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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 : 2.2.15 Mobility Aids : 2.2.15.24 Accessories, Modifications, Adjustments and Repairs

2.2.15.24
Accessories, modifications, adjustments, and repairs are benefits of Texas Medicaid as outlined below.
All modifications and adjustments to a wheeled mobility system, 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.
Mobility aids that have been purchased are anticipated to last a minimum of five years.
A major modification to a wheeled mobility system requires the completion of a new seating assessment by a qualified practitioner (physician, occupational therapist, or physical therapist), with the participation of a QRP.
Prior authorization for equipment replacement is considered within five years of equipment purchase when one of the following occurs:
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.
2.2.15.24.1
Modifications
Modifications to custom equipment after the first six months from fitting and delivery may be considered for prior authorization if a change occurs in the client’s needs, capabilities or physical/mental capability, that cannot be anticipated.
Documentation supporting the medical necessity of the requested modification must include the following:
Description of the change in the client’s condition that requires accommodation by different seating, drive controls, electronics, or other mobility base components.
Major modifications to a wheeled mobility system also require that a new seating assessment be completed and submitted with the prior authorization request. A request for authorization of the QRP’s participation in the seating assessment for the major modification must be included with the prior authorization request for the major modification.
Minor modifications to a wheeled mobility system do not require the completion of a new seating assessment.
Requests for equipment submitted as a minor modification to a wheeled mobility system must be submitted with modifier RB.
Adjustments
Adjustments within the first six months after delivery, including adjustments to a wheeled mobility system within the first six months after fitting and delivery by a QRP will not be prior authorized.
A seating or positioning component alteration that does not require replacement components to accommodate a change in the client’s size (height or weight) is considered an adjustment and not a major modification.
A maximum of one hour of labor for adjustments may be prior authorized as needed after the first six months from delivery.
Documentation must include the date of purchase, the serial number of the current equipment, and the reason for adjustments.
Repairs
Repairs to client-owned equipment may be considered for prior authorization as needed with documentation of medical necessity. Technician fees are considered part of the cost of the repair.
HHSC or its designee reserves the right to request additional documentation about the need for repairs when there is evidence of abuse or neglect to equipment by the client, client’s family, or caregiver. Requests for repairs when there is documented proof of abuse or neglect will not be authorized.
Requests for equipment submitted as a repair to a wheeled mobility system must be submitted with modifier RB.
Providers are responsible for maintaining documentation in the client’s medical record specifying the repairs and supporting medical necessity.
Documentation must include the date of purchase and serial number of the current equipment, the cause of the damage or need for repairs, the steps the client or caregiver will take to prevent further damage if repairs are due to an accident, and when requested, the cost of purchasing new equipment as opposed to repairing current equipment.

Texas Medicaid & Healthcare Partnership
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