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DURABLE MEDICAL EQUIPMENT/
  MEDICAL SUPPLY SERVICES
  COVERAGE AND LIMITATIONS
         HANDBOOK
UPDATE LOG
DURABLE MEDICAL EQUIPMENT AND MEDICAL SUPPLY SERVICES COVERAGE
                  AND LIMITATIONS HANDBOOK

How ...
DURABLE MEDICAL EQUIPMENT AND MEDICAL SUPPLY SERVICES


                                           Coverage and Limitation...
Patient Lifts .......................................................................................................2-42
...
DME/Medical Supply Services Coverage and Limitations Handbook



                  INTRODUCTION TO THE HANDBOOK

Overview
...
DME/Medical Supply Services Coverage and Limitations Handbook




Handbook Use and Format


Purpose              The purpo...
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Handbook Use and Format, continued


White Space        ...
DME/Medical Supply Services Coverage and Limitations Handbook




Characteristics of the Handbook , continued


Topic Rost...
DME/Medical Supply Services Coverage and Limitations Handbook




Handbook Updates, continued


Effective Date of      The...
DME/Medical Supply Services Coverage and Limitations Handbook


                        CHAPTER 1
       DURABLE MEDICAL E...
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Purpose and Definitions, continued


Medicaid Provider  ...
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Provider Qualifications


Who Can Provide           The ...
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 Provider Qualifications, continued



Medical Oxygen   ...
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April 2001                                              ...
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Provider Enrollment


General               DME and medi...
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Provider Enrollment, continued


Surety Bond           A...
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Provider Enrollment, continued


Site Visit            A...
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Provider Responsibilities, continued


Provider         ...
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Provider Responsibilities, continued


HME Providers    ...
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April 2001        ...
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                         CHAPTER 2
       DURABLE MEDICAL ...
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In This Chapter        Pediatric Dynamic Splinting Device...
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April 1998                                              ...
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Service Requirements, continued


Medical Necessity     M...
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Service Requirements, continued



Medical Necessity    ...
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Service Requirements, continued


Supply Quantities     M...
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Service Requirements, continued


PA Documentation      ...
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Service Requirements, continued


Exceptions To         ...
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Equipment Purchase, Trade, or Rental, continued



Used E...
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Equipment Purchase, Trade, or Rental, continued


Trade ...
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Equipment Purchase, Trade, or Rental, continued


Replace...
DME/Medical Supply Services Coverage and Limitations Handbook




Equipment Maintenance, Repair, and Renovation, continued...
DME/Medical Supply Services Coverage and Limitations Handbook




Apnea Monitors


Description        An apnea monitor is ...
DME/Medical Supply Services Coverage and Limitations Handbook




Apnea Monitors, continued


Home Visit            When a...
DME/Medical Supply Services Coverage and Limitations Handbook



Apnea Monitors, continued


Event Recording       The res...
DME/Medical Supply Services Coverage and Limitations Handbook




Augmentative and Alternative Communication Systems, cont...
DME/Medical Supply Services Coverage and Limitations Handbook




Augmentative and Alternative Communication Systems, cont...
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Augmentative and Alternative Communication Systems, cont...
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Augmentative and Alternative Communication Systems, cont...
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Augmentative and Alternative Communication Systems, conti...
DME/Medical Supply Services Coverage and Limitations Handbook



Augmentative and Alternative Communication Systems, conti...
DME/Medical Supply Services Coverage and Limitations Handbook



Augmentative and Alternative Communication Systems, conti...
DME/Medical Supply Services Coverage and Limitations Handbook



Augmentative and Alternative Communication Systems, conti...
DME/Medical Supply Services Coverage and Limitations Handbook



Bathroom and Toileting Aids


Description          Bathro...
DME/Medical Supply Services Coverage and Limitations Handbook




Cribs (Safety)


Description          A safety crib is a...
DME/Medical Supply Services Coverage and Limitations Handbook




Glucose Monitors and Blood Lancets, continued


Blood La...
DME/Medical Supply Services Coverage and Limitations Handbook




Home Enteral Supplies and Equipment, continued


Enteral...
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Hospital Beds, Mattress, and Rails, continued


Service ...
DME/Medical Supply Services Coverage and Limitations Handbook




Hospital Beds, Mattress, and Rails, continued


Hospital...
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Infusion Pumps, continued


Infusion pump          An inf...
DME/Medical Supply Services Coverage and Limitations Handbook



Nebulizer


Description       A nebulizer is an apparatus...
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DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
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Transcript of "DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES"

