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December 2016 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2 Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.6 Durable Medical Equipment (DME) Supplier (CCP) : 2.6.10 Mobility Aids

2.6.10
2.6.10.1
Mobility aids and related supplies, including, but not limited to, strollers, special-needs car seats, and travel safety restraints are a benefit to assist clients to move about in their environment when medically necessary and Federal Financial Participation is available.
Mobility aids and related supplies may be considered for reimbursement through CCP for clients who are birth through 20 years of age who are CCP-eligible when documentation submitted clearly shows that the equipment is medically necessary and will correct or ameliorate the client’s disability or physical or mental illness or condition. Documentation must include the following:
Mobility aids may be considered through CCP if the requested equipment is not available through Texas Medicaid (Title XIX) Home Health Services or the client does not meet criteria through Texas Medicaid (Title XIX) Home Health Services.
Mobility aid lifts for vehicles and vehicle modifications are not reimbursed through Texas Medicaid in accordance with federal regulations.
Note:
2.6.10.1.1
Providers must use procedure code E0635 with modifier TG for the purchase of the portable client lift and is limited to once per lifetime, any provider. Portable electric lifts are a benefit of Texas Medicaid if they can fold-up for transport and can be used outside the home setting if the client must attend health-related services that require an overnight stay in a noninstitutional setting.
2.6.10.1.2
A wheeled mobility system is a manual or power wheelchair, or scooter that is a customized power or manual mobility device, or a feature or component of the mobility device, including, but not limited to, the following:
A stroller (a multipositional client transfer system with integrated seat, operated by caregiver) for medical needs may be considered for clients who are CCP-eligible when documentation submitted clearly shows that the equipment is medically necessary and will correct or ameliorate the client’s disability or physical or mental illness or condition. Documentation must include the following:
If the client does not meet criteria for a stroller, a wheelchair may be considered through Texas Medicaid (Title XIX) Home Health Services.
Scooters may be considered for reimbursement through Texas Medicaid (Title XIX) Home Health Services.
Definitions and Responsibilities
The following definitions and responsibilities apply to the provision of wheeled mobility systems:
Adjustments. The adjustment of a component or feature of a wheeled mobility system. Adjustments require labor only and do not include the addition, modification, or replacement of components or supplies needed to complete the adjustment.
Texas Medicaid will consider adjustments only to client-owned equipment that is considered a benefit of Texas Medicaid.
Major Modification. The addition of a custom or specialized feature or component of a wheeled mobility system that did not previously exist on the system due to changes in the client’s needs, including but not limited to, the items listed in this paragraph. This definition also includes the modification of a custom or specialized feature or component due to a change in the client’s needs, including but not limited to, the following:
The replacement of a previously existing custom or specialized feature or component with an identical or comparable component is considered a repair and not a major modification.
Texas Medicaid will consider major modifications only to client-owned equipment that is considered a benefit of Texas Medicaid.
Minor Modification. The addition or modification of non-custom or non-specialized features or components due to changes in the client’s needs, including but not limited to, the following:
The replacement of a previously existing noncustom or nonspecialized feature or component with an identical or comparable component is considered a repair and not a minor modification.
Texas Medicaid will consider minor modifications only to client-owned equipment that is considered a benefit of Texas Medicaid.
Mobility Related Activity to Daily Living (MRADL). An activity of daily living that requires the use of mobility aids (i.e., toileting, feeding, dressing, grooming, and bathing).
Occupational Therapist. A person who is currently licensed by the Executive Council of Physical Therapy & Occupational Therapy Examiners to practice OT.
Physical Therapist. A person who is currently licensed by the Executive Council of Physical Therapy & Occupational Therapy Examiners to practice PT.
Note:
An occupational or physical therapist is responsible for completing the required seating assessment for a client to obtain a wheeled mobility system.
Qualified Rehabilitation Professional (QRP). A QRP is a person who meets one or more of the following criteria:
Holds a certification as an Assistive Technology Professional (ATP) or a Rehabilitation Engineering Technologist (RET) issued by, and in good standing with, the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA).
Holds a certification as a Certified Rehabilitation Technology Supplier (CRTS) issued by, and in good standing with, the National Registry of Rehabilitation Technology Suppliers (NRRTS).
Being present at the time of delivery of the wheeled mobility system to direct the fitting of the system to ensure that the system functions correctly relative to the client.
Repairs. The replacement of a component or feature of a wheeled mobility system with an identical or comparable component that does not change the size or function of the system due to the component no longer functioning as designed.
Texas Medicaid will consider repairs only to client-owned equipment that is considered a benefit of Texas Medicaid.
2.6.10.1.3
A seating assessment is required for the rental or purchase of any device meeting the definition of a wheeled mobility system or purchase of any device meeting the definition of a wheelchair for a client with a congenital or neurological condition, myopathy, or skeletal deformity that requires the use of a wheelchair as defined under subsection 2.6.10.1.2, “Wheeled Mobility Systems” in this handbook.
A seating assessment with measurements, including specifications for exact mobility and seating equipment and all necessary accessories, must be completed by a physician, licensed occupational therapist, or licensed physical therapist.
A QRP directly employed or contracted by the DME provider must be present at, and participate in all seating assessments, including those provided by a physician.
