PART II POLICIES AND PROCEDURES FOR DURABLE MEDICAL EQUIPMENT SERVICES GEORGIA DEPARTMENT OF COMMUNITY HEALTH

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1 PART II POLICIES AND PROCEDURES FOR DURABLE MEDICAL EQUIPMENT SERVICES GEORGIA DEPARTMENT OF COMMUNITY HEALTH October l, 2014

2 PREFACE This manual contains basic information concerning the Durable Medical Services (DME) program and is intended for use in conjunction with the Part I Policy and Procedure Manual for Medicaid and PeachCare for Kids, which contains the Statement of Participation and encompasses general terms and conditions for receipt of reimbursement. We urge providers and their administrative and billing staff to become familiar with the contents of this manual and the Part I manual, and to refer to them when questions arise regarding policies and procedures for the proper billing and coding guidelines for these services. Use of the manuals will assist in the elimination of misunderstandings concerning the coverage levels, eligibility, and billing procedures that can result in delays in payment, incorrect payment, or denial of payment. Amendments to this manual will be necessary from time to time due to changes in federal and state laws and Department of Community Health (the Department), policy. When such amendments are made, they will be posted at which shall constitute formal notice to providers. The amended provisions will be effective on the date of the notice or as specified by the notice itself, and all providers are responsible for complying with the amended manual provisions as of their effective dates. Thank you for your participation and interest in Georgia s Medicaid/PeachCare program. Your service is greatly appreciated. Durable Medical Equipment

3 Notices and Summary of Manual Updates (all changes Effective 10/01/2014) The Oxygen Policy has been updated to include: INITIAL ORDER (CMN) REQUIREMENTS All initial orders for oxygen and oxygen related equipment require a blood gas study or pulse oximetry testing to be submitted with the request for prior approval (short-term use does not have this requirement see testing guidelines below). The blood gas study or pulse oximetry test must be the most recent study obtained within 90 days prior to the order for the oxygen therapy. If a member transitions from a Medicaid HMO to FFS Medicaid, then there is not a requirement for a new blood gas study or pulse oximetry test prior to the initial request for oxygen, but the most recent study must be submitted with the request for prior approval with a new order (CMN) for the services. RECERTIFICATION CMN REQUIREMENTS Recertification CMNs do not require repeat testing. The results from the initial qualifying blood gas study or oximetry test may be used on the Recertification CMN as long as the physician completing the order agrees that the oxygen therapy is improving or stabilizing the condition for which the oxygen is required and the medical need for the services still exists. The treating physician should see and re-evaluate the patient within 90 days prior to the recertification. Coverage Added : Continuous Glucose Monitors (A9276, A9277, A9278)- Coverage has been added for members under 21 years of age requiring long-term use of a CGM in the home setting. (See ) CMN Added for Continuous Glucose Monitors (See Appendix G) Coverage Ending: Apligraf and associated skin substitutes (Q4101-Q4111): Effective for dates of service on and after October 1, 2014, fee-for-service (FFS) Medicaid will no longer provide reimbursement for skin substitutes for in home use (HCPCS Code Q4101- Q4111), as a Durable Medical Equipment benefit. E0202- Phototherapy (bilirubin) light with photometer- Effective 10/01/2014 providers should submit this code with no modifier (do not report RR this will generate an error code for the PA requirement) for Medicaid claims. This will not affect the processing of crossover claims that are transmitted with modifier RR. Durable Medical Equipment

4 CMN Revisions: Effective 10/01/2014 providers must include information relating to whether a certificate of medical necessity (CMN) is the initial/revision/recertification of Apnea Monitors, Oxygen Therapy, Full Volume Ventilators and Enteral Nutrition. These CMNS have been revised to include fields for this information at the top of the form and will not be considered complete without this information F2F Requirements- Changed from every 6 months for long term rentals to within 6 months of a new, revised, or recertification of the CMN (annually or as specified whichever comes first). 903 # D & E Have been revised to reflect that providers must have orders for supplies recertified upon expiration or every 12 months whichever comes first. A valid order is always required for items billed. Section 909. Repairs and Maintenance- Revised: Effective 10/01/2014 has been revised to include: 1) Table of Repairs with Allowed Units of Service 14. Quote Invoices for Manually Priced Items This portion of the manual was updated to clarify: 1) The MSRP, Primary Discount, and Net Cost are the required elements on a quote invoice. Secondary and Tertiary discounts are considered proprietary business information and are not required. Submitting a quote without this information is acceptable, but any alteration of the three required elements will cause the PA to be denied. 2) A customer number is an acceptable form of identification as long as the item submitted for reimbursement matches the physician s order /CMN. If an audit occurs during a post payment review and the invoice with a matching customer number is not in the members file the payment is subject to recoupment. Provider Standard This provider standard has been updated to align with the updates listed above for Quote and Purchased invoices of manually priced items. Revised: Accessories (A7015, A7005) for Nebulizer (E0570 NU) This policy has been updated to clarify that A7015 and A7005 are not included in the reimbursement of a nebulizer and may reported separately at the time of purchase. Providers may provide replacement accessories beginning six months after the purchase date, and every six months following if it is reasonable and necessary. July 2014 Durable Medical Equipment

5 Provider Standards: The DME Provider Standards have been updated to include several revisions and additions. Refer to Chapter 600. Appendix F: Stander- The pricing for Standers has now been updated to one fee which will be calculated at 40% above the supplier s cost. Refer to Appendix F for stander updates. Appendix G: Providers are required to submit a Certificate of Medical Necessity (CMN) form with all elements included on the document as listed in the provider manual, effective July 1, Coverage Added: Altera Nebulizers- The Nebulizer policy has been expanded to cover replacement Altera Nebulizers for patients that meet policy guidelines. Revised: Breast Pump Policy- This policy has been revised. E0604 will be covered as a rental only for the duration of the NICU stay for a qualifying newborn and will be returned to the vendor upon discharge. E0603 may be purchased at the time of discharge for a qualifying newborn who has been discharged from the hospital. ICD 10 References have been revised throughout the manual to reflect an effective date of 10/01/2015 pending a final rule from CMS. April 2014 *Important Reminders* Effective 10/01/2015: ICD-10-CM Diagnosis codes must be reported on all claims. There will be no further delays and no exceptions expected as of this update. Providers are expected to be prepared and compliant. Please refer to question #14 in the FAQ section for an extensive list of ICD-10 training and educational resources. Effective June 1, 2014: The National Provider Identifier (NPI) of the ordering, prescribing, or referring (OPR) provider must be reported on DME claims. The OPR must be enrolled in the Georgia Medicaid program or the claim will not be reimbursed. Effective April 1, 2014, Georgia Medicaid will accept paper claims only on the revised CMS 1500 claim form, version 02/12; and on and after April 1, 2014, Georgia Medicaid will no longer accept claims on the old CMS 1500 claim form, version 08/05. ADDED: APPENDIX G- CMN Form for Mobile Device Use as a Speech Generating Device with AAC Therapy Application or Software Durable Medical Equipment

6 APPENDIX I Georgia 360 (formerly Documentation Requirements Appendix) APPENDIX L ICD 10 OVERVIEW (chart of commonly used codes and general equivalency mappings will be added for the July release) APPENDIX M- General Claims Submission Policy for Ordering, Prescribing, or Referring (OPR) Providers (information updated for April 2014) Speech Generating Device policy has been updated to include: Mobile Devices with Qualifying Software covered as a Speech Generating Device (SGD) for Alternative Augmentative Communication (AAC) Therapy REVISED: All references related to reporting ICD 9 codes have been revised to include reference to ICD 10 codes. On or before 09/30/2015 providers must report ICD-9-CM diagnosis codes and on or after 10/01/2015 providers must report ICD-10-CM codes. ALL APPENDICES have been revised as Appendix G now contains all CMN forms. These forms had individual appendices prior to this update; therefore, the other appendices will have a new naming convention. Appendix C- Revised CMS 1500 form- The CMS 1500 and related instructions have been updated to the most current version (02/12) that will be effective on 04/01/2014. Revised Appendix C- New CMS 1500 (02/12) has been added and Detailed Instructions for completing this form have been added to the manual. 12. Proof of Delivery (POD) Revised Revised Section 906- Noncovered Items Added: t) Services billed with a miscellaneous code when there is a designated code that meets the description of the item provided. u) Code combinations contained on the NCCI Table as invalid code combinations for any reason, and codes that exceed the maximum number of units as established on the MUE tables or listed on the DME SMAP or specific policy criteria. Chapter Part B has been revised to replace the terminology AAC device with Speech Generating Device (SGD) for Augmentative and Alternative Communication (AAC) therapy. This verbiage change covers all entries in this chapter. Durable Medical Equipment

7 Appendix K- #12- Proof of Delivery, Method 1-Directly to Beneficiary has been revised to include: Effective July 1, 2007 This will be released in a Banner Message - The technician or representative of the DME provider delivering the equipment must sign and date the delivery ticket. (example: DME Technician Date ) Bone Growth Stimulators has been updated to Osteogenesis Stimulators and a link to the CMS Policy as referenced for coverage guidance has been added Services That Require Prior Approval- has been revised to clarify the information regarding labor/repairs and when a PA is required (See ). January 2014 Physical Therapist Post-assessment for PMDs- This Requirement has been removed Effective 01/01/2014. For PMDs delivered on or before 12/31/2013 this requirement is valid and the assessment should be on file. For PMDs delivered on or after 01/01/2014 this requirement no longer exists (this information has been removed from Chapter 1102 #7 and the Q&A Section- #8 has been revised to reflect this information). Appendix K: Updates: Added-17. NCCI Billing Guidelines (See Also: Chapter 200 in the Part I Provider Manual) Revised: 10. Refills of Items Provided on a Recurring Basis Proof of Delivery Clarification 14. Quotes Invoices for Manually Priced Items: See information in box added as a clarification as it has been identified that the quotes submitted by many suppliers do not meet the guidelines for an actual quote. Coverage Added: B9998- U1 MIC-KEY Low-Profile Gastrostomy Tube Kit. This kit will be covered for ages 0-3 years (36 months). If the kit is billed, then no separate supplies may be reported during the same 30 day period (exception B9998 NU allows the 3 remaining extensions). MIC-KEY Gastrostomy Feeding Tube Kit Components Low Profile Feeding Tube. Proximal Anti-reflux Valve Secur-Lok Extension Set Connector Tapered Distal Tip Durable Medical Equipment

