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2012 Texas Medicaid Provider Procedures Manual

Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook

Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook
Table of Contents
1. General Information DM-9
2. Texas Medicaid (Title XIX) Home Health Services DM-9
2.1 Enrollment DM-9
2.1.1 Change of Address or Telephone Number DM-10
2.1.2 Pending Agency Certification DM-10
2.2 Services, Benefits, Limitations and Prior Authorization DM-10
2.2.1 Home Health Services DM-11
2.2.1.1 Client Eligibility DM-11
2.2.1.2 Prior Authorization Requests for Clients with Retroactive Eligibility DM-11
2.2.1.3 Prior Authorization DM-12
2.2.2 Durable Medical Equipment (DME) and Supplies DM-13
2.2.2.1 Modifications, Adjustments, and Repairs DM-15
2.2.2.1.1 Accessories DM-16
2.2.2.2 Prior Authorization DM-16
2.2.3 Medical Supplies DM-18
2.2.3.1 Supply Procedure Codes DM-19
2.2.3.2 Prior Authorization DM-19
2.2.3.3 Cancelling a Prior Authorization DM-20
2.2.4 Augmentative Communication Device (ACD) System DM-20
2.2.4.1 ACD System Accessories DM-22
2.2.4.1.1 Carrying Case DM-22
2.2.4.1.2 Nonwarranty Repairs DM-22
2.2.4.1.3 Trial Period DM-22
2.2.4.1.4 Rental DM-23
2.2.4.1.5 Purchase DM-23
2.2.4.1.6 Replacement DM-23
2.2.4.1.7 Software DM-23
2.2.4.2 Non-Covered ACD System Items DM-23
2.2.4.3 Prior Authorization DM-24
2.2.5 Bath and Bathroom Equipment DM-25
2.2.5.1 Hand-Held Shower Wand DM-25
2.2.5.2 Bath Equipment DM-26
2.2.5.2.1 Bath or Shower Chairs, Tub Stool or Bench, Tub Transfer Bench DM-26
2.2.5.3 Bathroom Equipment DM-27
2.2.5.3.1 Non-fixed Toilet Rail, Bathtub Rail Attachment, and Raised Toilet Seat DM-27
2.2.5.3.2 Toilet Seat Lifts DM-27
2.2.5.3.3 Commode Chairs and Foot Rests DM-28
2.2.5.3.4 Portable Sitz Bath DM-30
2.2.5.3.5 Bath Lifts DM-30
2.2.5.4 Prior Authorization DM-31
2.2.5.5 Documentation Requirements DM-32
2.2.5.5.1 Toilet Seat Lifts DM-32
2.2.6 Blood Pressure Devices DM-32
2.2.6.1 Prior Authorization DM-33
2.2.7 Breast Pumps DM-33
2.2.7.1 Prior Authorization DM-34
2.2.8 Cochlear Implants DM-34
2.2.9 Continuous Passive Motion (CPM) Device DM-34
2.2.9.1 Prior Authorization DM-34
2.2.10 Diabetic Equipment and Supplies DM-34
2.2.10.1 Obtaining Equipment and Supplies Through a Title XIX Form DM-35
2.2.10.2 Obtaining Equipment and Supplies Through a Verbal or Detailed
Written Order DM-35
2.2.10.3 Glucose Testing Equipment and Other Supplies DM-36
2.2.10.3.1 Prior Authorization DM-37
2.2.10.4 Blood Glucose Monitors DM-37
2.2.10.4.1 Prior Authorization DM-37
2.2.10.5 External Insulin Pump and Supplies DM-37
2.2.10.5.1 Prior Authorization DM-38
2.2.10.6 Insulin and Insulin Syringes DM-39
2.2.11 Hospital Beds and Equipment DM-40
2.2.11.1 Prior Authorization DM-40
2.2.11.2 Documentation Requirements DM-41
2.2.11.3 Mattresses and Support Surfaces DM-41
2.2.11.3.1 Documentation Requirements DM-42
2.2.11.3.2 Group 1 Support Surfaces DM-42
2.2.11.3.3 Group 2 Support Surfaces DM-43
2.2.11.3.4 Group 3 Support Surfaces DM-44
2.2.11.4 Equipment and Other Accessories DM-45
2.2.11.4.1 Prior Authorization DM-45
2.2.11.5 Decubitus Care Accessories DM-45
2.2.11.6 Replacement DM-46
2.2.11.6.1 Prior Authorization DM-46
2.2.11.7 Non-covered Items DM-46
2.2.11.8 Hospital Beds and Equipment Procedure Code Table DM-46
