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2012 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2. Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.4 Durable Medical Equipment (DME) Supplier (CCP) : 2.4.13 Phototherapy Devices

The rental of phototherapy devices (procedure code E0202) for use in the home are a benefit of Texas Medicaid for low-risk infants.
Low-risk infants are 35 or more weeks gestation at birth, without comorbidity, and with a total serum bilirubin (TSB) level within the following ranges:
TSB for infant 0-24 hours of age*
TSB for infant 25-48 hours of age*
TSB for infant 49-72 hours of age*
TSB for infant older than 72 hours of age*
Consideration for the rental of a home phototherapy device includes, but is not limited to, the following primary diagnoses:
The DME provider must perform routine maintenance and provide instructions to the parent or guardian on the safe use of the phototherapy device. Rental of a phototherapy device is reimbursed as a daily global fee and is limited to one per day, per client, any provider.
Providers may not bill for those days the phototherapy device is at the client’s home and is not in use.
Skilled nursing visits for clients requiring phototherapy services may be reimbursed separately through Title XIX Home Health Services for nonroutine clinical teaching and assessment. Routine laboratory specimens are obtained during the skilled nursing visit, and may only be considered when the alternative to obtaining the specimen is to transport the client by ambulance.
If a client who is receiving private duty nursing (PDN) services requires phototherapy, instructions in the use of the equipment must be part of the existing PDN authorized hours. Skilled nursing visits will not be allowed on the same day as PDN services.
In accordance with American Academy of Pediatrics (AAP) guidelines, providers must conduct ongoing assessments for risk of severe hyperbilirubinemia for all infants who receive home phototherapy.
Initiation of home phototherapy for medium- and high-risk infants is not a benefit of Texas Medicaid. As defined by the AAP, medium- and high-risk infants should be considered for more extensive initial treatment in an inpatient setting. Medium- and high-risk infants include, but are not limited to, those who have one of the following known risk factors:

Texas Medicaid & Healthcare Partnership
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