8 Radiopaque Stripe Low Profile Feeding Tube Gauze Appendix G- Added A CERTIFICATION FOR TENS UNIT Coverage Added: E lead TENS Unit Eff. 12/01/2013 Coverage Added: A7047- Oral Interface for use with a respiratory suction pump (E0600) covered at 1 per 6 months (See DMESMAP) Coverage Added for A4452- Waterproof Tape (200 units per month [1 unit = 18sq in]) DME-SMAP updated to include the maximum number of units allowed over time and/or reasonable useful lifetime as indicated in current policy. Section Revised to clarify that DME that is issued for any diagnoses related to conditions that qualify a patient to elect the hospice lock-in benefit are not separately payable through the DME Program. The DMA-521 Hospice Referral form must be attached to the Prior Authorization Request and to the claim if approved Replacing or Repairing Purchased Equipment- has been revised to clarify what is needed to obtain a prior authorization for replacement equipment due to a fire. Provider Standards have been updated: has been revised has been revised (added to follow CMS guidelines for DMEPOS Suppliers) November 2013 Effective November 1, 2013, probes (disposable or nondisposable) will be included in the rental fee for a pulse oximeter. Providers are required to dispense the probes as ordered, but will not receive additional reimbursement for the probes. The rental Fee for E0445 (Pulse Oximeter) has been revised to per month. Durable Medical Equipment

9 October 2013 Appendix K- Documentation Requirements A new appendix has been added to provide guidance on the documentation requirements set forth by the Division. Place of Service Requirements- Effective 10/01/2013 place of service requirements will be strictly enforced. Any DME item billed in a place of service other than the patient s community home will be denied. There are limited exceptions that allow the patient to receive items in a Nursing Facility, Skilled Nursing Facility, or Dialysis Treatment Center (parenteral nutrition only). See REMINDER: NCCI Edits are in effect. You will begin seeing denials for claims from 01/01/2013 to current for Procedure to Procedure and Medically Unlikely Edits. You should become familiar with these edits to avoid unnecessary denials. Systems/National-Correct-Coding-Initiative.html Electric Breast Pumps (E0603, E0604) will be purchase only with NU modifier effective October 1, Breast pumps will only be covered once per 3 years, and if the item is used for multiple pregnancies during the reasonable useful lifetime, only the kits will be covered. Coverage has been added for E0603. E0604 E0240- Billing Guidance added for modifiers NU and U1. Note: Refer to the DME SMAP for pricing of the shower/bath chair. Refer to Appendix D for manual pricing applied to modifier U1 for other rehab toilet aids (excluding noncovered items). July Custom Rehab Providers: Effective July 1, providers of custom rehab equipment must submit a copy of the ATP certification during the prior authorization process. Appendix U: Effective 07/01/2013- The NRRTS Member must submit a copy of a valid certification as an attachment with the prior authorization request. If the NRRTS Member is not present when the OT/PT assessment is performed, then this form cannot be signed, and claims will be denied. HCPCS code K0011 is being end dated for 06/30/2013. Labor and repairs may be prior approved for patients who purchased this item prior to the end date. Durable Medical Equipment

10 Pgs. XI-6 and XI-7 Additional Documentation Guidance was added for Power Mobility Devices. Rev. 07/13 Pg. XI-3, Chapter 1100, #6 was revised to include: The actual wheelchair provided MUST contain all components listed in the retail quote and must be NEW equipment. Used equipment or equipment identified as a Demo is not covered. The equipment must have a 2 year warranty on all major parts and components. Appendix D- was revised by moving all codes that do not require manual pricing (invoice pricing) to the SMAP-DME located on the MMIS website under Fee Schedules. Codes that are not invoice priced have a standard rate whether established from 80% of the 2007 DMEPOS Medicare Fee Schedule or as a DCH Rate C. Wound Care Supplies- Effective July 1, coverage has been added certain wound care items which includes: A4217, A4432, A4452, A5120, A5122, A6021, A6154, A6196, A6197, A6216, A6252, A6402, A6403, and A6446. Existing code A4371 was revised from a maximum allowed of 1 (1oz) to 10 (10oz). Please refer to the Schedule of Maximum Allowable Payments for DME Services for more information on the maximum allowed units and payments. All claims billed in excess of the maximum allowed amount will be denied. Q&A Section Added: A Q&A section has been added to the end of the DME manual to address commonly asked questions. Please refer to this section for guidance on commonly asked questions and concerns expressed throughout the provider community. Revision to the Noncovered Items Section: Added i. Equipment that is not NEW when provided to the Medicaid beneficiary. This includes demos or any equipment that is issued after the warranty has begun. (This does not apply to crossover claims where equipment may be billed as used) Modification/Repairs This section was revised to provide usage guidance for K0739 U1 and U2. April 2013 Affordable Care Act (Ordering, Referring, or Prescribing NPI Requirements): Durable Medical Equipment

11 The Affordable Care Act (ACA) requires physicians or other eligible professionals to be enrolled in the Medicaid Program to order, prescribe and refer items or services for Medicaid beneficiaries. Physicians or other eligible professionals who are already enrolled in Medicaid as billing providers are not required to enroll separately as Ordering, Prescribing, or Referring (OPR) providers. Enrollment of these providers will begin on April 1, Effective April 1, 2014 the National Provider Identifier (NPI) of the ordering, prescribing, or referring (OPR) provider must reported on the DME claim. The OPR must be enrolled in the Georgia Medicaid program or the claim will not be reimbursed. January 2013 National Correct Cording Initiative (NCCI): The Centers for Medicare and Medicaid Services (CMS) has directed all State Medicaid agencies to implement the National Correct Coding Initiative (NCCI) as policy in support of Section 6507 of the Patient Affordable Care Act of March 23, Georgia Medicaid uses NCCI standard payment methodologies. NCCI Procedure to Procedure edits prevent inappropriate payment of services that should not be bundled or billed together and to promote correct coding practices. Based on NCCI Coding Manual and CPT guidelines, some services/procedures performed in conjunction with an evaluation and management (E&M) code will bundle into the procedure when performed by same physician and separate reimbursement will not be allowed if the sole purpose for the visit is to perform the procedures. NCCI editing also includes Medically Unlikely Edits (MUEs) which prevent payment for an inappropriate number/quantity of the same service on a single day. An MUE for a HCPCS/CPT code is the maximum number of units of service under most circumstances reportable by the same provider for the same patient on the same date of service. Providers must correctly report the most comprehensive CPT code that describes the service performed, including the most appropriate modifier when required. For additional questions regarding the NCCI or MUE regulations, please see the CMS website: CMS added the following code for 2013: E2378 (PW ACTUATOR REPLACEMENT) will be an open code for GA Medicaid. Pricing will be updated after CMS announces their pricing expected in July 2013 per CMS. Durable Medical Equipment

12 October, Coverage added for Wearable Cardioverter Defibrillator: Wearable Cardioverter Defibrillator (WCD) K0606 covered for Medical Necessity with a Prior Approval for a maximum of 6 rental months per lifetime. January 1, 2011 Affordable Care Act (Face-To-Face Encounter Requirement): In accordance with the provisions of the Patient Protection and Affordable Care Act of 2010 and in addition to specific prior authorization requirements, the Department of Community Health (Department) will review claims submission effective January 1, 2011, for compliance with the requirement that there must be documentation that there has been a face-to-face encounter between the patient and the treating physician before the treating physician may certify the need for home health services. Additionally, there must be a face-to-face encounter by a treating physician, nurse practitioner or clinical nurse specialist working in collaboration with the physician, or a certified nursemidwife; or a physician assistant under the supervision of the physician during the 6- month period preceding a written order for DME. The face-to-face encounter may be made through the use of telehealth technology and billing the appropriate E&M code. All documentation must be retained for a minimum of five years and made available to the Department upon request. Please refer to Section 904 of this manual for more information. Automatic Refills and Shipping The Department of Community Health (Department) requires that prescription refills be performed and recorded in a manner consistent with state and federal licensure laws rules and regulations. Effective January 1, 2011, automatic refills and automatic shipping to Medicaid members will not be permitted. No items should be billed to the Department prior to delivery to the member. In accordance with Section , Special Conditions of Participation of Part II Policies and Procedures for Durable Medical Equipment (DME) Services, delivery records are to be kept by provider for a minimum of five (5) years. Effective 01/01/2014: For members that receive items through a shipping service, the tracking number of the item delivered (service's package identification number), supplier s invoice number or alternative method that links the supplier s delivery documents with the delivery service's records is required. All prescription refills must be initiated by request from the physician, member, or caregiver and/ or legal guardian authorized to act as an agent of the member. The supplies/equipment must be appropriate for home use The Department does not reimburse under the DME program for supplies or equipment for members residing in a Durable Medical Equipment