2.2.12 Incontinence Supplies DM-47
2.2.12.1 Skin Sealants, Protectants, Moisturizers, and Ointments for
Incontinence-Associated Dermatitis DM-47
2.2.12.2 Diapers, Briefs, Pull-ons, and Liners DM-48
2.2.12.3 Diaper Wipes DM-48
2.2.12.4 Underpads DM-48
2.2.12.5 Ostomy Supplies DM-49
2.2.12.6 Indwelling or Intermittent Urine Collection Devices DM-49
2.2.12.6.1 Indwelling Catheters and Related Insertion Supplies DM-49
2.2.12.6.2 Intermittent Catheters and Related Insertion Supplies DM-49
2.2.12.6.3 External Urinary Collection Devices DM-50
2.2.12.6.4 Urinals and Bed Pans DM-50
2.2.12.7 Prior Authorization DM-50
2.2.12.8 Documentation Requirements DM-50
2.2.12.9 Incontinence Procedure Codes with Limitations DM-50
2.2.13 Intravenous (IV) Therapy Equipment and Supplies DM-55
2.2.13.1 Prior Authorization DM-56
2.2.13.2 Documentation Requirements DM-57
2.2.14 Mobility Aids DM-58
2.2.14.1 Canes, Crutches, and Walkers DM-58
2.2.14.2 Wheelchairs DM-58
2.2.14.2.1 Prior Authorization DM-58
2.2.14.2.2 Documentation Requirements DM-58
2.2.14.3 Manual Wheelchairs-Standard, Standard Hemi, and Standard Reclining DM-59
2.2.14.3.1 Prior Authorization DM-59
2.2.14.4 Manual Wheelchairs-Lightweight and High-Strength Lightweight DM-60
2.2.14.4.1 Prior Authorization DM-60
2.2.14.5 Manual Wheelchairs-Heavy-Duty and Extra Heavy Duty DM-60
2.2.14.5.1 Prior Authorization DM-61
2.2.14.6 Wheeled Mobility Systems DM-61
2.2.14.6.1 Definitions and Responsibilities DM-61
2.2.14.6.2 Prior Authorization DM-62
2.2.14.6.3 Documentation Requirements DM-62
2.2.14.7 Manual Wheeled Mobility System - Tilt-in-Space DM-63
2.2.14.8 Manual Wheeled Mobility System- Pediatric Size DM-63
2.2.14.9 Manual Wheeled Mobility System -Custom (Includes Custom
Ultra-Lightweight) DM-63
2.2.14.9.1 Prior Authorization DM-64
2.2.14.10 Seating Assessment for Manual and Power Custom Wheelchairs DM-65
2.2.14.10.1 Prior Authorization DM-65
2.2.14.10.2 Documentation Requirements DM-66
2.2.14.11 Fitting of Custom Wheeled Mobility Systems DM-66
2.2.14.11.1 Prior Authorization DM-67
2.2.14.11.2 Documentation Requirements DM-68
2.2.14.12 Power Wheeled Mobility Systems- Group 1 through Group 5 DM-68
2.2.14.12.1 Prior Authorization DM-69
2.2.14.12.2 Group 1 PMDs DM-69
2.2.14.12.3 Group 2 PMDs DM-70
2.2.14.12.4 Group 3 PMDs DM-70
2.2.14.12.5 Group 4 PMDs DM-71
2.2.14.12.6 2.2.14.12.6 Additional Requirements - Group 2 through Group 4
No-Power Option DM-72
2.2.14.12.7 Group 2 through Group 4 Single-Power Option DM-72
2.2.14.12.8 Group 2 through Group 4 Multiple-Power Option DM-72
2.2.14.12.9 Group 5 PMDs DM-72
2.2.14.12.10 Group 5 Multiple-PMDs DM-74
2.2.14.13 Wheelchair Ramp-Portable and Threshold DM-74
2.2.14.14 Power Elevating Leg Lifts DM-74
2.2.14.14.1 Prior Authorization DM-74
2.2.14.14.2 Documentation Requirements DM-75
2.2.14.15 Power Seat Elevation System DM-75
2.2.14.15.1 Prior Authorization DM-75
2.2.14.15.2 Documentation Requirements DM-75
2.2.14.16 Seat Lift Mechanisms DM-76
2.2.14.16.1 Prior Authorization DM-76
2.2.14.16.2 Documentation Requirements DM-76
2.2.14.17 Batteries and Battery Charger DM-76
2.2.14.17.1 Prior Authorization DM-77
2.2.14.17.2 Documentation Requirements DM-77
2.2.14.18 Power Wheeled Mobility Systems- Scooter DM-77
2.2.14.18.1 Prior Authorization DM-77
