24.5.17 Bath and Bathroom EquipmentBath and bathroom equipment is DME that is included in a treatment protocol, serves as a therapeutic agent for life and health maintenance, and is required to treat an identified medical condition. Bath and bathroom equipment may be considered for reimbursement for those clients who have physical limitations that do not allow for bathing, showering, or bathroom use. Note: THSteps eligible clients who qualify for medically necessary services beyond the limits of this Home Health Services benefit may be considered under THSteps-CCP. The following criteria must be met to qualify for Home Health Services:
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• Bath seats are not considered for clients younger than one year of age or weighing less than 30 pounds. Prior authorization is required for all bath and bathroom equipment and related supplies, including any accessories, modifications, adjustments, replacements and repairs to the equipment. The bath and bathroom equipment must be able to accommodate a 20 percent change in the client's height and/or weight. To request prior authorization for bath or bathroom equipment, the following documentation must be provided:
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• A completed, signed, and dated Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form prescribing the DME and/or supplies must be signed and dated by a prescribing physician who is familiar with the client before requesting authorization. All signatures must be current, unaltered, original, and handwritten. Computerized or stamped signatures will not be accepted. The completed Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form must be maintained by the DME provider and prescribing physician in the client's record. The original signature must be maintained in the client's record. To avoid unnecessary denials, the physician must provide correct and complete information, including documentation of the medical necessity of the requested equipment and/or supplies. The physician must maintain documentation of medical necessity in the client's medical record. The requesting provider may be asked for additional information to clarify or complete a request for the bath or bathroom equipment. Rental of equipment includes all necessary supplies, adjustments, repairs, and replacement parts. A determination as to whether the equipment will be rented, purchased, replaced, repaired, or modified will be made by HHSC or its designee based on the client's needs, duration of use, and age of the equipment. Hand-Held Shower/Shower Wand A hand held shower/shower wand is a shower head attached to a flexible tubing. Hand held showers/shower wands with attachments are limited to one every five years. A hand-held shower/shower wand with attachments may be considered for prior authorization only if the client currently owns or meets the criteria for a bath/shower chair, tub stool/bench, or tub transfer bench. Prior authorization of a hand-held shower/shower wand includes all attachments and accessories. Use procedure code J-E1399 when billing for a hand held shower/shower wand. Hand held showers/shower wands with attachments are limited to one every five years. Bath/Shower Chairs, Tub Stool/Bench, Tub Transfer Bench A bath/shower chair, tub stool/bench, or tub transfer bench may be considered for those clients who cannot safely use a regular bath tub or shower. Bath/shower chairs, tub stool/benches and tub transfer benches are grouped into three levels of design to assist the client based on their physical condition and mobility status. Bath/shower chairs, tub stool/bench, and tub transfer benches are limited to one every five years. A bath/shower chair is a stationary or mobile seat with or without upper body/head support used to support a client who is unable to stand or sit independently in the shower or tub. A tub stool/bench is a stationary seat/bench used to support a client who is unable to stand or sit independently in the shower or tub. A tub transfer bench is a stationary bench that sits in the tub and extends outside the tub used to support a client who is unable to stand or sit independently in the shower or tub to sit and allows the client to scoot/slide over the side of the tub. Level 1 Group A level 1 device is defined as stationary equipment. Level 1 devices may be considered if the client meets either of the following two criteria:
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• Use procedure code J-E0240 for level 1 group bath/shower chairs. Level 2 Group A level 2 device is defined as mobile equipment with or without a commode cut out. A level 2 device may be considered if the client has good upper body stability and one of the following:
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• The client must have a shower that is adapted for rolling equipment; ramps are not acceptable for access to showers. Use procedure code J-E0240 with modifier TF (Intermediate Level) for level 2 group bath/shower chairs. Level 3 Group A level 3 device is a custom stationary or mobile chair with or without a commode cut out. A level 3 device may be considered if the client requires trunk and/or head/neck support or positioning to accommodate conditions that include, but are not limited to, spasticity or frequent/ uncontrolled seizures. A bath/shower chair may be prior authorized for clients who meet the level 1, 2, or 3 criteria. A custom bath/shower chair may be considered for reimbursement only if the client does not also have any type of commode chair. Use procedure code J-E0240 with the TG modifier (Complex/high level) for level 3 group bath/shower chairs. A level 3 custom bath/shower chair may be prior authorized only if the client does not also have any type of commode chair. The client must have a shower that is adapted for rolling equipment; ramps will not be prior authorized for access to showers. A tub transfer