13 nursing home or other institution. Refer to Chapter 900, Sections of this manual for information regarding scope of services and the granting of prior approvals for additional supplies. October 1, 2010 Stander modifications and accessories: Effective November 1, 2010, a modifier must be billed in conjunction with either of the DME stander codes, E0637 (Combination sit to stand system, any size including pediatric, with seatlift feature, with or without wheels) and E0638 (Standing frame system, one position (e.g., upright, supine, or prone stander, any size including pediatric, with or without wheels). These updates apply to all paper, Web and EDI claims submissions. The modifiers are as follows: U4, U5, U6, U7, U8, U9 AND UA, UB, UC, and UD. Please refer to Section 1103 (#9) of this policy manual for more information and Appendix F for description and pricing. July 1, 2010 Apligraf and associated skin substitutes (Q4101-Q4111): Effective for dates of service on and after March 1, 2010, fee-for-service (FFS) Medicaid will begin providing reimbursement for a range of skin substitutes (HCPCS Code Q4101- Q4111), with prior authorization. HCPCS code A4221 A4221 (Supplies for maintenance of drug infusion catheter, per week (list drug separately) is now a covered supply by GA Medicaid, effective for dates of service on or after May 1, This is also known as the injection port (I-port), which functions, as a medication delivery channel directly into the subcutaneous tissue. For more information pertaining to prior authorization and units covered, please refer to Section of this manual and Schedule of Maximum Allowable Payments for DME. April 1, 2010 REMINDER Discontinued HCPCS With Crosswalk Code: If a HCPCS code has been discontinued and/or replaced with a crosswalk code, please remember to update your prior authorization (PA) requests with the replacement code before submitting a claim. For example, E1340 U1 and E1340 U2 repair or non-routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes has been discontinued by Medicare, effective January 1, The replacement Durable Medical Equipment

14 CONTENTS PREFACE CHAPTER 600 CHAPTER 700 CHAPTER 800 NOTICES AND SUMMARY OF UPDATES CONDITIONS OF PARTICIPATION SPECIAL ELIGIBILITY CONDITIONS PRIOR APPROVAL Section 801 Section 802 Section 803 Section 804 Section 805 Section 806 Section 807 General Services Which Require Prior Approval Procedures for Obtaining Prior Approval Provider s Review of an Approved Request Billing for Prior Authorized Services Special Considerations Equipment Rentals CHAPTER 900 SCOPE OF SERVICES Section 901 Section 902 Section 903 Section 904 Section 905 Section 906 Section 907 Section 908 Section 909 Section 910 Section 911 General Coverage for Durable Medical Equipment Coverage for Medical Supplies Face-To-Face Encounters Coverage for Nebulizer Accessories Non-Covered Services Purchasing Guidelines Rental Guidelines Repairs and Maintenance Replacing or Repairing Purchased Equipment Out of State Providers and Service Limitations CHAPTER 1000 BASIS FOR REIMBURSEMENT Section 1001 Reimbursement Methodology CHAPTER 1100 CHAPTER 1200 COMPLEX CUSTOM REHAB (PART A) AND OTHER ASSISTIVE TECHNOLOGY (PART B) AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICES (PART B)

15 Appendix A B C D E F G H I J K L M DESCRIPTION SAMPLE MEDICAID ID CARD STATEMENT OF PARTICIPATION INSTRUCTIONS FOR COMPLETING THE PRIOR AUTHORIZATION REQUEST FORM AND CMS 1500 (version 02/12) CLAIM FORM (FORMS ATTACHED) DURABLE MEDICAL EQUIPMENT CODES THAT REQUIRE MANUAL PRICING (MANUFACTURER S QUOTE INVOICE REQUIRED) LIST OF COVERED WHEELCHAIR COMPONENTS OR ACCESSORIES NOT OTHERWISE SPECIFIED () THAT REQUIRE MANUAL PRICING (MANUFACTURER S QUOTE INVOICE REQUIRED) STANDER ACCESSORIES AND MODIFICATIONS CERTIFICATE OF MEDICAL NECESSITY FORMS Apnea/Bradycardia Monitor Group 1 Pressure Reducing Support Surface Continuous Positive Pressure Airway Device (CPAP) Intermittent Assist Device (BIPAP) Transcutaneous Electrical Nerve Stimulators (TENS) Enteral Nutrition (*Must be under 21 years of age*) Hospital Bed Insulin Infusion Pump (Attach manufacturer s Invoice) Continuous Glucose Monitor Nebulizer Oxygen Equipment Patient Lift Suction Pump Full Volume Ventilator Custom Wheelchair (Requires PT/OT Evaluation) Standard Wheelchair (Requires PT/OT Evaluation if under 21years of age) Power Wheelchair (Requires PT/OT Evaluation) Scooter (POV) (Requires PT/OT Evaluation) Mobile Device Used As A Speech Generating Device With AAC Application or Software (Requires SLP Evaluation) GEORGIA HEALTH PARTNERSHIP (GHP) GEORGIA FAMILIES GEORGIA 360 DOCUMENTATION REQUIREMENTS FOR DURABLE MEDICAL EQUIPMENT ICD-10 OVERVIEW (INCLUDES TABLE OF COMMONLY REPORTED CODES) GENERAL CLAIMS SUBMISSION POLICY FOR ORDERING, PRESCRIBING, REFERRING (OPR) PROVIDERS

16 PART II - CHAPTER 600 Rev. 01/14 New 07/14 DME SUPPLIER STANDARDS FOR GEORGIA MEDICAID ENROLLMENT 601. In addition to all conditions of participation in the Medical Assistance Program, as outlined in Part 1, Section 106, Providers of Durable Medical Equipment must: A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements, and agree to adhere to all policies and procedures of the Durable Medical Equipment Program as herein stated and hereafter amended A supplier must provide the Division with a valid business license. A business license is considered valid if it is in accordance with the services to be provided. If the local county business codes do not require a business license, then the provider must submit evidence to that effect to Provider Enrollment A supplier must submit proof of comprehensive liability insurance in the amount of no less than $300, that covers both the supplier s place of business and all customers and employees of the provider. If the supplier manufacturers its own items this insurance must also cover product liability and completed operations A supplier must submit proof of accreditation for each location enrolled in the Durable Medical Equipment Program. All DME suppliers must be fully accredited by a CMS approved accreditation agency by 09/30/2009 in order to receive and retain a provider billing number from Georgia Medicaid. The accreditation must indicate the specific products and services for which the supplier is accredited in order for the supplier to receive payment for those specific products and services. Suppliers must remain accredited for the duration of enrollment as a Georgia Medicaid provider. CMS Excludes a Pharmacy from accreditation if it meets ALL of the following criteria: The total billings by the pharmacy for DMEPOS are less than 5% of total pharmacy sales; The pharmacy has been enrolled as a provider of durable medical equipment and has been issued a provider number for at least 5 years; No final adverse action has been imposed on the pharmacy in the past 5 years; The pharmacy submits attestation, as determined by CMS, that the pharmacy meets the first three criteria; The pharmacy agrees to submit materials as requested during the course of an audit conducted on a random sample of pharmacies selected annually

17 New 07/14 New 07/14 New 07/14 CMS Approved Accreditation Organizations for DMEPOS Providers Include: The Joint Commission (TJC) Commission on Accreditation of Rehab Facilities (CARF) Community Health Accreditation Program (CHAP) Healthcare Quality Association on Accreditation (HQAA) Accreditation Commission for Health Care (ACHC) The American Board for Certification in Orthotics & Prosthetics, Inc. (ABC) Board of Certification/Accreditation (BOC) The Compliance Team, Inc. National Association of Boards of Pharmacy (NABP) The National Board of Accreditation for Orthotic Supplies (NBAOS) DME suppliers are responsible for selecting the appropriate accreditation organization (AO) for their business. Complex Custom Rehab Providers must be accredited through one of the following approved accreditation organizations for the service of Complex Custom Assistive Technology: TJC, CARF, CHAP, HQAA, or ACHC Complex Respiratory Providers must be accredited through one of the following approved accreditation organizations: TJC, CARF, CHAP, HQAA, ACHC or The Compliance Team A supplier must notify their accreditation agency when a new DME location is opened and enrolled in Georgia Medicaid to ensure they are accredited or in the process of becoming accredited All physical locations whether owned or subcontracted, must meet the Georgia Medicaid Provider Statement of Participation requirements and be SEPARATELY accredited in order to receive a provider ID to be reimbursed by Georgia Medicaid. Any accreditation exceptions made by accrediting organizations where suppliers have more than one location in the same state must be submitted to provider enrollment for verification through the accrediting agency A supplier must have an authorized individual whose signature is binding sign the enrollment application for billing privileges.

18 New 07/14 New 07/14 New 07/14 New 07/ A supplier must notify the Provider Enrollment Unit in writing of any change in enrollment status, including changes to the address of the physician location or phone number A supplier must submit all information requested by provider enrollment including, but not limited to, the types of services provided with a list of equipment/supplies and the associated HCPCS codes, and the location(s) to be serviced A supplier must be open to the public for business during posted hours of operation (a minimum of thirty (30) hours per week).exception: Occupational or Physical Therapists and DME providers who are also enrolled in COS 330 who work with custom orthotics and prosthetics An Out-Of-State provider that is enrolled in Medicare may enroll with Georgia Medicaid for the purpose of reimbursement of crossover claims for Georgia residents. See Section 910 for Out-Of-State Providers and Service Limitations for services provided to Georgia Medicaid members in an Emergency or when prior approval is obtained from the Department before the service is provided A supplier must have a physical location on an appropriate site that is within the state of Georgia or within fifty (50) miles of the state border and be in an area in which Georgia residents customarily obtain medical services. The location must have a visible sign with hours of operation posted. The location must be opened to the public, handicapped accessible, and staffed during normal business hours (a minimum of 30 hours per week). The provider must have a physical location that has sufficient storage space for medical records and for the equipment and supplies which they provide A supplier must maintain a primary business telephone listed under the name of the business in a local directory or a toll free number available through directory assistance. The exclusive use of a mobile device, answering machine, or answering service during normal business hours is prohibited A supplier must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking or hold accreditation. New 07/14 New 07/ A supplier must disclose any person having ownership, financial or control interest in the business A supplier must permit Georgia Medicaid or its agents to conduct on-site inspections to ascertain the supplier s compliance with supplier standards or to investigate allegations of fraud, waste, and abuse.