2.2.14.18.2 Documentation Requirements DM-78
2.2.14.19 Client Lift DM-78
2.2.14.19.1 Prior Authorization DM-78
2.2.14.20 Electric Lift DM-78
2.2.14.21 Hydraulic Lift DM-78
2.2.14.21.1 Documentation Requirements DM-78
2.2.14.22 Standers DM-78
2.2.14.22.1 Prior Authorization DM-79
2.2.14.22.2 Documentation Requirements DM-79
2.2.14.23 Gait Trainers DM-79
2.2.14.23.1 Prior Authorization DM-79
2.2.14.24 Accessories, Modifications, Adjustments and Repairs DM-79
2.2.14.24.1 Prior Authorization DM-80
2.2.14.25 Replacement DM-81
2.2.14.26 Procedure Codes and Limitations for Mobility Aids DM-81
2.2.15 Nutritional (Enteral) Products, Supplies, and Equipment DM-89
2.2.15.1 Enteral Nutritional Products, Feeding Pumps, and Feeding Supplies DM-89
2.2.15.2 Prior Authorization Requirements DM-90
2.2.15.2.1 Enteral Formulas DM-91
2.2.15.2.2 Nasogastric, Gastrostomy, or Jejunostomy Feeding Tubes DM-91
2.2.15.2.3 Enteral Feeding Pumps DM-91
2.2.15.2.4 Enteral Supplies DM-92
2.2.15.3 Documentation Requirements DM-92
2.2.16 Osteogenic Stimulation DM-92
2.2.16.1 Ultrasound Osteogenic Stimulator DM-93
2.2.16.2 Professional Services DM-93
2.2.16.3 Prior Authorization DM-93
2.2.16.3.1 Noninvasive Electrical Osteogenic Stimulator DM-93
2.2.16.3.2 Invasive Electrical Osteogenic Stimulator DM-94
2.2.16.3.3 Ultrasound Osteogenic Stimulator DM-94
2.2.16.4 Documentation Requirements DM-94
2.2.17 Phototherapy Devices DM-95
2.2.18 Prothrombin Time/International Normalized Ratio (PT/INR) Home
Testing Monitor DM-95
2.2.18.1 Prior Authorization DM-95
2.2.19 Respiratory Equipment and Supplies DM-96
2.2.19.1 Prior Authorization DM-96
2.2.19.2 Nebulizers DM-96
2.2.19.2.1 Prior Authorization DM-97
2.2.19.3 Vaporizers DM-97
2.2.19.3.1 Prior Authorization DM-97
2.2.19.4 Humidification Units DM-97
2.2.19.5 Secretion Clearance Devices DM-98
2.2.19.5.1 Incentive Spirometer DM-98
2.2.19.5.2 Intermittent Positive-Pressure Breathing (IPPB) Devices DM-98
2.2.19.5.3 Mucous Clearance Valve DM-98
2.2.19.5.4 Prior Authorization DM-98
2.2.19.6 Electrical Percussor DM-99
2.2.19.6.1 Prior Authorization DM-99
2.2.19.7 Chest Physiotherapy Devices DM-99
2.2.19.7.1 HFCWCS DM-99
2.2.19.7.2 Cough-Stimulating Device (Cofflator) DM-99
2.2.19.7.3 Prior Authorization DM-100
2.2.19.7.4 Documentation Requirements DM-100
2.2.19.8 Positive Airway Pressure System Devices DM-101
2.2.19.8.1 Prior Authorization DM-101
2.2.19.9 Continuous Positive Airway Pressure (CPAP) System DM-101
2.2.19.9.1 Adult CPAP (19 years of age and older) DM-101
2.2.19.9.2 Pediatric CPAP Criteria DM-102
2.2.19.9.3 Prior Authorization DM-102
2.2.19.10 Bi-level Positive Airway Pressure System (BiPAP S) Without Backup DM-102
2.2.19.10.1 Prior Authorization DM-103
2.2.19.11 Bi-level Positive Airway Pressure System With Backup (BiPAP ST) DM-103
2.2.19.11.1 Prior Authorization DM-103
2.2.19.12 Home Mechanical Ventilation Equipment DM-103
2.2.19.12.1 Prior Authorization DM-104
2.2.19.13 Volume Ventilators DM-104
2.2.19.13.1 Ventilation Modes DM-104
2.2.19.13.2 Breath Types DM-104
2.2.19.13.3 Prior Authorization DM-104
2.2.19.14 Negative Pressure Ventilators DM-104
2.2.19.14.1 Prior Authorization DM-105
2.2.19.15 Ventilator Service Agreement DM-105
2.2.19.15.1 Prior Authorization DM-105
2.2.19.15.2 Documentation Requirements DM-105
