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2012 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 : 2.2.23 Wound Care Supplies or Systems : 2.2.23.5 Documentation Requirements

2.2.23.5
2.2.23.5.1 Wound Care Supplies
To request prior authorization for wound care supplies, the following documentation must be provided with the completed Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form:
Accurate diagnostic information pertaining to the underlying diagnosis/condition as well as any other medical diagnoses/conditions, to include the client's overall health status
2.2.23.5.2 Wound Care Systems
To request prior authorization for a wound care system, the documentation listed below must be provided on the Statement for Initial Wound Therapy System In-Home Use Form for an initial request or on the Statement for Recertification of Wound Therapy System In-Home Use Form for a recertification request, in addition to the Title XIX form.
The prescribing physician and provider must submit the appropriate initial or recertification form, which must also be maintained in the client's medical record.
The following documentation must be submitted with the prior authorization request, and must be maintained in the client's medical record:
Accurate diagnostic information pertaining to the underlying diagnosis/condition and all other medical diagnoses/conditions, including the client's overall health status.
Albumin level within the last 30 days (If the albumin level is below 3.0, documentation must show that a nutritional supplement has been prescribed, and that the client is compliant with its use.)
Identification of the caregiver who agrees to be available to assist the client during this time and agreement of this person not to operate the negative pressure or the pulsatile jet irrigation system if used.
Documentation that a licensed health-care provider who has received the appropriate training in the use of the wound care system is performing the wound care when a negative pressure or pulsatile jet irrigation wound care system is used. All requirements for skilled nursing care must be met.

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