19 New 07/14 New 07/14 Rev. 07/14 New 07/14 New 07/ A supplier may not directly solicit Medicaid beneficiaries. This excludes (1) members that have given permission for the contact in writing (2) members who previously received a covered item for which the supplier is making the contact (3) telephone contact to a member in regards to an item other than the covered item that was previously furnished if the member has received a covered item from the supplier in the previous fifteen (15) months Suppliers are subject to the Anti-Kickback Statute which prohibits the exchange (or offer to exchange), anything of value, in an effort to induce (reward) the referral of Federal/State healthcare program business (reimbursement) Suppliers must maintain copies of current licenses or certifications of the healthcare professionals involved in and qualified to perform services related to complex respiratory services (apnea monitors, volume ventilators, therapeutic ventilators, respiratory assist devices [CPAP/BIPAP]), ALL custom or complex rehab equipment, home phototherapy, or any other equipment requiring licensure or certification as specified, per Georgia Medicaid policy Effective on or after January 1, 2006, Custom/Complex Rehab Providers must be or must have employees who are registrants of NRRTS (National Registry of Rehab Suppliers) AND are ATP (Assistive Technology Professional) certified through RESNA (Rehabilitation, Engineering and Assistive Technology Society of North America). Effective 07/01/2013 providers must submit a copy of the valid certification when requesting a prior authorization. Custom rehab suppliers must have a repair and service department at their physical location with a qualifying repair technician who is available during normal posted business hours (open to the public a minimum of 30 hours per week) A supplier must fill orders and fabricate and fit items from its own inventory or by contracting with other companies for the purchase of items necessary to fill the order. If it does, it must provide upon request copies of contracts or other documentation showing compliance with this standard. A supplier may not contract with any entity that is currently excluded from Medicare or any State Medicaid Program, or from any other Federal Government Executive Branch procurement or nonprocurement program or activity. A subcontractor that only performs these services does not need to be accredited Suppliers must provide binding quotes containing the provider s net cost, primary discounts and MSRP (secondary and tertiary discounts are not required) attached to

20 Rev. 07/14 Rev. 01/14 Rev. 01/14 requests for prior authorization for all items requiring manual pricing (power mobility devices, custom/complex rehab equipment, and miscellaneous items) Suppliers must agree to provide quality items of service and maintain/repair items provided. If complaints are filed with the Division, the Division may perform an investigation and/or review of the provider. If the results of the investigation and/or review indicate noncompliance with Division policies, the Division may perform an additional investigation and/or review to establish continuing competency of the provider. If the results of this investigation and/or review are not in compliance with Division policies, adverse actions as outlined in Part I, Chapter 400 apply A supplier must accept returns of substandard (less than full quantity) and/or inappropriate items (items not meeting quality standards, not properly fitted based on the height and weight of the patient, or not reasonable and necessary for the patient for which it was provided) that were not appropriate for the member at the time the item was fitted, rented or purchased. Providers must submit a refund to Georgia Medicaid or replace the device promptly when these situations are identified. Constituent complaints resulting in replacement of items by another provider for correct item (same or similar services) will result in recoupment of the original item Suppliers must stand behind a two (2) year warranty of the major components of custom wheelchairs (see 902.5) A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable state law, and repair or replace free of charge Medicaid covered items under warranty A supplier must maintain, repair, or replace at no charge items that are being rented (capped or indefinite). These services are considered to be included in the rental fee A supplier must bill the Division their usual and customary fee (usual and customary is defined as the lowest of: the lowest price charged to other third party payers including HMO s or the lowest price regularly and routinely offered to any segment of the general public, but excluding charitable donations) for services provided for which a fee schedule amount exists, unless the item is manually priced on the prior authorization, per DCH Policy. (See-Appendix D/E). For manually priced items, the amount submitted must be the amount that has been approved for reimbursement on the prior authorization A supplier must accept the Division s payment as payment in full for covered services to a patient accepted as a Medicaid member. A patient will be deemed

21 New 07/14 Rev. 01/14 New 07/14 New 07/14 accepted as a Medicaid member if (s)he is eligible as a member for those services, the provider represents or demonstrates to the patient that (s)he will treat the patient as a Medicaid member, or the provider bills the Division for covered services. Note: This does not prohibit the provider from receiving reimbursement from liable third parties in accordance with Division policies. See Part 1, Section A supplier must accept responsibility for providing the appropriate equipment/supplies, setting up and assembling the equipment in the home, and training the patient on the appropriate usage or utilization of the equipment and/or supplies according to the manufacturer s instructions and the Division s policies and procedures. Suppliers are responsible for follow-ups, additional training, compliance monitoring, and maintenance and repairs A supplier is responsible for the delivery of all items supplied and must instruct beneficiaries on the use of Medicaid covered items, and must maintain proof of delivery and beneficiary instructions in the patient s record A supplier must answer questions and respond to complaints of beneficiaries and maintain documentation of these contacts. A complaint resolution protocol must be established to address complaints related to these standards. These records must contain the members name, address, and phone number, health insurance claim number (HICN), a summary of the complaint and any actions taken to resolve the issue. The complaint and resolution record must be maintained at the physical location and must be made available to the Division upon request A supplier must maintain documentation from the Ordering or Prescribing provider for all services billed to Georgia Medicaid for reimbursement. The Ordering or Prescribing provider s information must be submitted on claims submitted to Georgia Medicaid on or after June 1, Suppliers are prohibited from filling out initial clinical evaluation information that is outside of their scope of practice, including but not limited to: Physical Therapy/Occupational Therapy Evaluations, Certificates of Medical Necessity, Prescriptions, or any other document for which they do not hold licensure to complete. DME provider s may only complete or assist in the completion of equipment based information that requires collaboration between the clinical professional and the supplier of equipment Suppliers must make home visits as necessary and regularly follow-up on the all life-supporting equipment for maintenance and member compliance :apnea monitors,

22 New 07/14 volume ventilators, therapeutic ventilators, respiratory assist devices (CPAP/BIPAP), oxygen systems, and insulin or parenteral infusion pumps Suppliers must obtain oxygen from a state-licensed oxygen supplier Suppliers must submit procedure code(s) that most accurately describe the item or service actually provided when requesting a prior authorization or submitting a claim. Rev. 07/14 New 07/14 New 07/ Suppliers are prohibited from submitting claims for items or services that have not delivered prior to the claim submission. The record of delivery (delivery ticket) must be kept on file and must provide verification that the item billed was delivered on or before the date the claim was submitted Delivery tickets for all items must be kept on file for a minimum of five (5) years, and must be signed by the patient or a representative of the patient at the patient s community home. For mail order only items, a printed confirmation of delivery that contains a tracking number and the patients name and demographic information must be present in the patient chart with a packing order describing the items delivered Suppliers are prohibited from denying services to any eligible Medicaid member based on the inability to pay the copayment Suppliers must maintain a complete and accurate patient record in the state of Georgia in accordance with the Conditions of Participation in Part I, Section for no less than five (5) years from the date of service of the most recent claim submitted to Georgia Medicaid for all patients Suppliers must comply with requests for documentation from the Division for any item for which they have attested during the prior authorization process (example: face to face evaluation). New 10/ Suppliers must have on file an invoice correlating to a binding quote for any custom, complex, or manually priced item for which they submitted for and received reimbursement from the Department. This documentation must validate that the item provided is exactly the same item that was reimbursed as evident by the invoice number, MSRP and Net pricing, patient information (customer ID or Name), manufacturer, and serial numbers if applicable. The MSRP, primary discount and resulting net cost, (if applicable), and manufacturer s product numbers must align with the quote that was

23 submitted for prior approval and reimbursement. Any discounts beyond the primary discount; including but not limited to secondary, tertiary or other are considered to be proprietary business information of the supplier and are not required to be submitted to the Department..

24 PART II - CHAPTER 700 SPECIAL ELIGIBILITY CONDITIONS In addition to any eligibility conditions listed in Part I, Policies and Procedures Services Manual Applicable to Medicaid Providers, Section 113, members seeking services under this Program must be referred by a physician, have a prescription signed by the physician and must not be institutionalized. (Refer to Section 902.1) VII-1

25 PART II - CHAPTER 800 PRIOR APPROVAL 801. General Rev. 10/13 Rev. 10/09 As a condition of reimbursement, the Division requires that certain services be approved prior to the time that they are rendered. Prior approval from the Division pertains to medical necessity only, not appropriateness of service. It does not guarantee payment, member eligibility or payment of submitted charges. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows or items that are not appropriately billed together (unbundled) Healthcare Common Procedure Coding System (HCPCS) Coding Georgia Medicaid employs the nationally accepted HCPCS and applicable standards to report/bill for approved DME services. The HCPCS coding scheme for DME includes the following levels of procedure codes: a) Level II Alphanumeric codes for covered Medicare and Medicaid services. These codes begin with A, B, E, K, L, Q (temporary), or S (temporary/non-medicaid). b) Level III Codes created by CMS or its intermediaries for services for which no Level II codes have been established. The Department utilizes unique HCPCS codes to further safeguard against unnecessary or inappropriate use of Medicaid services and against excess payments, as outlined in the Code of Federal Regulations, 42CFR For a list of approved unique HCPCS codes, refer to the Schedule of Maximum Allowable Payments for DME Services, and Appendix D of this manual. The Department does not recognize miscellaneous, unlisted, unspecified, not otherwise specified (NOS) HCPCS codes; except for certain wheelchair accessory services, not otherwise specified (), until such time a unique code is assigned by CMS refer to Appendix E of this manual Services That Require Prior Approval The Division requires prior approval for the services listed below: Medical supplies exceeding the allowed monthly maximums Medical equipment purchases in excess of $ (except as noted as not required) Medical equipment rentals (RR) ALL labor (K0739 U1) ALL repairs for miscellaneous items (K0739-U2) Re. 04/ ALL Repairs exceeding a combined total of $200 require prior approval.