bench may be considered if the client meets the Level 1 or 2 criteria. A tub stool/bench may be prior authorized for clients who meet the level 1 criteria. Use procedure code J-E0245 for a tub/stool bench. Use procedure code J-E0247 for a tub transfer bench. A heavy duty tub transfer bench may be considered for clients who meet the level 1 or 2 criteria and who weigh more than 200 pounds. Use procedure code J-E0248 for a heavy duty tub transfer bench. Bathroom Equipment Non-fixed Toilet Rail, Bathtub Rail Attachment, and Raised Toilet Seat Non-fixed toilet rails sit on the floor and attach to the commode to allow support while sitting/standing during use of the toilet. Non-fixed toilet rails are limited to two every five years. A bathtub rail attachment is a rail that screws onto the side of the tub to provide support while climbing into or out of the tub. Bathtub rails are limited to one every five years. A raised toilet seat is a device that adds height to the toilet seat. It is either fixed height or adjustable and is either attached to the toilet or is resting on the bowl. Raised toilet seats are limited to one every five years. Non-fixed toilet rails, bathtub rail attachments, and raised toilet seats may be considered for prior authorization for a client who has decreased functional mobility and is unable to safely self-toilet or self-bathe without assistive equipment. Use procedure code J-E0243, J-E0244, or J-E0246 for non-fixed toilet rails, bathtub rails or raised toilet seats. Portable Sitz Bath Portable sitz bath is used to immerse only the perineum and buttocks, that fits over commode seats. Portable sitz baths that fit over commode seats are limited to two per year. A portable sitz bath, may be considered for prior authorization if the client requires any of the following:
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• Use procedure codes J-E0160 or J-E0161 for portable sitz baths. Bath Lifts A bath lift is a client lift for use in the bathroom designed to accommodate the smaller space. The purchase of bath lifts are limited to one every five years. The rental of bath lifts are limited to one per month. A bath lift may be considered for prior authorization if the client has:
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• Use procedure code J/L-E0625 for the purchase or rental of bath lifts. The purchase of a lift sling is limited to one every five years. Use procedure code J-E0621 for the purchase of a lift sling. Home adaptation for use of medical equipment is not a benefit of Home Health Services. The following are payable procedure codes for bath and bathroom equipment:
Bath and bathroom equipment that have been purchased are anticipated to last a minimum of five years and may be considered for replacement when five years have passed and/or the equipment is no longer repairable. The DME may then be considered for prior authorization. Replacement of equipment may also be considered when loss or irreparable damage has occurred. A copy of the police or fire report, when appropriate, and the measures to be taken to prevent a recurrence must be submitted. Modifications, Adjustments, and Repairs Modifications are the replacement of components because of changes in the client's condition, not replacement because the component is no longer functioning as designed. All modifications/adjustments within the first six months after delivery are considered part of the purchase price. Modifications to custom equipment may be prior authorized should a change occur in the client's needs, capabilities, or physical/mental status which cannot be anticipated. Documentation must include all projected changes in the clients mobility needs, the date of purchase, the serial number of the current equipment, and the cost of purchasing new equipment versus modifying current equipment. All modifications within the first six months after delivery are considered part of the purchase price. Adjustments do not require supplies. Adjustments made within the first six months after delivery will not be prior authorized. Adjustments made within the first six months after delivery are considered part of the purchase price. A maximum of one hour of labor for adjustments may be prior authorized as needed after the first six months following delivery. Repairs to client-owned equipment may be prior authorized as needed with documentation of medical necessity. Technician fees are considered part of the cost of the repair. Repairs require the replacement of components that are no longer functional. Providers are responsible for maintaining documentation in the client's medical record specifying the repairs and supporting medical necessity. Bathroom/toilet lift rentals may be prior authorized during the period of repair up to a maximum of four months per lifetime per client. Prior authorization will not be considered for modifications, adjustments, or repairs to bath or bathroom equipment delivered to a client's home and then found to be inappropriate for the client's condition within the first six months after delivery. This applies unless there is a significant change in the client's condition that is documented by a physician familiar with the client. Routine maintenance of rental equipment is the provider's responsibility. In situations where the equipment has been abused or neglected by the client, the client's family, or the caregiver, a referral to the DSHS THSteps Case Management Department will be made by the Home Health Services Prior Authorization Department for clients under 21 years of age. Providers will be notified that the state will be monitoring this client's services to evaluate the safety of the environment for both the client and equipment. Accessories Equipment accessories including, but not limited to, pressure support cushions, may be prior authorized with documentation of medical necessity. |
The requested equipment must be medically necessary.
