decimal point followed by a 0 to designate whole numbers (e.g., Do not enter 1.0 to signify one unit)
47. Total Charges9 digitsRequired

Enter the total charge for each line item. Calculate the total charge as the number of units multiplied by the unit charge. Do not subtract Medicare or third-party payments from line charge entries. Do not enter negative amounts.
A grand total on line 23 is required for all charges.
48. Non-covered ChargesUp to 9 digitsConditional

Enter incurred charges that are not payable by Health First Colorado.

Non-covered charges must be entered in both FL 47 (Total Charges) and FL 48 (Non-Covered Charges.)

Each column requires a grand total.
50. Payer Name1 letter and text

Enter the payment source code followed by name of each payer organization from which the provider might expect payment.
At least one line must indicate Health First Colorado.

Source Payment Codes
BWorkmen's Compensation
DHealth First Colorado
EOther Federal Program
FInsurance Company
GBlue Cross, including Federal Employee Program
HOther - Inpatient (Part B Only)
Line APrimary Payer
Line BSecondary Payer
Line CTertiary Payer
51. Health Plan ID8 digitsRequired
Enter the provider's Health Plan ID for each payer name.
Enter the NPI number assigned to the billing provider. Payment is made to the enrolled provider or agency that is assigned this number.
52. Release of InformationN/ASubmitted information is not entered into the claim processing system.
53. Assignment of BenefitsN/ASubmitted information is not entered into the claim processing system.
54. Prior PaymentsUp to 9 digitsConditional
Complete when there are Medicare or third-party payments.
Enter third party and/or Medicare payments.
55. Estimated Amount DueUp to 9 digitsConditional
Complete when there are Medicare or third-party payments.
Enter the net amount due from Health First Colorado after provider has received other third party, Medicare or member liability amount.
Medicare Crossovers
Enter the sum of the Medicare coinsurance plus Medicare deductible less third-party payments and member payments.
56. National Provider Identifier (NPI)10 digitsRequired
Enter the billing provider's 10-digit National Provider Identifier (NPI).
57. Other Provider ID Optional
Submitted information is not entered into the claim processing system.
58. Insured's NameUp to 30 charactersRequired
Enter the member's name on the Health First Colorado line.
Other Insurance/Medicare
Complete additional lines when there is third party coverage. Enter the policyholder's last name, first name, and middle initial.
60. Insured's Unique IDUp to 20 charactersRequired
Enter the insured's unique identification number assigned by the payer organization exactly as it appears on the health insurance card. Include letter prefixes or suffixes shown on the card.
61. Insurance Group Name14 lettersConditional
Complete when there is third party coverage.

Enter the name of the group or plan providing the insurance to the insured exactly as it appears on the health insurance card.
62. Insurance Group Number17 digitsConditional
Complete when there is third party coverage.

Enter the identification number, control number, or code assigned by the carrier or fund administrator identifying the group under which the individual is carried.
63. Treatment Authorization CodeUp to 18 charactersConditional
Complete when the service requires a PAR.
Enter the authorization number in this FL if a PAR is required and has been approved for services.
64. Document Control NumbernoneEnter Previous ICN in field 64a
65. Employer NameTextConditional
Complete when there is third party coverage.
Enter the name of the employer that provides health care coverage for the individual identified in FL 58 (Insured Name).
66. Diagnosis Version Qualifier Submitted information is not entered into the claim processing system.
Enter applicable ICD indicator to identify which version of ICD codes is being reported.
0ICD-10-CM (DOS 10/1/15 and after)
67. Principal Diagnosis CodeUp to 6 digitsRequired
Enter the exact diagnosis code describing the principal diagnosis that exists at the time of admission or develops subsequently and affects the length of stay. Do not add extra zeros to the diagnosis code.
67A. - 67Q. - Other Diagnosis6 digitsOptional
Enter the exact diagnosis code corresponding to additional conditions that co-exist at the time of admission or develop subsequently and which effect the treatment received or the length of stay. Do not add extra zeros to the diagnosis code.
Enter applicable ICD indicator to identify which version of ICD codes is being reported.
69. Admitting Diagnosis Code6 digitsNot Required

Enter the diagnosis code as stated by the physician at the time of admission.
70. Patient Reason Diagnosis Submitted information is not entered into the claim processing system.
71. PPS Code Submitted information is not entered into the claim processing system.
72. External Cause of Injury code (E-Code)6 digitsOptional
Enter the diagnosis code for the external cause of an injury, poisoning, or adverse effect. This code must begin with an "E".
74. Principal Procedure Code/Date7 characters and 6 digitsNot Required
74A. Other Procedure Code/Date7 characters and 6 digitsNot Required
76. Attending NPI - RequiredNPI - 10 digitsHealth First Colorado ID Required
NPI - Enter the 10-digit NPI number assigned to the physician having primary responsibility for the member's medical care and treatment. This number is obtained from the physician and cannot be a clinic or group number.
(If the attending physician is not enrolled in the Health First Colorado or if the member leaves the ER before being seen by a physician, the hospital may enter their individual numbers.)
Hospitals and FQHCs may enter the member's regular physician's 10- digit NPI in the Attending Physician ID form locator if the locum tenens physician is not enrolled in the Health First Colorado.
QUAL - Enter "1D" for Health First Colorado
Enter the attending physician's last and first name.
This form locator must be completed for all services.
77. Operating NPI Optional
Submitted information is not entered into the claim processing system.
78 - 79. Other IDNPI - 10 digitsRequired

Complete when attending physician is not the PCP or to identify additional physicians.