26 802.7 Augmentative and alternative communication devices (AAC) (see Chapter1100, Part B) 803. Procedures for Obtaining Prior Approvals Prior Authorization Request Forms ev. ev. Rev. 01/09 Re Rev. 04/13 Providers can submit requests for prior approval via the web portal at or by fax or mail utilizing the appropriate prior authorization request form (DMA 610). All PA requests for custom wheelchairs, rehab equipment, AAC devices, respiratory equipment and all exceptions must be submitted via the web portal, fax, or mail with all requested attachments. Certificate of Medical Necessity (CMN) attachments for PA requests sent via the web portal will be requested by the review staff (and may be faxed), if it is not attached by the provider. If required information is not submitted, the case is considered incomplete and will be denied for missing information. All initial requests for prior approvals are reviewed by the Department s Medical Review Agent, Alliant GMCF. Review Coordinators, trained in utilization review and URAC standards will evaluate the PA requests in accordance with the DCH DME Prior Approval Medical Review Process Guidelines. Rev. 01/13 Rev. 01/09 Prior approval request forms must be submitted prior to placement of equipment with members. The PA/UM Department will evaluate the medical necessity for the purchase, rental, replacement, or repair of the equipment and/or supply and render a decision within 30 calendar days of the receipt of a completed case. An attending medical physician s prescription or certificate of medical necessity (CMN) must always accompany this form or it will be denied. The physician must sign and date the prescription. Signature stamps or dates are not acceptable. Providers must not alter the signed CMN. Providers must store the original CMN or prescription on file. Durable medical equipment requests must include the manufacturer s name and model number on the PA form. The PA may be denied if the manufacturer s name and model number are not on the request. This information will be listed in Item 19 (Statement of Services) on the CMS 1500 claim form for specific durable medical equipment. All requested items on the CMN must be listed in field 19 of the PA (one item per line). Request forms received beyond ninety (90) days from the requested date of service cannot be retrospectively approved. Instructions for completing the prior authorization request form (DMA-610) are provided in Appendix C. Cases that are considered incomplete will be returned to the provider with a written notification, explaining what is missing. Providers will also have the option to submit the missing information within 30 business days of the date the notification was issued. Untimely cases will be denied. The requestor will be notified, in writing, of the option to appeal a denied case within 30 calendar days of the denial. Providers will receive notification of completed cases within 10 business days of receipt. Notification letters will be sent to both the provider and the member. Decisions may reflect an approval or denial of DME devices and supplies. Any adverse decisions may be appealed per DCH Policy, Part I, Chapter 503.

27 803.2 Prior Approval Requests Prior approval can only be obtained through the web, at by fax, or mail. Rev. 01/09 Questions regarding covered services and prior approvals should be directed to the Automated Inquiry Unit at Once the inquirer has reached the Inquiry Unit, the caller will be instructed to press a specific number depending on the nature of the inquiry Prior Approval Procedure 1. The Review Coordinator enters faxed or mailed PA requests received electronically via the mail center into the required PA screens. 2. The Review Coordinator screens and reviews each request for completeness, timeliness, and clarity, per DCH policy for DME (see DCH Medical Review Procedures). Each request for the purchase or rental of DME devices, accessories, or supplies requiring attachments shall include the following information: a) A prescription from a physician (dated fewer than 90 days prior to the date of service.) b) A DME evaluation prepared by a Georgia Licensed professional in the healing arts may be required (i.e. occupational therapy, speech/language pathology, and physical therapy), giving a comprehensive clinical summary including history, current and projected capabilities and limitations as pertains to the equipment being requested. DME providers may not generate, complete, or alter these documents. c) A complete description of the medical equipment and/or supplies that you are requesting including the model number and manufacturer s name and address. The period of time the equipment or supplies are needed, the number of months the item is needed and if you are requesting a purchase item, the length of time of need must indicate 10 months or greater; d) The member s medical diagnosis or condition requiring the use of medical equipment, accessories, attachments and/or supplies, the reason item is needed; Rev. 04/13 Rev. 10/13 e) The member s specific physical limitations; and f) The physician s handwritten or electronic signature and date the physician signs the medical necessity. Signature stamps and date stamps are not acceptable. g) Results of any previous trial periods of rental equipment. 3. The Review Coordinator and the DCH Program Specialist must discuss requests for DME exceptions to determine appropriate disposition (see DME Exceptions Procedure). 4. Incomplete cases may be denied for missing information and returned to the provider with a written notification of missing data (if any), and the option to submit the missing

28 information within 30 business days. Untimely cases are denied and the requestor is notified of the option to appeal within 30 days. 5. On complete cases, the Review Coordinator approves the cases meeting Inter-Qual or DCH approved policy criteria or will identify areas of concern for Peer Review. Requests for DME devices may be approved for purchase or rental, or may be denied. Requests for attachments, replacements, or repairs should include copies of original warrantees and may be approved or denied. Multiple repairs totaling greater than $ within a calendar year require a PA. An explanation of benefits for the repair history during the previous twelve (12) months must be submitted with the PA request. Rev. 01/09 6. Forms which may assist the provider in obtaining prior authorization for apnea/bradycardia monitors, blood glucose monitors, continuous positive airway pressure devices, intermittent assist devices, enteral nutrition, hospital beds, insulin infusion pumps, nebulizers, oxygen equipment, patient lifts, suction pumps, volume ventilators, and wheelchairs (custom, standard, power and scooter) have been included in Appendix G. The information requested on these forms assists the reviewer in determining medical necessity for the equipment requested. Although the provider is not required to use these forms, the information that the forms contain is vital in the expeditious review and processing of your requests. If the provider has forms that contain this information, they may be used instead of the ones provided in Appendix G. If a prior approval is not required, the forms may be used as prescriptions or detailed written orders to be kept on file by the provider. The Division reserves the right to request additional documentation of the medical necessity and appropriateness of the equipment from other medical or non-medical professionals involved in the patient s care (e.g., physical therapist, home health nurse, school nurse, teachers, manufacturer s invoice or cost price to the provider etc., if applicable). The prior approval (PA) analyst may request any reasonable and necessary information to help assess the medical necessity for the PA process Provider s Review of an Approved Request Providers should carefully review the request for services that have been approved by the Division. The Division must be notified in writing, or by telephone, of a provider s intent not to supply the equipment at the Division s stated maximum rate. The purpose of this is to allow the Division to assist the member in obtaining services elsewhere and to void the prior authorization number in the system. Rev. 04/13 The equipment provided to a member must be the equipment approved by the Division as described to be medically necessary on the prior authorization request form (based on the attending medical physician s prescription) for the Division s allowed amount. The Division does not purchase used equipment except in cases where the equipment was new prior to rental to the same member. All modifications to base equipment must be supported by the prescribing medical physician s detailed written order. Should this information not be present, requests will be adjusted to basic items only.

29 Claims submitted to Georgia Medicaid for reimbursement must be submitted exactly as approved on the prior authorization. For items that are submitted for manual pricing the approved quantity and approved amount must be submitted as approved. Anything submitted in excess of what is approved will be recouped by Georgia Medicaid and referred to Program Integrity if the occurrence is identified as a standard of billing or trend Transfer of Service to another Provider When a member or physician has decided to change providers, there is specific documentation that is needed before the Division can cancel or amend the first prior approval and issue a second: a) The member must notify the Division in writing the date the original provider s equipment was picked up. This notice should be attached to the second provider s prior authorization request Requests for an Extension on the Date of Service If the provider is unable to supply the requested equipment that has been Prior Approved within the approved dates of service and is requesting an extension of time for billing purposes he must: a) Resubmit a new Prior Authorization Request form (DMA-610); and b) Resubmit a new certificate of medical necessity signed and dated by the physician; or c) The analyst may adjust the Prior Authorization form to expedite the review process Billing for Prior Authorized Services General The authorization number in the upper right hand corner of the prior authorization request form (DMA-610) must be entered in box 23 on the claim form for the claim to be reimbursed. Rev. 04/14 The ICD-9-CM (on or before 09/30/2015) or ICD-10-CM (on or after 10/01/2015) (International Classification of Diseases- Clinical Modification) codes entered in box 17 of the DMA-610 must also be entered in box 21 and box 24e on the claim form. Rev. 01/07 Rev. 04/13 The serial number of all purchased wheelchairs, lifts, fracture frames for complete traction, and the foot spring serial number of hospital beds must be entered on the claim with the appropriate purchase modifier. For equipment rentals (RR), enter the serial number on the claim for the tenth (10) month when the equipment is considered to be purchased by the Division. Claims submitted without these serial numbers will be rejected by the system. For both purchases and rentals enter the VP qualifier followed by the serial number. There is no space between the qualifier and serial number (example: VPXXXXXX).