  1. 1. DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES COVERAGE AND LIMITATIONS HANDBOOK
  2. 2. UPDATE LOG DURABLE MEDICAL EQUIPMENT AND MEDICAL SUPPLY SERVICES COVERAGE AND LIMITATIONS HANDBOOK How to Use the Update Log Introduction Changes to the handbook will be sent out as handbook updates. An update can be a change, addition, or correction to policy. It may be either a pen and ink change to the existing handbook pages or replacement pages. It is very important that the provider read the updated material and file it in the handbook as it is the provider’s responsibility to follow correct policy to obtain Medicaid reimbursement. Explanation of the The provider can use the update log to determine if all the updates to the Update Log handbook have been received. Update No. is the number that appears on the front of the update. Effective Date is the date that the update is effective. Instructions 1. Make the pen and ink changes and file new or replacement pages. 2. File the cover page and pen and ink instructions from the update in numerical order after the log. If an update is missed, write or call the Medicaid fiscal agent at the address given in Appendix C of the Reimbursement Handbook, HCFA-1500 and Child Health Check-Up 221. UPDATE NO. EFFECTIVE DATE Nov1999—Replacement Pages October 1999 May2000—Replacement Pages January 2000 May2000 Errata—Pen-and-Ink Correction January 2000 April2001—Replacement Pages April 2001 April2001—Errata April 2001 Jan2002—Replacement Pages January 2002 March 2003 – Replacement Pages March 2003
  3. 3. DURABLE MEDICAL EQUIPMENT AND MEDICAL SUPPLY SERVICES Coverage and Limitations Handbook Table of Contents Chapter/Topic Page Introduction Handbook Use and Format ...............................................................................ii Characteristics of the Handbook ........................................................................iii Handbook Updates ...........................................................................................iv Chapter 1 – Provider Qualifications and Enrollment Purpose and Definitions .....................................................................................1-1 Provider Qualifications.......................................................................................1-3 Provider Enrollment ...........................................................................................1-5 Provider Responsibilites.....................................................................................1-7 Chapter 2 - Covered Services, Limitations and Exclusions Service Requirements ........................................................................................2-2 Equipment Purchase, Trade, or Rental................................................................2-7 Equipment Maintenance, Repair, and Renovation...............................................2-10 Ambulatory Aids ...............................................................................................2-11 Apnea Monitors ................................................................................................2-12 Augmentative and Alternative Communication Systems.......................................2-14 Bathroom and Toileting Aids..............................................................................2-23 Compressors.....................................................................................................2-23 Cribs (Safety)....................................................................................................2-24 Glucose Monitors and Blood Lancets.................................................................2-24 Heat Lamps and Pads........................................................................................2-25 Home Enteral Supplies and Equipment ...............................................................2-25 Hospital Beds, Mattress, and Rails.....................................................................2-26 Infusion Pumps..................................................................................................2-28 Lymphedema Pump...........................................................................................2-29 Nebulizer...........................................................................................................2-30 Orthopedic Footwear ........................................................................................2-31 Orthotic Devices................................................................................................2-32 Osteogenesis Stimulator.....................................................................................2-33 Oxygen and Oxygen Related Equipment.............................................................2-33 Passive Motion Device ......................................................................................2-41
  4. 4. Patient Lifts .......................................................................................................2-42 Peak Flow Meter ..............................................................................................2-42 Pediatric Dynamic Splinting Device ....................................................................2-43 Pressure Ulcer Care ..........................................................................................2-43 Phototherapy (Bilirubin) Light with Photometer...................................................2-44 Prosthetic Devices.............................................................................................2-45 Prosthetic Eyes..................................................................................................2-45 Resuscitator Bag................................................................................................2-46 Suction Machines ..............................................................................................2-46 Traction Equipment............................................................................................2-47 Trapeze Equipment............................................................................................2-48 Ventilator and Respiratory Equipment ................................................................2-48 Wheelchairs.......................................................................................................2-53 Appendix A: Summary of Oxygen Coverage .....................................................A-1 Chapter 3 - Procedure Codes and Fees Reimbursement Information................................................................................3-1 How to Read the Fee Schedule..........................................................................3-3 Non-Classified Procedure Codes.......................................................................3-7 By Report (BR).................................................................................................3-8 Appendix B: Procedure Codes and Fee Schedule for All Medicaid Recipients...................................................................................B-1 Appendix C: Procedure Codes and Fee Schedule for Recipients Under 21........................................................................................C-1
  5. 5. DME/Medical Supply Services Coverage and Limitations Handbook INTRODUCTION TO THE HANDBOOK Overview Introduction This chapter introduces the format used to prepare the Medicaid Reimbursement and Coverage and Limitations Handbooks and tells the reader how to use the handbooks. Background The Coverage and Limitations Handbook explains covered services, their limits and who is eligible to receive them. It is to be used with the Reimbursement Handbook which describes how to complete and file claims for reimbursement by Medicaid. Legal Authority The Medicaid program is authorized by Title XIX of the Social Security Act and Title 42, Code of Federal Regulations. The Florida Medicaid program is authorized by Chapter 409, Florida Statutes (F.S.) and Chapter 59G, Florida Administrative Code (F.A.C.). Federal Regulations, Florida Statutes, and the Florida Administrative Code, which deal with the purpose, implementation, and administration of each Medicaid program, are cited for reference in each program Coverage and Limitations Handbook. In This Chapter This chapter contains: TOPIC PAGE Handbook Use and Format ii Characteristics of the Handbook iii Handbook Updates iv May 1996 i
  6. 6. DME/Medical Supply Services Coverage and Limitations Handbook Handbook Use and Format Purpose The purpose of the Medicaid handbooks is to furnish the Medicaid provider with the policies and procedures needed to receive reimbursement for covered services provided to eligible Florida Medicaid recipients. The handbooks provide descriptions and instructions on how and when to complete forms, letters or other documentation. “Provider” The term “provider” is used to describe any entity, facility, person or group who is enrolled in the Medicaid program and renders services to Medicaid recipients and bills Medicaid for services. “Recipient” The term “recipient” is used to describe an individual who is eligible for Medicaid. Coverage and Each service handbook is named for the service it describes and is referred Limitations to as a "Coverage and Limitations Handbook." A provider who furnishes Handbook more than one type of service will have more than one coverage and limitations handbook. Reimbursement Each reimbursement handbook is named for the claim form that it describes. Handbook A provider who bills on more than one type of claim form will have more than one reimbursement handbook. Chapter Numbering The first page of each chapter designates the chapter number. The chapter System number will appear as the first number of the page number at the bottom of each page in the handbook. Page Numbering Pages are numbered consecutively by chapter. Page numbers follow the chapter number found at the bottom of each page. May 1996 ii
