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December 2016 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 : 2.2.5 Bath and Bathroom Equipment : 2.2.5.3 Bathroom Equipment

2.2.5.3
2.2.5.3.1
Nonfixed toilet rails are limited to two every five years. A bathtub rail is limited to one every five years.
Raised toilet seats are limited to one every five years. Nonfixed toilet rails and bathtub rail attachments may be considered for prior authorization for a client who has decreased functional mobility and is unable to safely self-toilet or self-bathe without assistive equipment. Raised toilet seats do not require prior authorization. Providers must use procedure code E0243 when billing for non-fixed toilet rails, procedure code E0244 when billing for raised toilet seats, and procedure code E0246 when billing for bathtub rails.
2.2.5.3.2
A toilet seat lift mechanism is designed for the top of the toilet to assist lifting the body from a sitting position to a standing position.
A toilet seat lift mechanism must be prior authorized. To qualify for prior authorization, clients must meet all the following criteria:
The client’s difficulty or incapability of getting up from a chair is not sufficient justification for a toilet seat lift mechanism. Almost all clients who are capable of ambulating can get out of an ordinary chair if the seat height is appropriate and the chair has arms.
Prior authorization will be given for either mechanical or powered toilet assist devices, not for both. If a client already owns one or more mechanical toilet-assist devices, a powered toilet seat lift mechanism will not be prior authorized unless there has been a documented change in the client’s condition such that the client can no longer use the mechanical equipment.
Toilet seat lift mechanisms are limited to those types that operate smoothly, can be controlled by the client, and effectively assist a client in standing up and sitting down without other assistance. A toilet seat lift operated by a spring release mechanism with a sudden, catapult-like motion that jolts the client from a seated to a standing position is not a benefit of Texas Medicaid.
Providers must use procedure code E0172 when billing for a toilet seat lift mechanism. A toilet seat lift mechanism is limited to one purchase very five years.
2.2.5.3.3
Commode chairs, foot rests, and replacement commode pails or pans may be considered as benefits, depending on the client’s level of need. The client must meet the criteria for the level of commode chair or foot rest requested.
A commode chair with or without a foot rest may be considered a benefit for the client who also has a stationary bath chair without a commode cutout.
Documentation must support medical necessity for a customized commode chair or the addition of attachments to a standard commode chair.
Level 1: Stationary Commode Chair
A Level 1 commode chair is defined as a stationary commode chair with fixed or removable attachments to support the arms.
A stationary commode chair with fixed or removable arms may be considered for prior authorization when the client has a medical condition that results in an inability to ambulate to the bathroom safely (with or without mobility aids).
Providers must use procedure code E0163 or E0165 when billing for a stationary and mobile commode chair.
Level 2: Mobile Commode Chair
A Level 2 commode chair is defined as a mobile commode chair with fixed or removable attachments to support the arms.
A mobile commode chair with fixed or removable arms may be considered for prior authorization when the following criteria are met:
In addition to meeting the criteria for a Level 1 commode chair, the client must be on a bowel program and require a combination commode or bath chair for performing the bowel program and bathing after.
A mobile commode chair will be considered for reimbursement with prior authorization only if the client does not also have any type of bath chair. If the client meets the criteria for a stationary bath chair, prior authorization of a stationary chair may be considered.
Level 3: Custom Commode Chair
A Level 3 commode chair is defined as a custom commode chair with all of the following characteristics:
A custom stationary or mobile commode chair with fixed or removable arms and head, neck, and/or trunk support attachments may be considered for prior authorization when the following criteria are met:
In addition to meeting the criteria for a Level 1 or 2 commode chair, the client must have a medical condition that results in an inability to support their head, neck, or trunk without assistance.
Providers must use procedure code E0163 or E0165 with modifier TG when billing for a custom stationary or mobile commode chair.
Extra-wide and Heavy-Duty Commode Chair
An extra-wide, heavy-duty commode chair is defined as one with a width greater than or equal to 23 inches, and capable of supporting a client who weighs 300 pounds or more.
An extra-wide or heavy-duty commode chair may be considered for prior authorization when the client meets the criteria for a Level 1, 2, or 3 commode chair and weigh 300 pounds or more.
