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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 : Cough-Stimulating Device (Cofflator)
The cough stimulating device requires prior authorization. Prior authorization may be given for monthly rental only. Purchase of the cough stimulating device is not a benefit and will not be considered for prior authorization.
The completed Title XIX Form and the Medicaid Certificate of Medical Necessity for Chest Physiotherapy Devices Initial or Extended form must be maintained by the provider in the client’s medical record.
The cough stimulating device (procedure code E0482) may be prior authorized for those clients who have chronic pulmonary disease or neuromuscular disorders that affect the respiratory musculature.
The cofflator may be approved initially for a three-month rental period based on the following required documentation:
Diagnosis and background history including recent illnesses, complications, medications used, history of recent hospitalizations, results of pulmonary function studies if applicable, or history of school, work, or extracurricular activity absences due to diagnosis related complications.
Requests for prior authorization of an extension must include documentation by the physician familiar with the client that the client is compliant with the use of the equipment and that the treatment is effective.
A tracheostomy tube may be reimbursed for purchase only and is limited to one per month. Add modifier TF when billing a tracheostomy with specialized functions. Add modifier TG when billing a custom-made tracheostomy. The MSRP information and a physician statement addressing the reason the client cannot use a standard tracheostomy tube are required when requesting prior authorization. Disposable tracheostomy inner cannulas are considered a convenience item and are not a benefit.
Prior authorization requests for tracheostomy tubes must provide sufficient information to support the determination of medical necessity for the requested item. Prior authorization for a tracheostomy tube
will be considered with procedure codes A7520, A7521, or A7522. Providers must use procedure code A4623 when requesting prior authorization for the tracheostomy tube inner cannula. An inner cannula is limited to one per month and will not be prior authorized when a custom manufactured tracheostomy tube (procedure code A7520-TG or A7521-TG) is requested.

Texas Medicaid & Healthcare Partnership
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