30 The date of delivery must be within the prior approved dates in Box 14 of the DMA-610. The date of service on the claim form may be the same as the date of delivery of the items to the member. Do not bill the Division prior to the date of delivery. Only items that have been prior approved may be billed on the same claim. Do not include items that do not require prior approval on a claim with items that do require prior approval. The billed amount MUST not exceed the amount approved on the prior authorization. Any amount billed in excess of the amount approved on the PA will be subject to recoupment Retroactive Eligibility As outlined in Part I, Section 201.3, claims must be received by the Division within six (6) months from the month that the determination of retroactive eligibility is made. For services requiring a prior approval (PA), the Certification of Retroactive Eligibility (Form 964) or other official forms issued by the county Division of Family and Children Services (see Billing Manual) must be attached to the PA and must be received within sixty (60) days from the effective date the Division enters the retroactive eligibility data into the system. It is the responsibility of the provider to verify eligibility when providing a service Third Party Since the Division of Medical Assistance is the payer of last resort, Retroactive Authorizations may be granted for Medicaid members who have a primary insurance only if the primary insurer has reimbursed for a portion of the price of the equipment previously or if the item submitted is considered to be payable by Medicaid when it is noncovered by the primary payer. When submitting a prior authorization request for possible reimbursement of the balance when another insurance has reimbursed or the allowed amount for items that are covered by Medicaid when the primary pays a zero dollar amount, submit the prior authorization request form with explanation of medical benefits (EOB) attached as if the full amount (retail price), was being requested from the Division. The Authorization Request must be received within sixty (60) days of date on the primary payer s EOB. If the primary insurance company paid the maximum amount the Division allows, additional reimbursement will not be made. Rev. 04/ Medicaid/Medicare If the member has Part B Medicare and Medicaid, then Medicare policy determines the medical necessity of the durable medical equipment or medical supplies as they are the primary payer. Cigna Government Services, Jurisdiction C, is the Medicare

31 Administrative Contractor (MAC) for the state of Georgia. Please refer to: for Medicare coverage of DMEPOS items. The following items are covered by Medicaid but not covered Medicare and may be billed directly to Medicaid without an EOB or the Prior Authorization Request Form. HCPCS MOD Description E0241 NU Bath tub wall rail E0243 NU Toilet Rail E0244 NU Raised toilet seat with clamps E0245 NU Tub stool or Bench E0246 NU Seat, w. clamps/bathtub transfer A4204 NU Absorptive dressing/hydroactive A4500 NU Surgical Stockings, below knee length A4510 NU Surgical Stockings, full length A4495 NU Surgical Stockings, thigh length Nursing Home Residents Who Transition to the Community Members transitioning from a nursing home to the community must have an approved Care Plan/Individual Service Plan (ISP) for placement or community based services by the case manager/support coordinator. The DME vendor may assess the member for complex rehab or other equipment, devices or supplies and obtain prior approval for the items necessary for the community setting. Approved DME items must be delivered to the community home and reported with the appropriate place of service indicating where the item was delivered. Items cannot be delivered to the nursing home/institution. DME items and supplies are only covered when they are provided for use in the patient s home SPECIAL CONSIDERATIONS Respiratory Services A. Complex Respiratory Suppliers: are determined by the scope of service and includes suppliers that meet the following: Rev. 01/09 Rev. 10/09 : 1. Effective September 30, 2009, must be accredited by one of the following Accreditation Agencies a. TJC formerly JCAHO b. CARF c. CHAP d. HQAA e. ACHC f. ABC g. BOC h. the Compliancy Team

32 2. Must be or employ a Licensed Registered Respiratory Technologist (RRT) or a Licensed Certified Respiratory Technologist (CRT). The licensure must be current at all times 3. The RRT or CRT must be employed by one supplier and may not provide services to additional providers 4. Must provide service coverage seven days a week and provide a delivery service 5. Must have a warehouse and qualified repair staff during normal business hours 6. Must be responsible for all delivery, set-up and teaching/instruction of all services provided 7. May provide all respiratory services with no restriction to the codes including oxygen for children B. Non Complex Respiratory: DME suppliers that do not meet the above Complex Respiratory definition: 1. may provide oxygen to adults only (members twenty one years of age and older) 2. may provide nebulizers (E0570 NU/RR) 3. must be accredited by a designated accreditation company approved for regular DME effective September 30, 2009 (See ) i. I Oxygen Coverage: E0431, E0434, E0439, E0441, E0442, E0482, E1390, E1392, K0738 Oxygen therapy is covered for in-home use when it is reasonable and necessary and the member meets all required criteria for coverage. Rev. 04/13 a) The prescribing physician s detailed written order for oxygen must be specific as to the type of oxygen equipment prescribed, supply and delivery systems, liter flow per minute and hours used per day, e.g., compressed gas by nasal cannula at 1.5 liters per minute, hours a day. Intermittent, supplemental or P.R.N. oxygen is not covered. i) Continuous oxygen is based upon: a. physician s interpretation of a blood oxygen analysis report (i.e., arterial blood gas) or b. physician s interpretation of an oximetry study that was performed no more than ninety (90) days from the date the prior authorization is received by the Division. If the member has recently been discharged from the hospital, the study that was performed closest to, but no earlier than 2 days prior to discharge should be utilized in determining coverage of oxygen and oxygen equipment. The original or a copy of the original laboratory report must be submitted with the PA request. ii) Continuous nocturnal oxygen is based upon: a. oxygen saturation at sleep by polysomnograph or IDTF being 88% or less for five (5) continuous minutes or more cumulative b.oxygen saturation during CPAP/BIPAP for five (5) continuous minutes or more.

33 Rev. 04/13 b) Arterial blood gases or oximetry levels are required for all members receiving oxygen. At rest and awake on room air the member must meet either policy criteria number 1 or 2 of the following: 1. Arterial PO 2 at or below 55mmHg or arterial oxygen saturation at or below 88%. 89% plus one of the following: OR 2. Arterial PO 2 between 56 to 59mmHg or an arterial blood oxygen saturation at or below 2a. CHF and dependent/ pitting edema 2b. HCT above 56% 2c. Pulmonary HTN 2d. Right ventricular Hypertrophy 2e. Cor Pulmonale INITIAL ORDER (CMN) REQUIREMENTS All initial orders for oxygen and oxygen related equipment require a blood gas study or pulse oximetry testing to be submitted with the request for prior approval (short-term use does not have this requirement see testing guidelines below). The blood gas study or pulse oximetry test must be the most recent study obtained within 90 days prior to the order for the oxygen therapy. If a member transitions from a Medicaid HMO to FFS Medicaid, then there is not a requirement for a new blood gas study or pulse oximetry test prior to the initial request for oxygen, but the most recent study must be submitted with the request for prior approval with a new order (CMN) for the services. RECERTIFICATION CMN REQUIREMENTS Recertification CMNs do not require repeat testing. The results from the initial qualifying blood gas study or oximetry test may be used on the Recertification CMN as long as the physician completing the order agrees that the oxygen therapy is improving or stabilizing the condition for which the oxygen is required and the medical need for the services still exists. The treating physician should see and re-evaluate the patient within 90 days prior to the recertification. TESTING GUIDELINES Rev. 07/14 PO 2 blood tests must be done by the physician, hospital or a lab. Overnight Oximetry studies may be performed in the home and the data may be submitted to an independent diagnostic testing facility (IDTF) and sent directly to the physician for initial certification of oxygen. PO 2 and Oximetry studies are to be done on room air with the member at rest and be submitted with the PA request. Other conditions under which laboratory tests are performed must be specified, e.g., on oxygen. If the test values do not qualify; however, are a lower than normal value, and the member cannot be tested while breathing room air, supporting documentation is required from the physician. Coverage of oxygen for members with a blood gas study that exceeds the qualifying coverage criteria for PO 2 and pulse oximetry saturations must include documentation from the physician indicating the need for oxygen therapy. Such cases will be reviewed on an individual basis. Please note that members under the age of twenty one (21) are

34 reviewed for medical necessity based on information submitted by the pediatric specialist specific to the needs of the pediatric population, and the specific pediatric diagnosis. The Division may request a consultation from a pulmonologist and/or additional lab studies. c) Oxygen concentrators may be provided if the Liter flow is over.5 L. For those that require a higher concentration of oxygen than what is provided by the base concentrator, the prescribing physician must indicate the need for additional devices to obtain the concentration required. Rev. 04/13 d) Portable oxygen, for the purpose of reimbursement, may be liquid or gaseous. The Division covers portable oxygen for M.D. visits and must be stated as such on the medical necessity or prior approval request. Only one unit of service per month will be approved for reimbursement. If a portable system is covered, the supplier must provide whatever quantity of oxygen the beneficiary uses based on medical necessity; Medicaid s reimbursement is the same, regardless of the quantity of oxygen dispensed. Home Fill Systems (K0738) and Portable Concentrator Systems (E1392) are covered and billed in conjunction with the concentrator (E1390) when medically necessary. e) Members whose records document four or more hours of activity daily (i.e., school, work) may be approved for liquid oxygen. The prescribing physician must document in a separate letter the activities performed and the approximate number of hours the oxygen is reasonable and necessary. f) The Division will reimburse for only one stationary system. The system may be liquid or gaseous. Liquid will be approved only for high concentration users and at the discretion of the Division. Rev. 04/13 g) The Division oxygen purchase and oxygen equipment rental may be approved for up to twelve months. A current qualifying blood gas report and a certificate of medical necessity or detailed written order indicating the need for twelve months of service, must be attached to the prior authorization. h) The Division will reimburse oxygen when it is reasonable and necessary for members with lung-related diseases and cardiac conditions when hypoxemia is present and when improvement with oxygen therapy is indicated. Rev. 11/13 Rev. 10/14 i) Members and/or caregivers and providers must sign a statement that there is no smoking within the member s home this documentation may be in the form of information that is contained on the delivery ticket for the initial delivery of the equipment, a separate attestation form, or an environmental check list as long as the date and signature are captured. j) The Division will cover a pulse oximeter (E0445) for children (up to 21 years of age) who are covered for oxygen therapy services. Probes (non-disposable or disposable) are included in the rental fee for the pulse oximeter, and must be dispensed as ordered. If billed separately, probes will be paid at $0.00 indicating the service is covered, but included in the payment for the more comprehensive procedure (E0445). The MD must document the saturation levels and maintain this information in the medical record.