  7. 7. DME/Medical Supply Services Coverage and Limitations Handbook Handbook Use and Format, continued White Space The "white space" throughout a handbook is characteristic of the handbook format style. It enhances readability and allows space for writing notes during training and for on-the-job reference. Characteristics of the Handbook Format The format used in this handbook represents a concise and consistent way of displaying complex, technical material. Information Block One of the major features of the format is the information block, which replaces the traditional paragraph. Blocks are separated by horizontal lines. The block consists of one or more paragraphs or diagrams about a portion of a subject. Each block is identified or named with a label. Label Labels or names are located in the left margin of each information block. They describe the content or function of the block. Labels provide key subject matter identification which facilitates scanning and locating information quickly within a chapter or section within a chapter. Note Note: is used most frequently to refer the user to material located elsewhere in a handbook that is pertinent to the subject being addressed within the information block. Note: also refers the user to other documents or policies contained in other handbooks. May 1996 iii
  8. 8. DME/Medical Supply Services Coverage and Limitations Handbook Characteristics of the Handbook , continued Topic Roster Each chapter contains a topic roster which lists the major subject areas covered in the chapter and gives the page number where the subject can be found. This topic roster serves as a table of contents for major sections within each chapter. Forms Copies of all the forms discussed in the handbook appear in the section of the handbook that describes and discusses the particular document. Handbook Updates How Changes Are The Medicaid handbooks will be updated as needed. Updated Lengthy changes or multiple changes that occur at the same time will be sent on replacement pages. Brief changes will be sent as pen and ink updates. The pen and ink updates will be incorporated on replacement pages the next time replacement pages are produced. Update Log A page designated as the log will accompany handbook updates. This log serves as a reference for the provider to be sure that each update has been received. An “Update No.” will be indicated in the first column on the update log. The second column is titled the “Update Issued” and indicates the date that the update was issued. Numbering Update Updated replacement pages will have the same number as the page they are Pages replacing. If additional pages are required, the new pages will carry the same number as the proceeding replacement page with an alphabetic character in ascending order. May 1996 iv
  9. 9. DME/Medical Supply Services Coverage and Limitations Handbook Handbook Updates, continued Effective Date of The month and year that the new material is effective will appear in the New Material bottom left corner of each page. The provider can check this date to ensure that the material being used is the most current and up to date. If an information block has an effective date that is different from the effective date on the bottom of the page, the effective date for the information block will be included in the label. Identifying New New material will be indicated by vertical, gray-shaded lines. The following Information information blocks give examples of how new labels, new information blocks, and new or changed material within an information block will be indicated. New Label A new label for an existing information block will be indicated by a vertical line to the left and right of the label only. New Label/New A new label and a new information block will be identified by a vertical line Information Block to the left of the label and to the right of the information block. New Material in an New or changed material within an existing information block will be Existing Information indicated by a vertical line to the left and right of the information block. Block New or Changed A paragraph within an information block that has new or changed material Paragraph will be indicated by a vertical line to the left and right of the paragraph. Paragraph with new material. May 1996 v
  10. 10. DME/Medical Supply Services Coverage and Limitations Handbook CHAPTER 1 DURABLE MEDICAL EQUIPMENT AND MEDICAL SUPPLY SERVICES PROVIDER QUALIFICATIONS AND ENROLLMENT Overview Introduction This chapter describes the purpose of the durable medical equipment (DME) and medical supplies program, the legal authority regulating the program, and provider qualifications, enrollment, and responsibilities. Legal Authority The Medicaid DME and medical supplies program is authorized by Title XIX of the Social Security Act and Title 42, Code of Federal Regulations (C.F.R.), Part 440.70. The program was implemented through Chapter 409, Florida Statute (F.S.) and the Florida Administrative Code (F.A.C.) Chapter 59G. In This Chapter This Chapter contains: TOPIC PAGE Purpose and Definitions 1-1 Provider Qualifications 1-3 Provider Enrollment 1-5 Provider Responsibilities 1-7 Purpose and Definitions Purpose The purpose of the DME and medical supplies program is to promote, maintain, or restore health and minimize the effects of illness, disability, or a disabling condition. April 2001 1-1
  11. 11. DME/Medical Supply Services Coverage and Limitations Handbook Purpose and Definitions, continued Medicaid Provider This handbook is intended for use by DME and medical suppliers who Reimbursement provide services to Medicaid recipients. It must be used in conjunction with Handbook, HCFA- the Medicaid Provider Reimbursement Handbook, HCFA-1500 and 1500 and Child Child Health Check-Up 221, which contains general information about the Health Check-Up Medicaid program and procedures for submitting claims for payment. 221 Durable Medical DME is defined as medically-necessary equipment that can withstand Equipment (DME) repeated use, serves a medical purpose, and is appropriate for use in the recipient’s home as determined by the Agency for Health Care Administration (AHCA). Medical Supplies Medicaid reimbursable medical supplies are defined as medically-necessary medical or surgical items that are consumable, expendable, disposable, or non-durable and appropriate for use in the recipient’s home. Orthotic Devices Medicaid reimbursable orthotic devices are defined as medically-necessary devices or appliances that support or correct a weak or deformed body part, or restrict or eliminate motion in a diseased or injured part of the body. Prosthetic Devices Medicaid reimbursable prosthetic devices are defined as medically-necessary artificial devices or appliances that replace all or part of a permanently inoperative or missing body part. April 2001 1-2
  12. 12. DME/Medical Supply Services Coverage and Limitations Handbook Provider Qualifications Who Can Provide The following entities may enroll in the Medicaid DME and medical supplies Services program: • Businesses and pharmacies that supply DME and medical supplies; • Home health agencies; and • Physicians, optometrists, and opticians who supply artificial prosthetic eyes. Qualification To enroll as a Medicaid provider, a DME and medical supply entity must Requirements meet the following criteria: • Be licensed by the local government agency as a business or merchant or provide documentation from the city or county authority that no licensure is required; • Be licensed by the Department of Health, Medical Quality Assurance, Board of Orthotics and Prosthetics, if providing orthotics and prosthetic devices; • Be licensed by the Agency for Health Care Administration, Division of Health Quality Assurarnce, in possession of a Home Health Equipment license; • Be in compliance with all applicable laws relating to qualifications or licensure; and • Have an in-state business location or be located not more than fifty miles from the Florida state line. Note: See Chapter 2, Medicaid Provider Reimbursement Handbook, HCFA-1500 and Child Health Check-Up 221, for additional information on Medicaid provider qualifications. April 2001 1-3
  13. 13. DME/Medical Supply Services Coverage and Limitations Handbook Provider Qualifications, continued Medical Oxygen To be reimbursed for providing oxygen and oxygen related equipment, the Retailers provider must add specialty code 69 (oxygen) to his provider enrollment application and submit a copy of his oxygen retailer permit issued by the Department of Health, Central Pharmacy. Pharmacy providers who provide DME and bill Medicaid for oxygen must submit copies of their Department of Health pharmacy permits with their Provider Enrollment Applications. The oxygen provider must have a licensed certified respiratory therapy technician, registered respiratory therapist, or a registered nurse under contract or on staff. Note: See Chapter 2 for additional information about Oxygen and Oxygen Related Equipment. Pharmacy Pharmacy providers automatically receive a durable medical equipment Providers (DME) location code when they first enroll as a pharmacy. To be reimbursed for DME and medical supplies, the pharmacy provider must request activation of the location code by sending a request letter to the Medicaid fiscal agent to request activitation of the DME locator code. The letter must contain an original signature. Faxed letters will not be accepted. Mail the letter to: ACS Provider Enrollment P.O. 7070 Tallahassee, Florida 32314-7070 When the DME location code is activated, the fiscal agent will send the pharmacy provider a DME and Medical Supply Services Coverage and Limitations Handbook and the Medicaid Provider Reimbursement Handbook, HCFA-1500 and Child Health Check-Up 221. All DME billing must be on the HCFA-1500 claim form using the pharmacy’s provider number with the unique DME locator code. Operational at DME and medical supply entities must meet all the Medicaid provider Time of requirements and qualifications and their businesses must be fully operational Enrollment before they can be enrolled as Medicaid providers. April 2001 1-4
  14. 14. DME/Medical Supply Services Coverage and Limitations Handbook April 2001 1-5
