TMPPM 2008 > Texas Medicaid Services > Texas Medicaid (Title XIX) Home Health Services > Benefits

24.5.22 Phototherapy Devices

Phototherapy devices for use in the home are a benefit of the Texas Medicaid Program for low-risk infants. Medium- to high-risk infants, as defined by the American Academy of Pediatrics (AAP), should be considered for other, more extensive treatment in an inpatient setting. Home phototherapy devices use light exposure with white, blue, or green lights to increase bilirubin excretion in the infant with elevated bilirubin levels. Home phototherapy services include parent/guardian education and obtaining laboratory specimens. Laboratories performing analysis of laboratory specimens may bill according to established procedures. Home phototherapy must be prior authorized under a provider identifier that is enrolled as a DME supplier. Home phototherapy devices require prior authorization and are provided only for the days that are medically necessary. Consideration for the rental of a home phototherapy device includes, but is not limited to, the following primary diagnoses:

Authorization requirements include following the current guidelines and standards set by the AAP:

Note: Bilirubin levels are expressed in mg/dl

•Lower risk infants are greater than or equal to 38 weeks gestation and well.

•Risk factors may include but are not limited to isoimmune hemolytic disease, G6PD deficiency, asphyxia, significant lethargy, temperature instability, sepsis, acidosis, or albumin <3.0 g/dl (if measured).

Documentation of medical necessity is required if the infant does not meet authorization requirements. Documentation of medical necessity includes:

•Serum bilirubin level (in mg/dl).

•Gestational age.

•Any known risk factors (for example: breast feeding, jaundice within the first 24 hours, blood group incompatibility).

•Physician's POC for intervention after seven days.

•Anticipated number of days the client will need the phototherapy light.

•Documentation of parental education regarding the importance of monitoring and follow-up.

Note: The total serum bilirubin levels listed are guides for authorization only.

Prior authorization may be given up to a maximum of seven days at a time with the documentation of medical necessity that is listed above. A new prior authorization is required for requests beyond seven days.

Home phototherapy devices will not be considered for prior authorization if the client has an open authorization for skilled nursing visits to address hyperbilirubenemia.

In accordance with AAP guidelines, the Texas Medicaid Program expects that there will be an ongoing assessment for risk of severe hyperbilirubenemia for all infants who receive home phototherapy.

Retroactive Eligibility

Newborn babies may not have a Medicaid number at the time that services are ordered by the physician and provided by the supplier. In these cases, authorization may be given retroactively for services rendered between the start date and the date that the client's Medicaid number becomes available.

•The provider is responsible for finding out the effective dates of client eligibility.

•The provider has 95 days from the date on which the client's Medicaid number becomes available (add date) to obtain authorization for services that were already rendered.

Routine maintenance of rental equipment is the provider's responsibility.

Rental of a phototherapy device is reimbursed as a daily global fee. The global fee includes skilled nursing visits (SNV) for client teaching, monitoring, and customary and routine laboratory work.

The SNV will be denied as part of the phototherapy device rental.

Note: Providers may not bill for those days the phototherapy device is at the client's home and is not in use.

Use procedure code L-E0202 for home phototherapy devices.

Note: Services provided after the client's Medicaid number is available must be prior authorized within three business days.

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.

Refer to: Section 24.3.1, "Eligibility."