35 Rev. 04/13 Rev. 07/13 II. k) The Division will cover a Pulse Oximeter and Portable Oxygen for Medically Fragile Children who are trach dependent and who breathe room air, up to the age of five (5) years on a case by case basis through the prior approval process. Either an apnea monitor or an oximeter will be covered, not both. It will be determined through prior approval which device is feasible. No more than six (6) months will be approved per PA request. Ventilator Coverage Volume Ventilator (E0450)/Ventilator w pressure control with trach (E0463)/without trach E0464/Therapeutic Ventilator (BIPAP ST) (E0471) Institutional equipment is considered a non-covered item for home use. Provisions may be made to consider rental of volume ventilators or therapeutic ventilators (i.e., BIPAP ST) that are adaptable for home use should the Division find that it is more prudent than institutional placement of the member. In order for this item to be approved, the Prior Authorization Request form should be accompanied by: Rev.04/13 1) The detailed written order from the member s prescribing medical physician; 2) The copy of a history and physical from the prescribing medical physician; 3) The family and social history from the hospital social worker or discharge planner; 4) The member s medical diagnosis or condition requiring the use of a volume ventilator or therapeutic ventilator; 5) The list of all items or equipment necessary (i.e., back-up unit, suction equipment and supplies) for members to be on home ventilators; and 6) The checklist of the member s environment from the vendor. Rev. 04/13 Rev. 10/13 Rev. 01/14 A Pressure Support Ventilator w/pressure control (E0463) for use with invasive interface (tracheostomy tube [i.e. LTV950]) and E0464 for use without invasive interface (mask) is covered for infants and small children on a case-by-case basis and is a continuous rental for the duration of use, based on medical necessity. Additional information to justify this type of vent must be submitted. In limited cases, when medical necessity has been established, E0464 may be considered for children up to 21 years of age (members over 21 years of age will be considered for coverage on a case by case basis). If the provider is unable to obtain a family and social history from the hospital, then a vendor generated report documenting family and social history may be submitted. The report must be completed and signed by qualified personnel i.e., social worker and/or certified respiratory technician (RT). A certified RT is responsible for equipment set up, training/education on proper usage, and monthly visits to the home for all ventilators unless otherwise specified (not applicable to oxygen systems).

36 Should this information not be included, the Prior Authorization Request form will be returned requesting the submission of all required information. The Therapeutic Ventilator (BIPAP ST) is capped at 10 months rental. Supplies may be requested through prior approval using the purchase procedure codes A7031, A7032, A7033, A7034, A7035, A7036, A7037, A7038, A7039, A7044, and A7046. Rev. 04/13 Rev. 10/12 Note: Reimbursement for the rental of ventilators includes all fees for supplies and maintenance related to the equipment. Resuscitation bag (S8999) may be requested for members on artificial respiration for use during power failure or other catastrophic event. The Flutter device (S8185) and the precursor device (E0480) may be requested for various lung conditions requiring the loosening of mucous plugs and congestion. III. Continuous Positive Airway Pressure Device (CPAP) and BI-Level Positive Airway (BIPAP) and Accessories Rev. 04/14 Guidelines: Sleep Apnea Therapy Criteria includes the following: The patient had a recent sleep study which indicates a Respiratory Disturbance Index (RDI) (also called the apnea-hypopnea index) of 15 or greater; OR The member's sleep study shows an RDI of between 5 and 15, in addition to one of the following: Oxygen desaturation to less than 85% for greater than 20 seconds, or One episode of oxygen desaturation less than 70%, or Daytime somnolence, defined as dozing off at inappropriate times of the day, or A diagnosis of upper airway obstruction based on EEG arousal index over 10 The sleep study shows that the apnea episodes are not of central nervous system origin. A CPAP trial must demonstrate improvement in the member's RDI and increased oxygen saturation level to greater than 85%. Continued Coverage Beyond The First Three Months Of Therapy: Documentation demonstrating the patient has had a face-to-face clinical re-evaluation by the treating physician with documentation showing symptoms of obstructive sleep apnea are improved; and, objective evidence of adherence to use of the PAP device, reviewed by the treating physician this compliance documentation must be kept on file and may be requested by the Division at any time. Adherence to therapy is defined as

37 Rev. 04/13 us of PAP >4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. If a patient is noncompliant the device will no longer meet coverage criteria. Patients with severe COPD, end stage neuromuscular disease and kyphoscoliosis require medical documentation of a severely compromised respiratory status. For patients with respiratory insufficiency secondary to cystic fibrosis, CPAP/BIPAP may be used as a bridge to lung transplantation. The polysomnography (sleep study) must be performed no more than six (6) months from the date the prior authorization is received by the Division and must be performed in a facility based sleep study laboratory (Type 1 sleep study) and not in the home or in a mobile facility. A sleep specialist (i.e.: pulmonologist, otolaryngologist, neurologists, etc.) or the physician treating the condition that requires the respiratory assistive device can prescribe the device, and interpret the sleep study. For a study to be reported as a polysomnogram, sleep must be recorded and staged. Sleep studies should be performed in a hospital, sleep laboratory or by an Independent Diagnostic Treatment Facility (IDTF) that is supervised by a physician (MD/DO) trained in analyzing and interpreting the recordings. and should be attended by a trained technologist. The physician is required to indicate his/her specialty on the Certificate of Medical Necessity (CMN). Equipment provided must be new and have a manufacturer s warranty. The provider is responsible for all set-up and training. CPAP/BIPAP for Sleep Apnea will be prior approved for ten (10) months capped rental to purchase.providers must check compliancy during the ten (10) months and maintain the documentation in their records for audit purposes. If a member is documented as noncompliant, that member may be warned. If noncompliancy continues, the provider must retrieve the device and humidifier (if provided) and not bill Medicaid for any approved months not used. The provider is responsible for the set-up and training of the equipment. Set-up, training /education, home visits and associated professional services must be performed by a credentialed respiratory therapist (RT) or a certified sleep technologist. All supplies and replacement parts are covered through the prior approval process using the appropriate HCPCS purchase procedure code (s). A request for recurring supplies must be submitted and signed for by a physician. IV. Nebulizer With Compressor (E0570 NU) Rev. 07/13 A nebulizer with compressor is reimbursable only if the member has a respiratory related diagnosis and the item has been ordered by the physician treating the associated respiratory condition. A nebulizer is used to deliver aerosol medications for the treatment of respiratory conditions, all medications administered through the use of this device must be listed on the detailed written order, which is kept on file by the provider (See section 903 d).

38 The Division will not reimburse for repairs. Replacement of the medication holder and tubing may be reimbursed by using the appropriate accessory codes (A7015 NU and/or A7005 NU) beginning six (6) after the nebulizer has been purchased. Prior approval is not required. Nebulizers are subject to post payment review and are subject to recoupment if all policy guidelines have not been met. Rev. 10/14 Accessories (A7015, A7005) for Nebulizer (E0570 NU) Accessory codes A7015 and A7005 are not included in the purchase of the E0570 and may be separately reimbursed at the time of purchase. Providers may not replace these accessories until the member has owned the nebulizer for at least 6 months, but may replace them every six months thereafter if it is reasonable and necessary. No prior authorization is required. Accessory codes A7015 and A7005 may be used with purchased E0570 (Nebulizer with compressor) ONLY. When completing CMS-1500 claim forms, list the purchased procedure (HCPCS) code on line one with a billed amount of zero dollars, followed by the accessory procedure code on line 2. The accessory procedure code will be subject to post payment review. Altera Nebulizer Replacements Altera Nebulizer Systems are dispensed with the initial order for aztreonam inhalation solution (Cayston) and are not separately reimbursed. Altera Nebulizers come with a standard two (2) year limited manufacturer s warranty that covers the Altera Nebulizer System, Controller, Nebulizer Connection Cord, and Power Supply. These devices are considered for coverage by Georgia Medicaid as a replacement only, after the two (2) year warranty has expired (two years from the date the device is dispensed). Providers requesting a replacement nebulizer must provide documentation indicating when the initial order for Cayston and the Altera nebulizer were dispensed to the patient and provide a signed receipt of delivery. Georgia Medicaid considers the replacement of an Altera Nebulizer System medically necessary only to administer aztreonam inhalation solution (Cayston) when the member has diagnosis of cystic fibrosis and the member has a lung infection with a positive culture demonstrating Pseudomonas aeruginosa infection. The FDA-approved labeling for Cayston states that it should only be administered with the Altera Nebulizer System. Coverage requirements: - Initial order for Cayston and intial Altera Nebulizer was not dispensed within the previous 24 months (delivery ticket required) - Patient Has a diagnosis of Cystic Fibrosis with Pseudomonas Aeruginosa - Cystic Fibrosis with pulmonary manifestations (On or before 09/30/2015 report ICD-9-CM code ; on or after October 1, 2015 report ICD-10 CM code E84.0) - Pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of diseases classified elsewhere (On or before 09/30/2015 report ICD-9-CM code 041.7; On or after 10/01/2015 report ICD-10-CM code B96.5) - Physician s order indicates that a replacement Altera Nebulizer System & Handset are medically necessary to administer Cayston.