  15. 15. DME/Medical Supply Services Coverage and Limitations Handbook Provider Enrollment General DME and medical supply providers must meet the general Medicaid provider Enrollment enrollment requirements that are contained in Chapter 2 of the Medicaid Requirements Provider Reimbursement Handbook, HFCA-1500 and Child Health Check-Up 221. In addition, DME and medical supply providers must meet the specific enrollment requirements that are listed in this section. One Provider Per Medicaid can only enroll one DME and medical supply provider per physical Location location. If two or more DME and Medicaid supply entities share a physical location, only one can enroll as a Medicaid provider. Multiple Locations Providers who have offices at more than one location must have a separate location code for each location. A location code is a physical location identifier that corresponds to the last two digits of the provider’s Medicaid number. Providers must use the location code assigned to the office location when billing for services provided at that location. The provider must submit a Medicaid Provider Enrollment application to enroll an additional location. The application must include an effective date for the new location. Enrollment Applications can be obtained from the Medicaid fiscal agent by calling 800-289-7799 or from its website at http://floridamedicaid.consultec-inc.com. Any closure of a practice location must also be reported to the fiscal agent in writing on office letterhead stationery, along with the effective date of the closure. April 2001 1-6
  16. 16. DME/Medical Supply Services Coverage and Limitations Handbook Provider Enrollment, continued Surety Bond A surety bond must be submitted as part of the enrollment application by the Requirement provider type unless it is owned and operated by government entities. One $50,000 bond is required for each provider location up to a maximum of five (5) bonds statewide or an aggregate bond of $250,000 statewide. Bond Renewal Durable medical equipment and medical supply providers must renew their bonds annually unless a continuous bond is on file. Renewal must be made at least 30 days in advance of the termination date to ensure there is no break in services (termination because of an expired bond). Licenses/Permits Durable medical equipment and suppliers must have one of the following to Requirements enroll: • Pharmacy providers should submit a copy of their pharmacy permit acquired from the Department of Health; • Oxygen providers should submit a copy of their oxygen retailer permit issued from the Department of Health; • Any required Home Medical Equipment (HME) license, issued by the Agency for Health Care Administration; or • Orthotics and Prosthetics licenses. April 2001 1-7
  17. 17. DME/Medical Supply Services Coverage and Limitations Handbook Provider Enrollment, continued Site Visit A DME and medical supply provider must have a site visit before the Requirement provider’s enrollment application can be approved. Additional locations must also receive site visits before they can be approved for enrollment. When a provider receives a site visit, it does not mean that the provider will be approved for Medicaid participation. Medicaid reserves the right to contract with a private entity to conduct site visits. Site visits are not required for the following DME and medical supply providers: • Providers who are associated with pharmacies; • Providers who are associated with rural health clinics; and • Providers who provide only orthotic or prosthetic devices and who provide copies of their professional licenses from the Department of Health, Medical Quality Assurance, Board of Orthotics and Prosthetics, with their enrollment applications. Provider Responsibilities General In addition to the general provider requirements and responsibilities that are Requirements contained in Chapter 2 of the Medicaid Provider Reimbursement Handbook, HFCA-1500 and Child Health Check-Up 221, DME and medical supply providers are also responsible for the provisions contained in this section. April 2001 1-8
  18. 18. DME/Medical Supply Services Coverage and Limitations Handbook Provider Responsibilities, continued Provider A DME and medical supply provider is responsible for furnishing and Responsibilities supervising all aspects of DME and medical supply service provisions. A DME and medical supply provider must honor warranties and maintain and repair equipment. All products and items must be: • Appropriate; • Used for the purpose for which they were designed; • Reasonable and effective in meeting the medical needs of the recipient; and • Of equal quality as those furnished to non-Medicaid patients. Record Keeping In addition to the specific documentation that is required for the covered items Requirements listed in Chapter 2 of this handbook, DME and medical supply providers must follow the record keeping requirements listed in Chapter 2 of the Medicaid Provider Reimbursement Handbook, HCFA-1500 and Child Health Check-Up 221. Home Medical Title XIX, Chapter 400, Part X of the Florida Statutes contains regulations Equipment regarding Home Medical Equipment. According to S.400.93 F.S., any (HME) person or entity that holds itself out to the public as providing home medical equipment and services or accepts physician orders for home medical equipment and services, or any person or entity that holds itself out to the public as providing home medical equipment that typically requires home medical services must be licensed by the Agency for Health Care Administration to operate or provide home medical equipment and services in Florida. A separate license is required of all home medical equipment providers operating on separate premises, even if the providers are operated under the same management. April 2001 1-9
  19. 19. DME/Medical Supply Services Coverage and Limitations Handbook Provider Responsibilities, continued HME Providers Providers exempt from an HME license are those operated by the federal Exempt from government, nursing homes, assisted living facilities, home health agencies, Licensure hospices, intermedicate care facilities, hospitals and ambulatory surgical centers, manufacturers and wholesale distributors when not selling directly to suppliers only, suppliers of consumable and disposable items only, and licensed health care practitioners who utilize HME in the course of their practice, but do not sell or rent HME to their patients. Questions regarding HME licensure, may be directed to the Agency’s HME unit at (850) 414-6010. April 2001 1-10
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  21. 21. DME/Medical Supply Services Coverage and Limitations Handbook CHAPTER 2 DURABLE MEDICAL EQUIPMENT AND MEDICAL SUPPLY SERVICES COVERED SERVICES, LIMITATIONS AND EXCLUSIONS Overview Introduction This chapter describes durable medical equipment (DME), medical supplies, orthotic and prosthetic devices, the service requirements, and limitations. In This Chapter This chapter contains: TOPIC PAGE Service Requirements 2-2 Equipment Purchase, Trade, or Rental 2-7 Equipment Maintenance, Repair, and Renovation 2-10 Ambulatory Aids 2-11 Apnea Monitors 2-12 Augmentative and Alternative Communication Systems 2-14 Bathroom and Toileting Aids 2-23 Compressors 2-23 Cribs (Safety) 2-24 Glucose Monitors and Blood Lancets 2-24 Heat Lamps and Pads 2-25 Home Enteral Supplies and Equipment 2-25 Hospital Beds, Mattress, and Rails 2-26 Infusion Pumps 2-28 Lymphedema Pump 2-29 Nebulizer 2-30 Orthopedic Footwear 2-31 Orthotic Devices 2-32 Osteogenesis Stimulator 2-33 Oxygen and Oxygen Related Equipment 2-33 Passive Motion Device 2-41 Patient Lifts 2-42 Peak Flow Meter 2-42 April 1998 2-1
  22. 22. DME/Medical Supply Services Coverage and Limitations Handbook In This Chapter Pediatric Dynamic Splinting Device 2-43 (continued) Pressure Ulcer Care 2-43 Phototherapy (Bilirubin) Light with Photometer 2-44 Prosthetic Devices 2-45 Prosthetic Eyes 2-45 Resuscitator Bag 2-46 Suction Machines 2-46 Traction Equipment 2-47 Trapeze Equipment 2-48 Ventilator and Respiratory Equipment 2-48 Wheelchairs 2-53 Non-Covered Services and Exclusions 2-56 Appendix A: Summary Of Oxygen Coverage A-1 Service Requirements Introduction Many DME services are available only to recipients under 21 years of age. To determine if a service is available to all recipients or just a specific range of recipients see the DME Fee Schedule in Chapter 3 of this handbook, Appendix B: For All Medicaid Recipients and Appendix C: For Recipients Under Age 21. Prescribers DME/medical supplies, orthotic, or prosthetic devices must be prescribed by the Medicaid recipient’s attending physician, physician assistant (PA), advanced registered nurse practitioner (ARNP), or podiatrist. DME/Medical Medicaid reimburses home health agencies for DME/medical supplies Supplies Provided furnished by qualified providers in accordance with the physician approved Through Home plan of care. Health Agencies Plan Of Care A plan of care is an individualized written program for a recipient that is developed by health care professionals including the attending physician. The plan of care is designed to meet the medical, health, and rehabilitative needs of the recipient. April 1998 2-2
  23. 23. DME/Medical Supply Services Coverage and Limitations Handbook April 1998 2-3
  24. 24. DME/Medical Supply Services Coverage and Limitations Handbook Service Requirements, continued Medical Necessity Medicaid reimburses for services that are determined medically necessary, do not duplicate another provider’s service, and are: • individualized, specific, consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patient’s needs; • not experimental or investigational; • reflective of the level of services that can be safely furnished and for which no equally effective and more conservative or less costly treatment is available statewide; and • furnished in a manner not primarily intended for the convenience of the recipient, the recipient’s caretaker, or the provider. The fact that a provider has prescribed, recommended, or approved medical or allied care, goods, or services does not, in itself, make such care, goods, or services medically necessary or a covered service. Note: See Appendix D, Glossary, in the Medicaid Provider Reimbursement Handbook, HCFA-1500 and Child Health Check-Up 221, for the definition of medically necessary. Acceptable Medical Medical necessity must be established for each service and documented on a Necessity signed and dated: Documentation • prescription—prescriptions may be dated by the physician after service has been initiated, but cannot be dated more than 14 days after initiation; • Certificate of Medical Necessity (CMN)—Medicaid prohibits vendors from preparing the entire CMN; • established plan of care; or • hospital discharge plan. Required The documentation must include the following information: Information • the recipient’s name, • the attending practitioner’s name and license number, and • Medicaid or Medicare provider number. July 1997 2-4