Ordering, Prescribing or Referring NPI

NPI - Enter up to two 10-digit NPI numbers, when applicable. This form locator identifies physicians other than the attending physician. If the attending physician is not the PCP or if a clinic is a PCP agent, enter the PCP NPI number as the referring physician. The name of the Health First Colorado member's PCP appears on the eligibility verification. Review either for eligibility or PCP. Health First Colorado does not require that the PCP number appear more than once on each claim submitted.

The attending physician's last and first name are optional.
80. RemarksTextEnter specific additional information necessary to process the claim or fulfill reporting requirements.
81. Code - QUAL/CODE/VALUE (a-d)Qualifier: 2 digits
Taxonomy Code: 10 digits
Complete both the qualifier and the taxonomy code for the billing provider in field 81CC-a.
Field 81CC-a must be billed with qualifier B3 for the taxonomy code to be captured in the claims processing system. If B3 is missing, no taxonomy code will be captured in the claims processing system.
Only one taxonomy code can be captured from field 81CC. If more than one taxonomy code is provided, only the first instance of B3 and taxonomy code will be captured in the claims processing system.

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Private Duty Nursing Claim Example

Note: Medicare crossover claims are valid only with Medicare claims for visits rather than episodes. Low Utilization Payment Adjustment (LUPA) payments, not episode case mix payment.
PDN Claim example

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Timely Filing

Refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down for more information on timely filing policy, including the resubmission rules for denied claims.

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Institutional Provider Certification

The Institutional Certification Form is located on the Provider Forms web page under the Claim Forms and Attachments drop-down.

This document is an addendum to the UB-04 claim form and is required per 42 C.F.R. 445.18 (a)(1-2) to be attached to paper claims submitted on the UB-04.

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Early and Periodic Screening, Diagnostic and Treatment 

Hospice benefits are provided in accordance with Early and Periodic Screening, Diagnostic and Treatment (EPSDT) requirements as listed in 8.280.4.E: “Other EPSDT Benefits” 8.280.4.E reads as follows: 

Other health care services may include other EPSDT benefits if the need for such services is identified. The services are a benefit when they meet the following requirements:

  1. All goods and services described in Section 1905(a) of the Social Security Act are a covered benefit under EPSDT when medically necessary as defined at 10 C.C.R. 2505-10, Section, regardless of whether such goods and services are covered under the Colorado Medicaid State Plan.
  2. For the purposes of EPSDT, medical necessity includes a good or service that will, or is reasonably expected to, assist the client to achieve or maintain maximum functional capacity in performing one or more Activities of Daily Living; and meets the criteria set forth at Section - g.
  3. The service provides a safe environment or situation for the child.
  4. The service is not for the convenience of the caregiver.
  5. The service is medically necessary.
  6. The service is not experimental or investigational and is generally accepted by the medical community for the purpose stated.
  7. The service is the least costly.

Providers can ask for these additional services by following the PAR process as outlined for this benefit.

Visit the EPSDT web page for more information regarding EPSDT.

Contact Gina Robinson at Gina.Robinson@state.co.us with questions about EPSDT.

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Electronic Visit Verification 

Federal guidance requires Electronic Visit Verification (EVV) for Home and Community Based Services (HCBS) that include an element of Personal Care Services and State Plan Home Health Care Services. Colorado requires the use of EVV for several other services that are similar in nature and delivery to the federally mandated services. These additional services are included to enhance care coordination, promote quality outcomes for members, and to streamline requirements for providers. 

All Private Duty Nursing services require EVV.

Visit the EVV web page or refer to the EVV Program Manual for further information regarding the EVV program.

Contact EVV@state.co.us with EVV questions.

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Private Duty Nursing Revisions Log

Revision DateSection/ActionMade by
12/01/2016Manual revised for interChange implementation. Form annual revisions prior to 12/01/2016 Please refer to Archive.HPE (now DXC)
12/27/2016Updates based on Colorado iC Stage II Provider Billing Manual Comment Log v0_2.xlsxHPE (now DXC)
1/10/2017Updates based on Colorado iC Stage II Provider Billing Manual Comment Log v0_3.xlsxHPE (now DXC)
1/19/2017Updates based on Colorado iC Stage II Provider Billing Manual Comment Log v0_4.xlsxHPE (now DXC)
1/26/2017Updates based on Department 1/20/2017 approval emailHPE (now DXC)
3/8/2017Added Type of Bill 32x to row 4 of the Private Duty Nursing Claim example table.HCPF
3/13/2017Updated the Type of Bill section in the Paper Claims Table to reflect the NUBC manual.HCPF
3/14/2017Updated the type of bill in the paper claim example.HCPF
5/26/2017Updates based on Fiscal Agent name change from HPE to DXCDXC
6/15/2018Updated timely filing information and removed references to LBOD, removed general billing information already available in the General Provider Information manual.DXC
6/13/2019Updated Appendices' links and verbiage. Updated Institutional Provider Certification form information.DXC
12/9/2019Converted to web page.HCPF
8/7/2020Updated item 81 of the Paper Claim Reference Table for taxonomy code billing.DXC
9/17/2021Updated Billing manual with existing guidance regarding EPSDT and EVV.HCPF
7/22/2022Changed definition of PDN program to read continuous instead of intermittent.HCPF
9/11/2023Added Ordering, Prescribing, Referring (OPR) Policy. Updated Field #78-79 on claim reference table.HCPF

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