Upon completion of the seating assessment, the QRP must attest to his or her participation in the assessment by signing the Wheelchair/Scooter/Stroller Seating Assessment Form. This form must be submitted with all requests for wheeled mobility systems.
When the practitioner completing the seating assessment is an occupational therapist or physical therapist, the occupational therapist or physical therapist may perform the seating assessment as the therapist, or as the QRP, but may not perform in both roles at the same time. If the occupational therapist or physical therapist is attending the seating assessment as the QRP, the occupational therapist or physical therapist must meet the credentialing requirements and be enrolled in Texas Medicaid as a QRP.
If the seating assessment is completed by a physician, reimbursement is considered part of the physicians office visit and will not be reimbursed separately.
The practitioner (occupational therapist or physical therapist) completing the assessment must submit procedure code 97001 or 97003 with modifier U1, to bill for the seating assessment.
Services for the QRP’s participation in the seating assessment must be submitted for reimbursement by the DME provider billing for the wheeled mobility system using procedure code 97542 with modifier U1. The DME provider must include the QRP specialty as the performing provider on the claim for all components of the wheeled mobility system, including the QRP’s participation in the seating assessment.
Note:
2.6.10.1.4
The fitting of a wheeled mobility system is defined as the time the QRP spends with the client fitting the various systems and components of the system to the client. It may also include time spent training the client or caregiver in the use of the wheeled mobility system. Time spent setting up the system, or travel time without the client present, is not included.
A fitting is required for any device meeting the definition of a wheeled mobility system as defined under subsection 2.6.10.1.2, “Wheeled Mobility Systems” in this handbook.
The fitting of a wheeled mobility system must be:
The QRP performing the fitting will:
Verify that the client, parent, guardian of the client, and/or caregiver of the client has received training and instruction regarding the wheeled mobility system’s proper use and maintenance.
The QRP must complete and sign the DME Certification and Receipt form after the wheeled mobility system has been delivered and fitted to the client. Completion of this form by the QRP signifies that all components of the fitting as outlined above have been satisfied. The form must be completed prior to submission of a claim for a wheeled mobility system, and submitted to HHSC’s designee according to instructions on the form to allow for proper claims processing.
Services for fitting of a wheeled mobility system by the QRP must be submitted for reimbursement by the DME provider of the wheeled mobility system using procedure code 97542 with modifier U2. The DME provider must list the QRP who participated in the seating assessment as the performing provider on the claim for all components of the wheeled mobility system, including the fitting performed by the QRP.
Procedure code 97542 with modifier U2 must be billed on the same claim as the procedure code(s) for the wheeled mobility system in order for both services to be reimbursed.
2.6.10.1.5
Major and minor modifications, adjustments, and repairs to standard mobility aid equipment within the first six months after delivery are considered part of the purchase price.
Modifications, adjustments, and repairs, as well as the associated services by the QRP for the seating assessment and fitting, within the first six months after delivery are considered part of the purchase price.
Major modifications to a wheeled mobility system requires the completion of a new seating assessment by a qualified practitioner (physician, physical therapist, or occupational therapist), with the participation of a QRP.
Minor modifications, adjustments, or repair to a wheeled mobility system does not require the completion of a new seating assessment.
A wheeled mobility system that has been fitted and delivered to the client’s home by a QRP and then found to be inappropriate for the client’s condition will not be eligible for an upgrade, replacement, or major modification within the first six months following purchase unless there has been a significant change in the client’s condition. The significant change in the client’s condition must be documented by a physician familiar with the client.
Claims submitted for equipment provided as a minor modification or repair to a wheeled mobility system must be submitted with modifier RB.
2.6.10.1.6
A portable ramp is defined as a ramp that is able to be carried as needed to access a home and weighing no more than 90 pounds and measuring no more than 10 feet in length. A threshold ramp is defined as a ramp that provides access over elevated thresholds.
Portable ramps exceeding the above criteria may be considered on a case-by-case basis with documentation of medical necessity and a statement that the requested equipment is safe for use.
Ramps may be considered for rental for short-term disabilities. Ramps may be considered for purchase for long-term disabilities.
Providers must use procedure code E1399 for the purchase of portable and threshold stroller ramps.
2.6.10.1.7
Feeder seats, floor sitters, corner chairs, and travel chairs are not considered medically necessary and are not a benefit of CCP. If a client requires seating support and meets the criteria for a seating system, a stroller may be considered for reimbursement with prior authorization through CCP, or a wheelchair may be considered through Texas Medicaid (Title XIX) Home Health Services.
2.6.10.1.8
A special-needs car seat may be considered for a client who has outgrown an infant car seat and is unable to travel safely in a booster seat or seat belt.
A special-needs car seat for a client who does not meet the criteria may be considered on a case-by-case basis with documentation of medical necessity upon review by the state or its designee.
Providers must use procedure code E1399 for the purchase of a special-need car seat.
2.6.10.1.9
A travel safety restraint and ankle or wrist belts may be considered for clients with a medical condition requiring transportation in either a prone or supine position. The DME provider and the prescribing physician familiar with the client must maintain documentation in the client’s medical record supporting the medical necessity of the travel safety restraint.
Providers must use procedure code E0700 for the purchase of travel safety restraints, including ankle and wrist belts.

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