  25. 25. DME/Medical Supply Services Coverage and Limitations Handbook Service Requirements, continued Medical Necessity The medical necessity for disposable medical supplies must be redetermined For Medical every six months. Supplies Medical Necessity When DME, orthotic, or prosthetic devices are a one time purchase, medical For One Time necessity is required with each request. Purchase Medical Necessity The medical necessity for a rented item is based on the length of time specified For Rental Items in the prescription, CMN, plan of care, or hospital discharge plan. The exceptions to this policy are apnea monitors and oxygen. Note: See medical necessity renewal under Apnea Monitor and Oxygen and Oxygen Related Equipment in this chapter. Service Criteria DME/medical supplies, orthotics, and prosthetic devices must be: • functionally appropriate, • adequate for the intended medical purpose, • for conventional use, and • for the exclusive use of the recipient. Medical Supplies To be reimbursed by Medicaid, medical supplies must be needed for use with one of the following: • colostomy, urostomy, ileostomy appliances; • surgical, wound, and burn dressings; • gastric feeding sets and supplies; • urinary catheters, irrigation apparatus, and related items; • tracheostomy and endotracheal care supplies; • disposable items, which if not provided could reasonably cause the recipient to require emergency treatment, become hospitalized, or be placed in a long term care facility; or • support of Medicaid covered DME equipment used by the recipient. April 2001 2-5
  26. 26. DME/Medical Supply Services Coverage and Limitations Handbook Service Requirements, continued Supply Quantities Medical supply quantities must not exceed one month’s usage. Prescriptions for disposable supplies are effective for only twelve months. After twelve months, a new prescription will be required from the physician. Place Of Residence DME/medical supplies, orthotic and prosthetic devices are only reimbursed for an eligible Medicaid recipient who lives in a non-institutional setting. Exception To Place Recipients under 21 years of age who reside in a nursing facility may be eligible Of Residence for a customized wheelchair, some customized orthotic and prosthetic devices, and AAC devices. Recipients under 21 years of age who are hospital inpatients may be eligible for customized orthotic and prosthetic devices prior to discharge. Recipients who reside in an assisted living facility may be eligible for a customized wheelchair and other DME items. Prior Authorization DME procedures that require prior authorization are: (PA) • customized wheelchairs, specially sized and constructed (K0008, K0013); • durable medical equipment, miscellaneous (E1399); • substantial repairs or replacement of components or parts for medical equipment owned by the recipient (W6091); • hospital beds (E0250 and E0255) and new heavy duty hospital beds (E0298); and • augumentative/alternative communication devices (K codes) Note: See Chapter 7 in the Medicaid Provider Reimbursement Handbook, HCFA-1500 Child Health Check-Up 221, for information about prior authorization. July 1997 2-6
  27. 27. DME/Medical Supply Services Coverage and Limitations Handbook Service Requirements, continued PA Documentation DME providers must submit the following information with a prior authorization Requirements request: • a full description of the item; • the manufacturer’s name and address; • the model and serial number; • a list of parts, components, attachments, or special features; • if new or used equipment, purchased, or rented; • the acquisition cost; • the effective date of the item; • medical documents that justify all unique features and construction; • the diagnosis of the recipient’s condition and diagnosis code using the most current version of the International Classification of Diseases, Clinical Modification (ICD-9-CM); • the recipient’s prognosis, if significant; • the recipient’s physical limitations; • the estimated length of time the item will be required; and • documentation that a qualified individual gave instructions to the recipient, if necessary, regarding the frequency and use of the item. MediPass All DME and medical supplies must be authorized by the recipient’s MediPass Authorization primary care provider, if the recipient is enrolled in MediPass. Effective Note: See Chapter 1, Medicaid Provider Reimbursement Handbook, March 1, 1997 HCFA-1500 and Child Health Check-Up 221, for information on obtaining MediPass authorization. April 2001 2-7
  28. 28. DME/Medical Supply Services Coverage and Limitations Handbook Service Requirements, continued Exceptions To Service limits can be exceeded only for recipients under 21. If the service Service Limits limits must be exceeded, the additional services must be: • medically necessary, • meet all program requirements, • be authorized by the recipient’s MediPass provider if the recipient is enrolled in MediPass, and • documented, with the medical necessity documentation attached to paper claims and sent to the appropriate local area Medicaid office for processing. Providers should consult with the area Medicaid office on DME policy. Note: See Appendix C, Medicaid Provider Reimbursement Handbook, HCFA-1500 and Child Health Check-Up 221, for the area Medicaid offices telephone numbers and addresses. Equipment Purchase, Trade, or Rental Purchasing New Medicaid requires that equipment be warranted by the provider or Equipment manufacturer for a minimum of one year. No replacement or repairs will be reimbursed for equipment within the first year of service. The Medicaid reimbursement includes: • all elements of the manufacturer’s warranty; • all routine or special equipment servicing to the extent it is provided to non- Medicaid persons; • all adjustments and modifications needed by the recipient to make the item useful and functional during the first year; • delivery, set-up and installation of equipment in the home, and if possible, to the appropriate room in the home, if home delivery is usual and customary for the item; • training and instruction to the recipient or caregiver in the safe, sanitary, effective, and appropriate use of the item and necessary servicing and maintenance to be done by the user; and • providing the recipient or caregiver with all manufacturer’s instructions, servicing manuals, and operating guides needed for routine service and operation. July 1997 2-8
  29. 29. DME/Medical Supply Services Coverage and Limitations Handbook Equipment Purchase, Trade, or Rental, continued Used Equipment When used equipment is furnished to a recipient, the provider must: • Obtain a written signed and dated agreement from the recipient, to provide used equipment; • Ensure that equipment is functionally sound and in good operating condition; • Ensure that the product or item furnished includes the required “warranty” conditions listed under Purchasing New Equipment; • Ensure that the used equipment is fully serviced and attractively re- conditioned; • Ensure that repaired equipment or equipment with replaced parts is equivalent in quality and condition to the manufacturer’s warranty on a similar new item; and • Furnish all routine or special equipment servicing, to the extent it is provided to individuals who are not Medicaid recipients. Note: See Used Equipment Billing in Chapter 3 of this handbook for additional information. Repairs DME, medical supplies, orthotics, and prosthetics coverage includes general repairs and service of equipment that is owned and used by a recipient. No repair will be reimbursed for equipment within the first year of service for any recipient. May 1996 2-9
  30. 30. DME/Medical Supply Services Coverage and Limitations Handbook Equipment Purchase, Trade, or Rental, continued Trade When Medicaid purchased equipment is no longer suitable because of growth, development, or changes to the recipient’s condition, Medicaid and the provider may negotiate a good faith trade-in of the unneeded item. The provider must reflect the pro-rated trade-in amount on the claim for the new equipment purchased. Rental The provider may not discontinue the rental service unless medical necessity Discontinuation ends, the recipient is no longer eligible for Medicaid, or the rent-to-purchase period has ended. Rent-to-Purchase When equipment is rent-to-purchase, Medicaid’s reimbursement amount is Equipment divided over a ten-month period. At the end of the tenth months, the equipment becomes the property of the Medicaid recipient. Rental Agreement A rental agreement between a provider and recipient may not be discontinued without the consent of the recipient or caregiver. Provider When rental equipment is furnished to a recipient, the provider must: Responsibilities • service the rental equipment, including maintenance, repair, or replacement of all expendable parts or items; • substitute like equipment at no additional cost when broken or when damaged equipment is being repaired; and • maintain in his or her files a signed receipt that the recipient received the equipment and was trained on its proper use. October 1999 2-10
