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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 : 2.2.19 Respiratory Equipment and Supplies : Secretion Clearance Devices
Secretion clearance devices and incentive spirometers do not require authorization.
Purchase of the IPPB device (procedure code E0500) is not a benefit.
Rental of an IPPB device (procedure code E0500) requires prior authorization. Prior authorization may be granted when the request is submitted with documentation that indicates an ineffective response with other modalities such as treatment with a cough assist device for four months or longer. Rental of the IPPB device includes all supplies, such as humidification and tubing.
Purchase of the IPPB device will not be reimbursed.
In accordance with the American Association for Respiratory Care recommendations, IPPB may be considered when one of the following is documented:
Presence of acute severe bronchospasm or exacerbated COPD that fails to respond to other therapy patients who are at risk for the development of atelectasis and are unable or unwilling to deep breathe without assistance.
The IPPB device may be prior authorized for rental with the following diagnoses:
Providers must use procedure code S8185 when billing for the purchase of a mucous clearance valve. Purchase of the mucous clearance valve requires prior authorization.
Rental of the mucous clearance valve is not a benefit.
The mucous clearance valve may be prior authorized for the following diagnoses:
Other diagnoses may be considered based on review of documentation by HHSC or its designee. Hypertonic saline 7 percent for inhalation therapy is a benefit of Texas Medicaid for clients with a diagnosis of cystic fibrosis. Hypertonic saline 7 percent for inhalation therapy may be billed using procedure code T1999 and requires prior authorization. To request prior authorization, providers must submit either the MSRP, the provider’s invoice cost, or the AWP. Providers may be reimbursed 82 percent of the MSRP or 85 percent of the AWP per ampoule or the provider’s invoice cost if the MSRP is not available.

Texas Medicaid & Healthcare Partnership
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