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December 2016 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 8
1.1 Payment Window Reimbursement Guidelines for Services Preceding an Inpatient Admission 8
2 Texas Medicaid (Title XIX) Home Health Services 9
2.1 Enrollment 9
2.1.1 Pending Agency Certification 9
2.1.2 Surety Bond Requirements 10
2.1.2.1 Proof of Continuation 10
2.2 Services, Benefits, Limitations and Prior Authorization 11
2.2.1 Home Health Services 11
2.2.1.1 Client Eligibility 12
2.2.1.2 Prior Authorization Requests for Clients with Retroactive Eligibility 12
2.2.1.3 Prior Authorization 12
2.2.2 Durable Medical Equipment (DME) and Supplies 13
2.2.2.1 Modifications, Adjustments, and Repairs 16
2.2.2.1.1 Accessories 17
2.2.2.2 Prior Authorization 17
2.2.3 Medical Supplies 18
2.2.3.1 Supply Procedure Codes 20
2.2.3.2 Prior Authorization 20
2.2.3.3 Cancelling a Prior Authorization 20
2.2.4 Augmentative Communication Device (ACD) System 21
2.2.4.1 ACD System Accessories 22
2.2.4.1.1 Carrying Case 23
2.2.4.1.2 Nonwarranty Repairs 23
2.2.4.1.3 Trial Period 23
2.2.4.1.4 Rental 23
2.2.4.1.5 Purchase 23
2.2.4.1.6 Replacement 23
2.2.4.1.7 Software 24
2.2.4.2 Non-Covered ACD System Items 24
2.2.4.3 Prior Authorization 24
2.2.5 Bath and Bathroom Equipment 26
2.2.5.1 Hand-Held Shower Wand 26
2.2.5.2 Bath Equipment 26
2.2.5.2.1 Bath or Shower Chairs, Tub Stool or Bench, Tub Transfer Bench 26
2.2.5.3 Bathroom Equipment 27
2.2.5.3.1 Non-fixed Toilet Rail, Bathtub Rail Attachment, and Raised Toilet Seat 27
2.2.5.3.2 Toilet Seat Lifts 28
2.2.5.3.3 Commode Chairs and Foot Rests 28
2.2.5.3.4 Portable Sitz Bath 30
2.2.5.3.5 Bath Lifts 30
2.2.5.4 Prior Authorization 32
2.2.5.5 Documentation Requirements 32
2.2.5.5.1 Bath and Bathroom Equipment 32
2.2.5.5.2 Toilet Seat Lifts 32
2.2.6 Blood Pressure Devices 33
2.2.6.1 Prior Authorization 33
2.2.7 Bone Growth Stimulators 34
2.2.7.1 Professional Services 35
2.2.7.2 Prior Authorization Criteria and Documentation Requirements for Bone Growth Stimulators 35
2.2.7.2.1 Documentation for Noninvasive Electrical Bone Growth Stimulator 35
2.2.7.2.2 Documentation for Invasive Electrical Bone Growth Stimulators 36
2.2.7.2.3 Documentation for Ultrasound Bone Growth Stimulator 36
2.2.7.3 Claims Reimbursement for Professional Services 36
2.2.8 Breast Pumps 36
2.2.8.1 Prior Authorization 37
2.2.9 Cochlear Implants 37
2.2.10 Continuous Passive Motion (CPM) Device 37
2.2.10.1 Prior Authorization 37
2.2.11 Diabetic Equipment and Supplies 37
2.2.11.1 Obtaining Equipment and Supplies Through a Title XIX Form 38
2.2.11.2 Obtaining Equipment and Supplies Through a Verbal or Detailed Written Order 38
2.2.11.3 Glucose Testing Equipment and Other Supplies 39
2.2.11.3.1 Prior Authorization 41
2.2.11.4 Blood Glucose Monitors 42
2.2.11.4.1 Prior Authorization 42
2.2.11.5 External Insulin Pump and Supplies 42
2.2.11.5.1 Prior Authorization 43
2.2.11.6 Insulin and Insulin Syringes 44
2.2.12 Hospital Beds and Equipment 44
2.2.12.1 Hospital Beds 45
2.2.12.2 Prior Authorization 45
2.2.12.3 Documentation Requirements 46
2.2.12.4 Mattresses and Support Surfaces 47
2.2.12.4.1 Documentation Requirements 47
2.2.12.4.2 Group 1 Support Surfaces 48
2.2.12.4.3 Group 2 Support Surfaces 49
2.2.12.4.4 Group 3 Support Surfaces 50
2.2.12.5 Equipment and Other Accessories 51
2.2.12.5.1 Accessories 51
2.2.12.5.2 Prior Authorization 51
2.2.12.6 Decubitus Care Accessories 51
2.2.12.7 Replacement 51
2.2.12.7.1 Prior Authorization 52
2.2.12.8 Non-covered Items 52
2.2.12.9 Hospital Beds and Equipment Procedure Code Table 52
2.2.13 Incontinence Supplies 53