  31. 31. DME/Medical Supply Services Coverage and Limitations Handbook Equipment Purchase, Trade, or Rental, continued Replacement Replacement equipment will not be reimbursed in cases of misuse, abuse, Equipment neglect, loss, or wrongful disposition of equipment. If a piece of equipment is stolen, a police or insurance report will be required documentation in order to replace the stolen item. Medicaid may also replace certain items when medical necessity changes. Equipment Maintenance, Repair, and Renovation Maintenance Medicaid will reimburse maintenance of equipment when the following Requirements conditions are met: • maintenance was performed by an authorized technician; • the equipment is covered by Medicaid; • the equipment is owned by the recipient or the recipient’s family; • the recipient is the sole user of the equipment; • no other source is available to pay for the needed repairs; • the item is still medically necessary; and • the damage is not due to abuse or misuse. Note: Some maintenance requires prior authorization, see Chapter 7 of the Medicaid Provider Reimbursement Handbook, HCFA-1500 and Child Health Check-Up 221, for instructions on how to request a prior authorization. Routine The recipient or caregiver is responsible to perform routine maintenance as Maintenance By A described in the manufacturer’s operating manual. This includes testing, Recipient cleaning, regulating, and lubricating the equipment as needed. Non-Routine Medicaid may reimburse a provider for non-routine maintenance and repairs Maintenance And (E1340) needed to keep durable medical equipment functional. Repair Note: This procedure requires a report of approval and pricing. See Chapter 3 of this handbook for information on By Report. April 2001 2-11
  32. 32. DME/Medical Supply Services Coverage and Limitations Handbook Equipment Maintenance, Repair, and Renovation, continued Substantial Repair Providers may request prior authorization for substantial repairs or renovation Or Renovation (W6091) of durable medical equipment. The request for prior authorization must identify the item and detail the proposed repairs. Maintenance requirements listed above also apply to substantial repairs. When repairs or maintenance results in the need to replace equipment with rental equipment temporarily, the rental period must not exceed seven days. Note: See Chapter 7 in the Medicaid Provider Reimbursement Handbook, HCFA-1500 Child Health Check-Up 221, for information on requesting prior authorizations. Reimbursement Reimbursement for DME equipment maintenance is limited to the amount necessary to make the item serviceable but not to exceed 75 percent of the cost of an equivalent replacement. Ambulatory Aids Description An ambulatory aid is a medically necessary item that is needed because the recipient has impaired ambulation. Ambulatory aids include canes, crutches, and walkers that are to be complete with tips, pads, and grips. Pediatric Forearm Medicaid may reimburse for pediatric forearm crutches (W9761). The Crutches following must be documented in the recipient’s record: height, weight, growth patterns, and expected benefit for ambulating. Pediatric Postural Pediatric postural control walker may be reimbursed as an ambulating Control Walker aid. There must be an expected benefit in gait training for the recipient. Wheeled Walkers Wheeled walkers with a seat and wheel locks may be reimbursed when prescribed in lieu of a wheelchair. April 2001 2-12
  33. 33. DME/Medical Supply Services Coverage and Limitations Handbook Apnea Monitors Description An apnea monitor is a device that meets the Food and Drug Administration’s 510 (k) guidelines and is equivalent to the device marketed in interstate commerce prior to May 28, 1976; or to a device that has been classified into Class I or Class II since the enactment of the medical device amendments of May 28, 1976. Medicaid approved apnea monitors are: • Apnea/Bradycardia/Tachycardia (Impedance Monitoring Technique); • Apnea/Bradycardia (Impedance Monitoring Technique); and • Apnea/Bradycardia/Tachycardia (Piezoelectric Transducer Technique). Provider The provider must: Responsibilities • obtain documentation that the family or caregiver successfully completed infant Cardio Pulmonary Resuscitation training; • ensure that the monitor is a prescribed cardiorespiratory monitor; • provide maintenance coverage 24 hours a day, seven days a week; • handle emergency repair requests within six hours or set up a “loaner” monitor within two hours; • ensure a home visit is completed by a qualified registered nurse (RN), certified respiratory therapist technician (CRTT), or a registered respiratory therapist (RRT) within five days following a hospital discharge; • ensure a home visit is completed by a qualified RN, CRTT, or a RRT every 30 days after the initial visit; and • file a copy of the home visit report within five days of the provision of the home visit to the district Children’s Medical Services (CMS) office responsible for managing the recipient’s care. November 1997 2-13
  34. 34. DME/Medical Supply Services Coverage and Limitations Handbook Apnea Monitors, continued Home Visit When an RN, CRTT, or a RRT conducts a home visit, they must determine Documentation and document the following in the recipient’s medical record: Requirements • the recipient’s family situation, • the recipient’s home environment, • the diagnosis, • any telephone contacts with CMS or the HMO, • a change in the recipient’s address, and • any non-compliance in the use of the monitor. Provider Equipment The provider is responsible for ensuring the following equipment is available at Responsibilities set-up: • monitor, which includes the battery pack, case, and emergency battery; • two sets of electrodes and, if requested, one extra set for replacement; • if disposable electrodes are necessary, at least ninety (90) per month; • two sets of modified safety lead wires; • two electrode belts; • an operator’s manual; • a copy of the infant monitoring handbook; and • a remote alarm when ordered. Discontinued When service is discontinued, the provider has three days to remove the Service equipment from the recipient’s home. Medicaid payments will cease upon receiving physician’s orders to discontinue monitoring service. Event Recording The provider is responsible for initiating an event recording within two weeks of the verbal order unless otherwise specified in writing by the attending physician. The provider must send the interpretation to the attending practitioner within three days. The interpretation is completed by a regional apnea center. November 1997 2-14
  35. 35. DME/Medical Supply Services Coverage and Limitations Handbook Apnea Monitors, continued Event Recording The results of the event recording will determine if the practitioner will issue Continuation written orders to continue the event recordings for another month, continue regular monitoring, or discontinue the apnea monitoring. Event Recording Event recording documentation must include: Documentation • the age of the recipient; • the length of the recording; • the number, type, and duration of the events; and • the results of the event recording. Medical Necessity Medical necessity renewal time frame for apnea monitors is six months. Renewal Augmentative and Alternative Communication Systems Introduction Augmentative and alternative communication systems (AACs) are reimbursed through the Medicaid DME/medical supply services program. Evaluations for the system, ongoing training, and therapy are reimbursed through the Medicaid Therapy Services program and the Medicaid Certified School Match program. Note: See the Therapy Services and Certified School Match Coverage and Limitations Handbook for information about therapy services. Definitions AACs are designed to allow individuals the capability to communicate. As defined by the American Speech-Language Hearing Association (ASHA), an AAC attempts to compensate for the impairment and disability patterns of individuals with severe, expressive communication disorders, i.e., individuals with severe speech-language and writing impairments. Dedicated systems are designed specifically for a disabled population. Non-dedicated systems are commercially available devices such as lap top computers with special software. October 1998 2-15
  36. 36. DME/Medical Supply Services Coverage and Limitations Handbook Augmentative and Alternative Communication Systems, continued Exception to Place Recipients under 21 years of age who reside in a nursing facility may be eligible of Residence to receive an AAC device. Who is Eligible to For Medicaid to reimburse for an AAC, the recipient must meet the following Receive an AAC criteria: • be unable to communicate basic needs without the use of an AAC, and • have the physical, cognitive, and language abilities necessary to use the AAC. Prior AACs must be prior authorized by the Medicaid consultant. Procedure codes Authorization used for AAC devices are the K codes noted in the Medicaid fee schedule in Appendix B of this handbook. Steps for The following steps must be followed to obtain Medicaid authorization for an Completion of a AAC. The written documentation from each step must be included in the Prior Medicaid prior authorization package: Authorization 1. An interdisciplinary team (ID team), led by the speech-language Package pathologist (or only the speech-language pathologist for recipients over age 21 and older), evaluates the recipient, recommends an AAC, and writes an individualized plan. 2. If the recipient is in public school, school personnel must concur with the ID team’s written recommended plan. 3. The speech-language pathologist sends the evaluation, which includes the recommended AAC, the individualized action plan, and the speech- language pathologist’s plans for management of the recipient’s communication disorder to the recipient’s physician, ARNP/PA designee, or designated physician specialist. 4. The physician, ARNP/PA designee, or designated physician specialist must review the evaluation and individualized action plan, and if he concurs, sign and date the evaluation and prescribe the AAC. 5. If the recipient is in MediPass, the recipient’s MediPass provider must authorize the AAC. (The DME provider must obtain MediPass authorization in order to be reimbursed for the claim.). October 1998 2-16