2.2.19.16 Oxygen Therapy DM-105
2.2.19.17 Oxygen Therapy Home Delivery System DM-106
2.2.19.18 Prior Authorization DM-106
2.2.19.19 Documentation Requirements DM-107
2.2.19.19.1 Oxygen Therapy Recertification DM-107
2.2.19.20 Tracheostomy Tubes DM-108
2.2.19.20.1 Prior Authorization DM-108
2.2.19.21 Pulse Oximetry DM-108
2.2.19.21.1 Prior Authorization DM-108
2.2.19.22 Procedure Codes and Limitations for Respiratory Equipment
and Supplies DM-108
2.2.20 Special Needs Car Seats and Travel Restraints DM-111
2.2.21 Subcutaneous Injection Ports DM-111
2.2.21.1 Prior Authorization DM-111
2.2.21.2 Documentation Requirements DM-112
2.2.22 Total Parenteral Nutrition (TPN) Solutions DM-113
2.2.22.1 Prior Authorization DM-114
2.2.22.2 Documentation Requirements DM-114
2.2.23 Wound Care Supplies or Systems DM-114
2.2.23.1 Wound Care Supplies DM-116
2.2.23.2 Wound Care System DM-116
2.2.23.2.1 NPWT System DM-116
2.2.23.2.2 Pulsatile Jet Irrigation Wound Care System DM-117
2.2.23.3 Noncovered Services DM-117
2.2.23.4 Prior Authorization DM-117
2.2.23.4.1 Wound Care Supplies DM-117
2.2.23.4.2 Wound Care System DM-118
2.2.23.5 Documentation Requirements DM-119
2.2.23.5.1 Wound Care Supplies DM-119
2.2.23.5.2 Wound Care Systems DM-119
2.2.23.6 Wound Care Procedures and Limitations DM-120
2.2.24 Limitations, Exclusions DM-123
2.2.25 Procedure Codes That Do Not Require Prior Authorization DM-124
2.3 Other/Special Provisions DM-124
2.3.1 Medicaid Relationship to Medicare DM-124
2.3.1.1 Possible Medicare Clients DM-124
2.3.1.2 Benefits for Medicare/Medicaid Clients DM-125
2.3.1.3 Medicare and Medicaid Prior Authorization DM-125
2.4 Claims Filing and Reimbursement DM-126
2.4.1 Claims Information DM-126
2.4.1.1 Benefit Code DM-126
2.4.2 Reimbursement DM-126
2.4.3 Prohibition of Medicaid Payment to Home Health Agencies Based
on Ownership DM-127
3. Claims Resources DM-128
4. Contact TMHP DM-129
5. Forms DM-129
DM.1 DME Certification and Receipt Form (4 pages) DM-130
DM.2 External Insulin Pump DM-134
DM.3 Home Health Services (Title XIX) DME/Medical Supplies Physician Order
Form Instructions (2 pages) DM-135
DM.4 Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical
Supplies Physician Order Form DM-137
DM.5 Addendum to Home Health Services (Title XIX) DME/Medical Supplies Physician
Order Form DM-138
DM.6 Home Health Services Plan of Care (POC) Instructions DM-139
DM.7 Home Health Services Plan of Care (POC) DM-140
DM.8 Home Health Services Prior Authorization Checklist DM-141
DM.9 Medicaid Certificate of Medical Necessity for Chest Physiotherapy Device
Form—Initial Request DM-142
DM.10 Medicaid Certificate of Medical Necessity for Chest Physiotherapy Device
Form—Extended Request DM-143
DM.11 Medicaid Certificate of Medical Necessity for CPAP/BiPAP or Oxygen Therapy DM-144
DM.12 Pulse Oximeter Form DM-145
DM.13 Statement for Initial Wound Therapy System In-Home Use (2 pages) DM-146
DM.14 Statement for Recertification of Wound Therapy System In-Home Use (2 Pages) DM-148
DM.15 Ventilator Service Agreement DM-150
DM.16 Wheelchair/Scooter/Stroller Seating Assessment Form (CCP/Home Health
Services) (7 pages) DM-151
6. Claim Form Examples DM-158
DM.17 Home Health Services DME/Medical Supplies DM-159
Index DM-160

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