Providers must use procedure code E0168 and the appropriate modifiers when billing for an extra-wide or heavy-duty commode chair. Use modifier TF when billing for a mobile extra-wide, heavy-duty commode chair. Use modifier TG when billing for a custom extra-wide, heavy-duty commode chair.
Commode Chair With Integrated Seat Lift
A commode chair with integrated seat lift is designed to assist lifting the body from a sitting position to a standing position.
A commode chair with integrated seat lift mechanism for top of the commode must be prior authorized for clients who meet all the following criteria:
The commode chair with integrated seat lift must be a part of the physician’s course of treatment and be prescribed to correct or ameliorate the client’s condition.
Note:
The fact that a client has difficulty or is even incapable of getting up from a chair, particularly a low chair, is not sufficient justification for a seat lift mechanism. Almost all clients who are capable of ambulating can get out of an ordinary chair if the seat height is appropriate and the chair has arms.
Providers must use procedure code E0170 or E0171 when billing for a commode chair with integrated seat lift. The purchase of a commode chair with integrated seat lift is limited to one every five years.
Replacement Commode Pail or Pan
Replacement commode pails or pans are a benefit through Title XIX Home Health Services and are limited to one per year. Additional quantities may be considered for prior authorization with documentation of medical necessity.
Providers must use procedure code E0167 when billing for a commode pail or pan.
Foot Rest
A foot rest is used to support feet during use of the commode chair.
A foot rest may be considered for prior authorization if the client meets the criteria for a Level 1, 2, or 3 commode chair and the foot rest is necessary to support contractures of the lower extremities of clients who are paraplegic or quadriplegic.
Providers must use procedure code E0175 when billing for a foot rest.
2.2.5.3.4
Portable sitz baths that fit over commode seats are limited to two per year for clients requiring any of the following:
Providers must use procedure codes E0160 or E0161 when billing for portable sitz baths.
2.2.5.3.5
The purchase of a bath lift is limited to one every five years. The rental of a bath lift is limited to one per month.
The two types of bath lifts that are considered for reimbursement include:
An outside the tub bath lift which is a portable transfer system used to move a nonambulatory client a short distance from bed or chair to bath and is designed to accommodate the smaller space. This type of lift is either hydraulic or electric and consists of a base with wheels or casters and a sling which can transfer the client in and out of the bath.
An inside the tub bath lift is a portable transfer system used to lower and raise a nonambulatory client into and out of the bath tub. This type of lift is either hydraulic or electric and consists of a base which adheres to the tub surface using suction cups and a seat that will lower and raise the client into and out of the tub.
Providers must use procedure code E0625 with the appropriate modifier (U1, U2, or U3) if necessary when billing for a bath lift.
The bath lift must be free standing, it cannot be attached to the floor, walls, or ceiling. Home adaptation for use of medical equipment is not a benefit of Home Health Services.
A hydraulic bath lift is for a client who is unable to assist in their own transfers and is operated by the weight or pressure of a liquid.
An electric bath lift is operated by electricity and may be considered when a hydraulic lift will not meet the client’s needs.
A bath lift is not a benefit for the convenience of a caregiver.
There are four levels of bath lifts:
Level 1 - an outside the tub bath lift (hydraulic or electric) and must accommodate a client weighing up to 300 pounds. Providers must use procedure code E0625 when billing for the purchase of a Level 1 bath lift.
Level 2 - an in-tub bath lift (hydraulic or electric) and must accommodate a client weighing up to 300 pounds. Providers must use procedure code E0625 and the U1 modifier when billing for the purchase of a Level 2 bath lift.
Level 3 - a bariatric lift (hydraulic or electric, out of tub type) designed to lift a client weighing greater than 300 pounds. Providers must use procedure code E0625 and the U2 modifier when billing for the purchase of a Level 3 bath lift.
Level 4 - a bariatric lift (hydraulic or electric, in tub type) designed to lift a client weighing greater than 300 pounds. Providers must use procedure code E0625 and the U3 modifier when billing for the purchase of a Level 4 bath lift.
A bath lift may be considered for prior authorization if the client:
Has an inability to transfer to the bathtub or shower independently using assistive devices (including, but not limited to, a cane, walker, bathtub rails).
Providers must use procedure code E0621 when billing for a lift sling. The purchase of a lift sling is limited to one every five years.
The following are payable procedure codes for bath and bathroom equipment:
 

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