  37. 37. DME/Medical Supply Services Coverage and Limitations Handbook Augmentative and Alternative Communication Systems, continued Steps for 6. The ID team forwards the prior authorization package to the DME Completion of a provider. Prior 7. The DME provider completes the prior authorization package by attaching Authorization an invoice, proof of manufacturer’s cost, and a State of Florida/Florida Package Medicaid Authorization Request form and submitting the package to the (continued) Medicaid fiscal agent. 8. The Medicaid consultant reviews the prior authorization package and approves or denies the authorization request. Each step is described in detail in the following information blocks. Interdisciplinary For recipients under age 21, an interdisciplinary team (ID team) must be Team formed to evaluate the recipient, recommend an AAC, and write an individualized action plan. The ID team must consist of at least two members and must include a speech language pathologist who will lead the team. The speech-language pathologist may request the assistance of an occupational therapist and physical therapist. It is expected that most cases will require the need for an occupational therapist to be a part of the ID team. The recipient who will use the AAC should be encouraged to participate on the ID team, as well as the recipient’s caregivers, teachers, social workers, case managers, and any other members deemed necessary. For recipients age 21 and older, a speech-language pathologist is responsible for the evaluation, recommending an AAC and writing an individualized action plan. Speech-Language Once the ID team (or speech-language pathologist for recipients age 21 and Pathologist’s older) has evaluated the recipient and recommended an AAC, the speech- Evaluation language pathologist must document the following information in writing (the first three items are obtained from the recipient’s medical record): • significant medical diagnosis(es); • significant treatment information and medications; • medical prognosis; April 2001 2-17
  38. 38. DME/Medical Supply Services Coverage and Limitations Handbook Augmentative and Alternative Communication Systems, continued Speech-Language • motor skills, i.e., posture/positioning, selection abilities, range and accuracy Pathologist’s of movement, etc.; Evaluation • cognitive skills, i.e., alertness, attention span, vigilance, etc.; (continued) • sensory and perceptual abilities, i.e., hearing, vision, etc.; • language comprehension; • expressive language capabilities; • oral motor speech status; • use of communication and present communication abilities; • communication needs including the need to enhance conversation, writing, and signaling emergency, basic care and related needs; • writing impairments, if any; • environment, i.e., home, work, etc., with a description of communication barriers; and • AAC recommendation, which may include symbol selection, encoding method, selection set (physical characteristics of display), type of display, selection technique, message output, literacy assessment, vocabulary selection, and participation patterns. AAC Evaluations AAC evaluations are valid for six months from the date of the initial evaluation. Individualized The ID team members headed by the speech-language pathologist (or the Action Plan speech-language pathologist for recipients age 21 and older) are responsible for developing the recipient’s individualized action plan. April 2001 2-18
  39. 39. DME/Medical Supply Services Coverage and Limitations Handbook Augmentative and Alternative Communication Systems, continued Components of The recommended individualized action plan must include the following the Individualized information: Action Plan • an explanation of any AAC currently being used or owned by the recipient at home, work, or school; • the current use of the system(s) and its limitations; • the appropriate long and short-term therapy objectives; • the recommended AAC (based on cost-effectiveness and the recipient’s needs); • the recommended length of a trial period, if applicable; • a description of any AACs that the recipient has previously tried; • the specific benefits of the recommended AAC over other possibilities; • an established plan for mounting, if necessary, repairing, and maintaining the AAC; • who is responsible to deliver and program the AAC to operate at the level recommended by the ID team; • who will train the support staff, recipient, and primary caregiver in the proper use and programming of the AAC; and • documentation of medical necessity. AAC Selection The ID team must select an AAC that is based on the recipient’s current medical needs, and projected changes in the recipient’s communication development over at least a 3-year period. Concurrence by If the recipient is in the public school system, school personnel must be given School Personnel the opportunity to comment and concur with the ID team’s recommended device. School personnel must agree that the recipient’s teacher and school therapist are knowledgeable in the use of the AAC or will be trained regarding its use. April 2001 2-19
  40. 40. DME/Medical Supply Services Coverage and Limitations Handbook Augmentative and Alternative Communication Systems, continued Physician The recipient’s physician, ARNP or PA designee, or designated physician Approval specialist must review the evaluation and individualized action plan, and if he or she concurs, sign and date the evaluation and prescribe the AAC. The prescription must include the physician’s, ARNP or PA designee’s, or designated physician specialist’s name; address; telephone number; medical license number; and MediPass authorization number, if applicable. (If the recipient is in MediPass, the AAC must be authorized by the recipient’s MediPass primary care provider.) The physician, ARNP or PA designee, or designated physician specialist returns the signed and dated evaluation, individualized action plan, and prescription to the speech-language pathologist. Conflict of Interest The medical professionals who evaluate the recipient, serve on the ID team, or prescribe the AAC must not have a financial relationship with or receive any gain from the AAC manufacturer. Prior After receiving the prior authorization package, the DME provider must Authorization request prior authorization from Medicaid. Requirement For AACs, send prior authorization requests to the Medicaid fiscal agent: ACS State Healthcare P.O. Box 7090 Tallahassee, Florida 32314-7090 Note: See Chapter 7 of the Medicaid Provider Reimbursement Handbook, HCFA-1500 and Child Health Check-Up 221, for the prior authorization procedures. October 1999 2-20
  41. 41. DME/Medical Supply Services Coverage and Limitations Handbook Augmentative and Alternative Communication Systems, continued Prior The DME provider must complete and submit a prior authorization package to Authorization the Medicaid fiscal agent for Medicaid review and approval. The following Documentation components must be included in the prior authorization package: Requirements 1. The AAC evaluation signed by the ID team members (or speech-language pathologist for recipients age 21 and older) and the recipient’s physician, advanced registered nurse practitioner, or physician’s assistant; 2. The individualized action plan; 3. A prescription for the AAC signed and dated by the recipient’s physician, advanced registered nurse practitioner, or physician’s assistant that includes the provider’s name, address, telephone number, and medical license number; 4. The MediPass authorization number if the recipient is a MediPass participant; 5. A statement of concurrence from school personnel if the recipient is in the public school system; 6. A completed State of Florida/Florida Medicaid Prior Authorization form; 7. An itemized invoice listing retail costs for the equipment; and 8. Manufacturer’s catalogue information regarding cost and warranty information. The speech-language pathologist is responsible for submitting items 1 through 5 to the DME provider. The DME provider is responsible for completing items 6, 7, and 8. Medicaid Medicaid’s decision for coverage will be based on a medical rationale for the Approval request of a particular system and on a comparative analysis of equipment tested and the individual recipient’s ability to use the equipment as it relates to a medical need. Medicaid will not deny an AAC based solely on the fact that the recipient can communicate in writing. October 1999 2-21
  42. 42. DME/Medical Supply Services Coverage and Limitations Handbook Augmentative and Alternative Communication Systems, continued Medicare Effective January 1, 2001, Medicare began reimbursement of AAC devices. Approval Providers need to be aware that Medicare’s AAC policy differs from Medicaid AAC policy relative to prior authorization criteria. Additional Florida Medicaid reserves the right to request an AAC evaluation of a recipient Evaluation from either another physician or an individual who is board-certified as a Requested by neurologist, physiatrist, otolaryngologist, audiologist, optometrist, or Medicaid ophthalmologist. Service Medicaid reimbursement for AAC system procedure codes includes the Components following service components: • AAC device; • programming needed to custom fit the system to achieve the recipient’s specific speech-language goals; • modifications to adapt the system to the physical characteristics and limitations of the recipient, i.e., wheelchair; and • shipping and handling charges. Trial Period for The ID team (or speech-language pathologist for recipients age 21 and older) AACs may recommend that the recipient have a trial period with the AAC. The trial period must be prior authorized by Medicaid. All the steps for completion of a prior authorization package and the components of the prior authorization package must be completed for a trial period to be authorized. October 1999 2-22
  43. 43. DME/Medical Supply Services Coverage and Limitations Handbook Augmentative and Alternative Communication Systems, continued Rental-Only Medicaid reimburses for rental-only AACs for trial periods. Rental-only AACs reimbursements can continue past the trial period when the ID team (or speech-language pathologist for recipients age 21 and older) recommends and Medicaid approves a continued rental-only situation. Provider Prior to billing for an AAC system, the DME provider is responsible to ensure Responsibilities the properly selected system and all components have been delivered to the recipient and are operational in the recipient’s home. Reimbursement Medicaid will reimburse for one AAC every five years per recipient, and a Limitations software upgrade every two years, if needed. Modifications, which may be in the form of replacing the AAC or upgrading the AAC’s software, may be reimbursed only if the new technology will improve communication significantly. Medicaid will reimburse for replacement of devices, components, or accessories when there is irreparable failure or damage not caused by willful abuse or neglect. Videotape Medicaid may request a videotape to assist with reimbursement status. Requests October 1998 2-23