2.2.13.1 Skin Sealants, Protectants, Moisturizers, and Ointments for Incontinence-Associated Dermatitis 53
2.2.13.2 Diapers, Briefs, Pull-ons, and Liners 54
2.2.13.3 Diaper Wipes 54
2.2.13.4 Underpads 55
2.2.13.5 Ostomy Supplies 55
2.2.13.6 Indwelling or Intermittent Urine Collection Devices 55
2.2.13.6.1 Indwelling Catheters and Related Insertion Supplies 55
2.2.13.6.2 Intermittent Catheters and Related Insertion Supplies 55
2.2.13.6.3 External Urinary Collection Devices 56
2.2.13.6.4 Urinals and Bed Pans 56
2.2.13.7 Prior Authorization 56
2.2.13.8 Documentation Requirements 56
2.2.13.9 Incontinence Procedure Codes with Limitations 57
2.2.14 Intravenous (IV) Therapy Equipment and Supplies 61
2.2.14.1 Prior Authorization 62
2.2.14.2 Documentation Requirements 63
2.2.15 Mobility Aids 64
2.2.15.1 Canes, Crutches, and Walkers 64
2.2.15.2 Wheelchairs 64
2.2.15.2.1 Prior Authorization 65
2.2.15.2.2 Documentation Requirements 65
2.2.15.3 Manual Wheelchairs-Standard, Standard Hemi, and Standard Reclining 65
2.2.15.3.1 Prior Authorization 65
2.2.15.4 Manual Wheelchairs-Lightweight and High-Strength Lightweight 66
2.2.15.4.1 Prior Authorization 66
2.2.15.5 Manual Wheelchairs-Heavy-Duty and Extra Heavy Duty 67
2.2.15.5.1 Prior Authorization 67
2.2.15.6 Wheeled Mobility Systems 67
2.2.15.6.1 Definitions and Responsibilities 68
2.2.15.6.2 Prior Authorization 70
2.2.15.6.3 Documentation Requirements 70
2.2.15.7 Manual Wheeled Mobility System - Tilt-in-Space 70
2.2.15.7.1 Prior Authorization 71
2.2.15.8 Manual Wheeled Mobility System- Pediatric Size 71
2.2.15.9 Manual Wheeled Mobility System -Custom (Includes Custom Ultra-Lightweight) 71
2.2.15.9.1 Prior Authorization 72
2.2.15.10 Seating Assessment for Manual and Power Custom Wheelchairs 72
2.2.15.10.1 Prior Authorization 73
2.2.15.10.2 Documentation Requirements 74
2.2.15.11 Fitting of Custom Wheeled Mobility Systems 74
2.2.15.11.1 Prior Authorization 75
2.2.15.11.2 Documentation Requirements 75
2.2.15.12 Power Wheeled Mobility Systems- Group 1 through Group 5 76
2.2.15.12.1 Prior Authorization 77
2.2.15.12.2 Group 1 PMDs 77
2.2.15.12.3 Group 2 PMDs 77
2.2.15.12.4 Group 3 PMDs 78
2.2.15.12.5 Group 4 PMDs 79
2.2.15.12.6 Additional Requirements - Group 2 through Group 4 No-Power Option 80
2.2.15.12.7 Group 2 through Group 4 Single-Power Option 80
2.2.15.12.8 Group 2 through Group 4 Multiple-Power Option 80
2.2.15.12.9 Group 5 PMDs 80
2.2.15.12.10 Group 5 Single-PMDs 81
2.2.15.12.11 Group 5 Multiple-PMDs 81
2.2.15.13 Wheelchair Ramp-Portable and Threshold 82
2.2.15.14 Power Elevating Leg Lifts 82
2.2.15.14.1 Prior Authorization 82
2.2.15.14.2 Documentation Requirements 82
2.2.15.15 Power Seat Elevation System 83
2.2.15.15.1 Prior Authorization 83
2.2.15.15.2 Documentation Requirements 83
2.2.15.16 Seat Lift Mechanisms 83
2.2.15.16.1 Prior Authorization 83
2.2.15.16.2 Documentation Requirements 84
2.2.15.17 Batteries and Battery Charger 84
2.2.15.17.1 Prior Authorization 84
2.2.15.17.2 Documentation Requirements 84
2.2.15.18 Power Wheeled Mobility Systems- Scooter 85
2.2.15.18.1 Prior Authorization 85
2.2.15.18.2 Documentation Requirements 85
2.2.15.19 Client Lift 85
2.2.15.19.1 Prior Authorization 86
2.2.15.20 Electric Lift 86
2.2.15.21 Hydraulic Lift 86
2.2.15.21.1 Documentation Requirements 86
2.2.15.22 Standers 86
2.2.15.22.1 Prior Authorization 86
2.2.15.22.2 Documentation Requirements 86
2.2.15.23 Gait Trainers 87
2.2.15.23.1 Prior Authorization 87
2.2.15.24 Accessories, Modifications, Adjustments and Repairs 87
2.2.15.24.1 Prior Authorization 87
2.2.15.25 Replacement 88
