Table of Contents Previous Next

September 2014 Texas Medicaid Provider Procedures Manual

Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook : 2. Texas Medicaid (Title XIX) Home Health Services : 2.2 Services, Benefits, Limitations and Prior Authorization : 2.2.19 Respiratory Equipment and Supplies : 2.2.19.7 Chest Physiotherapy Devices

2.2.19.7
Chest Physiotherapy Devices
Either a cough-stimulating device (cofflator) or the High-Frequency Chest Wall Compression System (HFCWCS) generator with vest may be prior authorized. These systems are not prior authorized simultaneously.
Chest physiotherapy to promote bronchial drainage that is performed by a therapist or any other healthcare professional, including a private duty nurse, will not be prior authorized during the period of time that the HFCWCS or cough-stimulating device is prior authorized.
Intrapulmonary percussive ventilation (IPV) is not a benefit of Texas Medicaid.
2.2.19.7.1 HFCWCS
An HFCWCS is limited to the following diagnosis codes:
Other diagnoses may be considered based on review of documentation by HHSC or its designee.
A HFCWCS may be reimbursed only when it is demonstrated that other mechanical devices or chest physiotherapy by a client, parent, guardian, or caregiver have been ineffective.
Rental cost of the HFCWCS applies toward the purchase price. A HFCWCS generator purchase and vest purchase may be reimbursed only once per lifetime, due to the lifetime warranty provided by the manufacturer. Requests for a vest replacement due to growth may be considered with appropriate documentation.
Prior authorization for the rental or purchase of equipment in this section requires a Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form and the Medicaid Certificate of Medical Necessity for Chest Physiotherapy Device Initial Request or Extended Request form. These signed and dated forms must be maintained by the provider and prescribing physician in the client’s medical record.
Providers must use procedure code E0483 when billing for HFCWCS for either a rental or purchase.
2.2.19.7.2 Cough-Stimulating Device (Cofflator)
Providers must use procedure code E0482 when requesting rental of a cofflator.
2.2.19.7.3 Prior Authorization
HFCWCS
The HFCWCS requires prior authorization. An initial three-month rental may be authorized for the HFCWC. If the HFCWC is documented to be effective, at the end of the initial three-month rental, purchase of the system may be prior authorized. If at the end of the initial three-month rental a determination of purchase cannot be made, an additional three month rental may be given.
Cough-Stimulating Device (Cofflator)
The cofflator requires prior authorization and may be reimbursed for monthly rental only and includes all supplies. The cofflator may be prior authorized for those clients with chronic pulmonary disease or neuromuscular disorders that affect the respiratory musculature.
2.2.19.7.4 Documentation Requirements
HFCWCS
To obtain prior authorization for the initial three-month rental of a HFCWCS generator and vest, all of the following information must be provided:
A description of all previous therapy courses that have been tried and why these treatments did not adequately assist the client in airway mucus clearance. This must include the information that the client has used electrical percussor therapy for a minimum of four months before the request and that this therapy has been ineffective.
A physician’s statement of a trial of the HFCWCS in a clinic, hospital, or the home setting documenting the effectiveness and tolerance of the system, including a statement that the client has not exacerbated any gastrointestinal manifestations, nor caused aspiration and exacerbation of pulmonary manifestations, nor an exacerbation of seizure activity secondary to the use of the system.
Diagnosis and background history including complications, medications used, history of any IV antibiotic therapy with dosage, frequency and duration, history of recent hospitalizations or history of school, work, or extracurricular activity absences due to diagnosis-related complications.
Prior authorization for an extension of another three months rental may be considered with the above documentation. Requests for prior authorization of the purchase of a HFCWCS generator may be considered based on the outcome of a six-month rental period and the following required documentation. Documentation of vest tolerance and positive outcomes/results of therapy, including:
Physician’s description or assessment of the effectiveness such as decreased medication use, shorter hospital length of stay, decreased hospitalizations, and fewer school, work, or extracurricular activity absences due to diagnosis related complications.
The frequency and compliance graphs for the six-month period showing use of the system at least 50 percent of the maximum time prescribed by the physician for each day.
A statement that the client has not exacerbated any gastrointestinal manifestations, nor caused aspiration and exacerbation of pulmonary manifestations, nor an exacerbation of seizure activity secondary to the use of the system.
Cough-Stimulating Device (Cofflator)
The cofflator may be approved initially for a three-month rental period based on the following required documentation:
Diagnosis and background history including recent illnesses, complications, medications used, history of recent hospitalizations, results of pulmonary function studies if applicable, or history of school, work, or extracurricular activity absences due to diagnosis related complications.
Requests for prior authorization of an extension must include documentation by the physician familiar with the client that the client is compliant with the use of the equipment and that the treatment is effective.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2013 American Medical Association. All rights reserved.