  44. 44. DME/Medical Supply Services Coverage and Limitations Handbook Bathroom and Toileting Aids Description Bathroom and toileting aids are devices available to assist recipients who are incapable of using regular toilet facilities. Reimbursement Bedpans and urinals may be reimbursed when a recipient is confined to a bed. Limitations A commode may be reimbursed if a recipient has limited or no access to toilet facilities. A detachable or drop arm commode may be reimbursed if a recipient cannot pivot transfer without assistance. Portable paraffin bath units (E0235) may be reimbursed when a recipient has undergone a successful trial period of paraffin therapy and is expected to receive relief through long term use. Compressors Description Compressors are machines that compress air into storage tanks for use by air driven equipment. Service Medicaid may reimburse for an air power source compressor (E0565) when: Requirements • it is used to support medically necessary DME that is not self contained, or • used with a nebulizer that provides at least 50 pounds per square inch (psi). Medicaid can reimburse for a pneumatic compressor (E0650 through E0668). The recipient or caregiver must receive instructions for the pressure to be used while operating the machine and the frequency and duration of use. April 2001 2-24
  45. 45. DME/Medical Supply Services Coverage and Limitations Handbook Cribs (Safety) Description A safety crib is a stainless steel or aluminum constructed crib that has an enclosed top. Service Medicaid may reimburse for a pediatric safety crib (W9762) when it is Requirements prescribed as medically necessary treatment for self-protection. Documentation The following documentation must be included in the recipient record: Requirements • a medical statement that the recipient is confined to bed and will be in the crib at least 18 hours a day; • proof of medical necessity for continued care in the home; • supporting medical information that without the crib the recipient would be institutionalized; and • supporting information that the crib will provide effective treatment or prevent self harm or injury when the recipient bites or chews. Glucose Monitors and Blood Lancets Home Glucose Home glucose monitors are available through the Medicaid Prescription Drug Monitor Program. April 2001 2-25
  46. 46. DME/Medical Supply Services Coverage and Limitations Handbook Glucose Monitors and Blood Lancets, continued Blood Lancets Blood lancet devices are used by insulin dependent diabetics. Blood lancets (A4259) and blood lancet devices (W4165) may be reimbursed only for insulin dependent diabetics. Heat Lamps and Pads Description Appliances or equipment used to apply heat. Heat Lamps And Medicaid may reimburse for heat lamps and heat pads when the application of Pads heat is prescribed for the medical condition. Home Enteral Supplies and Equipment Description Enteral nutrition is the provision of nutritional requirements to the stomach or small bowel via a tube. Service Medicaid may reimburse for home enteral supplies and equipment when the Requirements recipient qualifies for food supplements under the Medicaid pharmacy program and the recipient has a functioning gastrointestinal tract, but regular oral feeding is impossible. April 2001 2-26
  47. 47. DME/Medical Supply Services Coverage and Limitations Handbook Home Enteral Supplies and Equipment, continued Enteral Nutrition Enteral therapy must be administered by nasogastric (B4081-B4082) or Tubes jejunostomy/gastrostomy (B4084) tube. Enteral Nutrition Enteral feeding supply kits must include a one-month supply of the following Supplies And disposable items: Equipment • feeding syringes, tapes/wipes (B4034); • pump sets, containers, syringes, tapes/wipes (B4035); and • lavage sets, containers, syringes, tapes/wipes (B4036). Home Enteral The provider must maintain documentation of medical necessity for the use of Therapy home enteral therapy. The documentation must specify all items and equipment Documentation (including pumps) necessary to support the recipient’s program. The provider must also maintain documentation of training provided to the recipient and caregiver regarding enteral feeding and the required sanitation. Hospital Beds, Mattress, and Rails Description A standard hospital bed consists of a modified gatch spring assembly mattress, bed ends with casters and two manually operated foot end cranks. It is equipped with IV sockets, is capable of accommodating a trapeze bar, side rails, an overhead frame, and other accessories. April 2001 2-27
  48. 48. DME/Medical Supply Services Coverage and Limitations Handbook Hospital Beds, Mattress, and Rails, continued Service Medicaid may reimburse for a hospital bed when the recipient requires Requirements repositioning of the body in a way not feasible in an ordinary bed, or attachments for the bed are required that cannot be used with an ordinary bed. In order to be reimbursed by Medicaid for hospital bed procedure codes E0298, E0250 and E0255, the provider must obtain prior authorization from Medicaid. To obtain prior authorization for hospital beds, the provider submits the prior authorization form and required documentation directly to the Medicaid fiscal agent, not to the area Medicaid office as the provider does for other DME prior authorization requests. Multi-height Bed Medicaid may reimburse for a multi-height bed when it is medically necessary to permit transfer from a bed to a wheelchair or permit ambulation. Justification for the multi-height bed must be included with the prior authorization request and other required documentation. Electric Bed Medicaid may reimburse for an electric bed when the electric bed is medically necessary. The practitioner must determine that the recipient’s condition requires frequent changes in body position and that the recipient cannot tolerate delays in re-positioning. The recipient must be capable of adjusting the position of the bed by operating the controls. April 2001 2-28
  49. 49. DME/Medical Supply Services Coverage and Limitations Handbook Hospital Beds, Mattress, and Rails, continued Hospital Bed The provider must submit the following documentation with the prior Documentation authorization request and maintain copies in the recipient’s record: • the place of service including address; • a description of the recipient’s diagnosis and symptoms; • the length of time the bed will be needed; • the severity and frequency of the symptoms that necessitate a hospital bed for positioning; and • the practitioner’s prescription or signed certificate of medical necessity (CMN). Heavy Duty Extra Medicaid may reimburse for a heavy duty, extra wide bed if the recipient Wide Hospital Bed weighs over 350 pounds. The recipient’s weight should be documented by the practitioner and submitted with the prior authorization request. Mattress Medicaid may reimburse a mattress replacement after four years. Replacement Hospital Bed Rails Medicaid may reimburse for bed rails replacement after eight years. Infusion Pumps Description An infusion pump is a device that is used to deliver solutions containing parenteral medications at a regulated flow. Infusion Pumps Medicaid may reimburse for infusion pumps (E0781, E0791, B9000, B9002) if the recipient is not receiving total parenteral nutrition (TPN) under the Medicaid prescribed drug program. April 2001 2-29
  50. 50. DME/Medical Supply Services Coverage and Limitations Handbook Infusion Pumps, continued Infusion pump An infusion pump (E0781) includes all supplies for the initiation of home Supplies infusion therapy, including dressing kits, injection cap, betadine wipes, alcohol wipes, two inch Dermiclear tape, one inch Dermiclear tape, one quart Sharps container, Destruclip box, and other miscellaneous supplies. Lymphedema Pump Description A non-segmental lymphedema pump (E0650) is a device that has a single outflow port on the compressor that produces a set level of pressure. A segmental lymphedema pump (E0651, E0652) is a device that has multiple outflow ports on the compressor that lead to distinct segments on the appliance which inflate sequentially. E0651 creates the same pressure in each segment. E0652 has calibrated gradient pressure and is further characterized by a regulator on each outflow port that delivers a specified pressure to an individual segment. Service Medicaid may reimburse for lymphedema pumps if medical necessity Requirements indicates this treatment is required for intractable lymphedema of the extremities. Documentation The following must be included in the recipient’s record: • indication that the recipient or recipient’s caregiver has been instructed on the operation of the machine and the amount of pressure to be used and • frequency and duration of use. April 1998 2-30
  51. 51. DME/Medical Supply Services Coverage and Limitations Handbook Nebulizer Description A nebulizer is an apparatus for producing a fine spray or mist. Nebulizer Medicaid may reimburse for a nebulizer if the recipient’s ability to breathe is severely impaired. The documentation of medical necessity must include required medications. Self-contained, When prescribed, Medicaid can reimburse for a self-contained ultrasonic Ultrasonic nebulizer (E0575), including a decontamination filter. Compressor and Medicaid may reimburse for a compressor and heater nebulizer (E0585) for Heater recipients with tracheostomies. Supply Kit The supply kit includes the hand held disposable nebulizer, pediatric or adult size, for use with compressor or regulator with or without tubing, connectors, and filters, with germicide. April 1998 2-31

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