2.2.15.26 Procedure Codes and Limitations for Mobility Aids 89
2.2.16 Nutritional (Enteral) Products, Supplies, and Equipment 97
2.2.16.1 Enteral Nutritional Products, Feeding Pumps, and Feeding Supplies 97
2.2.16.2 Prior Authorization Requirements 98
2.2.16.2.1 Enteral Formulas 99
2.2.16.2.2 Nasogastric, Gastrostomy, or Jejunostomy Feeding Tubes 99
2.2.16.2.3 Enteral Feeding Pumps 99
2.2.16.2.4 Enteral Supplies 100
2.2.16.3 Documentation Requirements 100
2.2.17 Phototherapy Devices 100
2.2.18 Prothrombin Time/International Normalized Ratio (PT/INR) Home Testing Monitor 101
2.2.18.1 Prior Authorization 101
2.2.19 Respiratory Equipment and Supplies 102
2.2.19.1 Prior Authorization 102
2.2.19.2 Nebulizers 103
2.2.19.2.1 Prior Authorization 103
2.2.19.3 Vaporizers 104
2.2.19.3.1 Prior Authorization 104
2.2.19.4 Humidification Units 104
2.2.19.5 Secretion Clearance Devices 104
2.2.19.5.1 Intermittent Positive-Pressure Breathing (IPPB) Devices 104
2.2.19.5.2 Mucous Clearance Valve 105
2.2.19.6 Electrical Percussor 106
2.2.19.7 Chest Physiotherapy Devices 106
2.2.19.7.1 HFCWCS 106
2.2.19.8 Cough-Stimulating Device (Cofflator) 107
2.2.19.8.1 Tracheostomy Tubes 108
2.2.19.9 Positive Airway Pressure System Devices 108
2.2.19.9.1 Heated and Non-heated Humidification For Use With Positive Airway Pressure System 108
2.2.19.9.2 Continuous Positive Airway Pressure (CPAP) System 108
2.2.19.9.3 Prior Authorization 109
2.2.19.9.4 Bi-level Positive Airway Pressure System (BiPAP S) Without Backup 109
2.2.19.9.5 Bi-level Positive Airway Pressure System With Backup (BiPAP ST) 110
2.2.19.9.6 Prior Authorization 110
2.2.19.10 Home Mechanical Ventilation Equipment 111
2.2.19.10.1 Negative Pressure Ventilators 112
2.2.19.10.2 Ventilator Service Agreement 112
2.2.19.11 Oxygen Therapy 113
2.2.19.11.1 Oxygen Therapy Home Delivery System 113
2.2.19.11.2 Prior Authorization 114
2.2.19.11.3 Initial Oxygen Therapy Medical Necessity Certification 114
2.2.19.11.4 Oxygen Therapy Recertification 115
2.2.19.12 Pulse Oximetry 115
2.2.19.12.1 Prior Authorization 115
2.2.19.13 Procedure Codes and Limitations for Respiratory Equipment and Supplies 115
2.2.20 Special Needs Car Seats and Travel Restraints 118
2.2.21 Subcutaneous Injection Ports 118
2.2.21.1 Prior Authorization 118
2.2.21.2 Documentation Requirements 119
2.2.22 Total Parenteral Nutrition (TPN) Solutions 120
2.2.22.1 Prior Authorization 121
2.2.22.2 Documentation Requirements 121
2.2.23 Wound Care Supplies or Systems 121
2.2.23.1 Wound Care Supplies 123
2.2.23.2 Wound Care System 123
2.2.23.2.1 NPWT System 123
2.2.23.2.2 Pulsatile Jet Irrigation Wound Care System 124
2.2.23.3 Noncovered Services 124
2.2.23.4 Prior Authorization 124
2.2.23.4.1 Wound Care Supplies 124
2.2.23.4.2 Wound Care System 125
2.2.23.5 Documentation Requirements 126
2.2.23.5.1 Wound Care Supplies 126
2.2.23.5.2 Wound Care Systems 126
2.2.23.6 Wound Care Procedures and Limitations 127
2.2.24 Limitations and Exclusions 130
2.2.25 Procedure Codes That Do Not Require Prior Authorization 131
2.3 Other or Special Provisions 131
2.3.1 Medicaid Relationship to Medicare 131
2.3.1.1 Possible Medicare Clients 131
2.3.1.2 Benefits for Medicare and Medicaid Clients 132
2.3.1.3 Medicare and Medicaid Prior Authorization 132
2.4 Claims Filing and Reimbursement 133
2.4.1 Claims Information 133
2.4.2 Reimbursement 134
2.4.3 Home Health Agency Reimbursement for DME Services 134
2.4.4 Prohibition of Medicaid Payment to Home Health Agencies Based on Ownership 134
3 Claims Resources 135
4 Contact TMHP 135
5 Forms 136
6 Claim Form Examples 136
 

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