39 Code/Modifier Combination for Altera Nebulizers E0574 U1 (Replacement only, Altera Nebulizer System for use with Cayston) E0574 U2 (Replacement only, Altera Nebulizer Handset for use with Cayston) Respiratory Suction Pump (E0600 NU/ RR) Rev. 04/13 E0600 is a portable or stationary home model respiratory suction pump The pump is an electric aspirator designed for oropharyngeal and tracheal suction. A respiratory suction pump (E0600) is covered for beneficiaries who have difficulty raising and clearing secretions due to: Cancer or surgery of the throat or mouth Dysfunction of the swallowing muscles Unconsciousness or obtunded state Tracheostomy The device will be approved on a case by case basis through the submission of a PA. The suction pump can be rented or purchased based on the prior authorization and method of billing (NU/RR). Supplies and accessories include (A7000, A7002) and will be covered after the base equipment (E0600) is considered to be purchased. These supplies do not require prior authorization. Rev. 01/14 Rev. 04/14 Rev. 04/14 Code A4605 will only be covered for members with a tracheostomy (On or before 09/30/2015 report ICD-9 codes: , , , , V44.0 or V55.0; on or after 10/01/2015 report ICD-10 codes: J95.00, J95.01 J59.02, J95.03, J95.04, J95.09, Z43.0 or Z93.0) who also meet the coverage guidelines described below: Closed system catheters (A4605) are reasonable and necessary only when all of the following are met: o The beneficiary has a tracheostomy described by the listed diagnosis codes (On or before 09/30/2015 report ICD-9 codes: , , , , V44.0 or V55.0; on or after 10/01/2015 report ICD-10 codes: J95.00, J95.01 J59.02, J95.03, J95.04, J95.09, Z43.0 or Z93.0) o The beneficiary requires the use of a covered respiratory suction pump (E0600) as described above, for tracheostomy suctioning o The beneficiary requires the use of a covered ventilator Claims for A4605 suction catheters that do not meet all of the criteria above will be denied as not reasonable and necessary. V. Cough Stimulating Device, Alternating Positive and Negative Airway (E0482) Assists with clearance of secretions when unable to cough and removes bronchial secretions:

40 Amyotrophic Lateral Sclerosis (ALS) Chronic Obstructive Pulmonary Disease Emphysema Muscular Dystrophy Post Polio Syndrome This device will be approved on a case by case basis through prior approval and approved for 10 months rent to cap only. Supplies are A7030, A7034, A7035, A7037, A7038, A7031, A7032 and will be covered after the device is considered purchased. VI. High Frequency Chest Wall Oscillation Air-pulse Generator System (E0483) (includes hoses and vest); maximum allowable reimbursement--$ RR (up to 10 months rental/lifetime maximum $8,505.00) Rev. 04/14 Rev. 04/13 Will be reviewed on a case-by-case basis through prior approval for children under the age of twenty one (21), and over the age of three (3) Will be reviewed for medical necessity for the diagnosis of cystic fibrosis (CF) (On or before 09/30/2015 report ICD-9 codes: , ; On or after 10/01/2015 report ICD-10 codes: E84.0, E84.9;) and Bronchiectasis (On or before 09/30/2015 report ICD-9 codes: , 494.0, 494.1, ; On or after 10/01/2015 report ICD-10 codes: A15.0, J47.1, J47.9, Q33.4), (a) characterized by daily productive cough for at least six (6) continuous months or frequent (i.e. more than 2/year) exacerbations requiring antibiotic therapy, and (b) Confirmed by high resolution or spiral CT scan. Other diagnoses may include: anciliary dysmotility syndromes, and neurologic dysfunction with secondary pneumonias. There must be well-documented failure of standard treatments to adequately mobilize retained secretions, The initial approval based on submitted information for review will be a trial of three months. Supporting documentation for purchase must demonstrate medical necessity, significant improvement of symptoms, no hospital admissions for primary diagnosis as listed above, no absent days from school for illness related to primary diagnosis, 100% compliancy as per physician s prescription and any other information requested by the analyst to assist in the review, Supporting documentation must demonstrate medical necessity as defined in Part I Policies and Procedures for Medicaid/Peachcare for Kids : Medically necessary, medical necessity, reasonable and necessary, or medically necessary and appropriate means medical services or equipment based upon generally accepted medical practices in light of conditions at the time of treatment which is (a) appropriate and consistent with the diagnosis of the treating physician and the omission of which could adversely affect the eligible member s medical condition, (b) compatible with the standards of acceptable medical practice in the United States, (c) provided in a safe, appropriate and cost-effective setting given the nature of the diagnosis and the severity of the symptoms, (d) not provided solely for the convenience of the member or the convenience of the health care provider or hospital, (e) not primarily custodial care unless custodial care is a covered service or benefit under the

41 member s evidence of coverage, and (f) there must be no other effective and more conservative or substantially less costly treatment, service and setting available Infant Apnea Monitor (E0619) The infant apnea monitor is covered for those members whose record documents an episode(s) of apnea and/or bradycardia with the diagnoses of reflux, Respiratory Syncytial Virus (RSV), Whooping cough [Includes Pertussis] or the sibling of a Sudden Infant Death Syndrome (SIDS) victim. The Division will reimburse the initial request for the infant apnea monitor for a maximum of four (4) months. Children with tracheotomies will be eligible for reimbursement for up to two (2) years. The Division may extend the reimbursement period beyond four months rental or two years rental for children with tracheotomies. The Prior Authorization request must have the following attachments: 1) A certificate of medical necessity (CMN) indicating the extended time period and with specific medical documentation that warrants continuation of medical necessity. 2) A one (1) page download summary from the physician indicating the continued apnea or bradycardia events. The Summary must be signed and dated by the MD. Extended requests will be approved at maximum intervals of three (3) months. The Division may request additional information, i.e., a sleep study for members over one (1) year of age. Rev. 10/14 The Division will only reimburse for monitors documenting in real time. The provider must download the monitor and send the report to the physician who prescribed the monitor before the device can be recertified for an extension of service. The provider must check for member compliance (i.e., make home visits, telephone modem). The manufacturer s name and model number must be indicated on the request or the PA may be denied. The provider is responsible for the initial set up and for training the parent or caregiver in the safe and effective use of the apnea monitor. Home health agencies may not bill for training, downloading or home visits to check for compliance with the device. The Division does not reimburse for monitors until the infant is discharged from the hospital Blood Pressure Apparatus and Weight Scales Blood pressure apparatus and weight scales for adults are not covered in the DME Program. This service is covered in the Dialysis Program Standard Wheelchairs

42 Rev. 04/13 Rev. 04/13 Providers that are not Complex Custom Rehab providers (see Chapter 1100, Part A.) may provide standard wheelchairs on a case by case basis through prior approval for short term situations or for conditions that do not warrant an OT/PT evaluation. i.e. fractured limb with no weight bearing allowed. Standard wheelchair codes: E1130 NU, RR, E1140 NU, RR, E1150 NU, RR and E1160 NU, RR and the following: Standard Heavy Duty chairs: E1280 and E1290 are acceptable. Standard heavy duty chairs include seat dimensions up to 24 inches wide and 18 inches deep and member weight up to 350 pounds. Member weight over 350 pounds must be evaluated by an OT/PT at a seating clinic and equipment must be provided by a complex rehab provider Standard Hospital Beds and Bariatric Beds Hospital beds are not approved for ambulatory members. The bed bound status of the member must be described in detail. When requesting prior authorization for hospital beds, documentation must include what positions the member will need to be placed that cannot be met in an ordinary bed. The documentation must also indicate that the member or caretaker can perform these changes in body position only by use of electronic controls. The special positioning of the body must be described in the request. Requests for bariatric beds for members who are morbidly obese must include information regarding weight management. Those members requesting bariatric beds must meet the criteria for a hospital bed. A hospital bed will not be approved for morbid obesity alone. The manufacturer s name and model must be on the PA, or the PA will be denied. The documentation must indicate that the member or caretaker can perform these changes in body positioning only by use of electric controls. The request also must include: 1. What percentage of time member is bed bound; 2. What percentage of time member is left alone; 3. Who is the primary caregiver, what is his or her condition and if the member has decubitus ulcers; and 4. The height and weight of the member. Rev. 04/13 Hospital beds will not be approved for use as cribs or as a convenience item for the member or caregiver who could reasonably use an ordinary bed without adversely affecting any related medical conditions. Hospital beds cannot be approved for safety or convenience reasons only. Diagnoses of Arteriosclerotic Heart Disease, Angina, Congestive Heart Failure or other general cardiac conditions, morbid obesity, epilepsy or mental retardation do not in and of themselves justify the medical necessity of purchasing or renting hospital beds. The foot spring serial number of the hospital bed must be entered in field 24(k) on the claim form (DMA\CMS 1500). For rentals, enter the serial number on the tenth month when the bed is considered purchased. If there are more than ten (10) digits, enter the last ten (10).

43 Rev. 04/13 Hospital beds must accommodate the physical characteristics of the member. The warranty must cover the height and weight of the member and allow for some weight increase. This should include an allowance of up to an additional 100 pounds for bariatric members; see Elastic Support Stockings Rev. 04/13 Rev. 07/13 Rev. 01/14 Rev. 07/13 The Division will reimburse for elastic support stockings only for the specific diagnoses of Arterial Insufficiency with Venous Insufficiency, Chronic Venous Insufficiency, Post-phlebitic Venous Insufficiency, Post-ligation or Vein Stripping. The detailed written order must reflect the member s diagnosis and be kept on file by the provider (See Section 903 d). Elastic support stockings do not require prior approval. Custom compression stockings are noncovered Transcutaneous Electrical Nerve Stimulator (E0720, E0730 RR) A TENS device (E0720, E0730) requires a detailed written order prior to delivery, and a face to face (F2F) evaluation must have occurred within 6 months prior to the date of the order. The ordering physician must be the physician treating the disease or condition justifying the need for the TENS device. Total reimbursement for a TENS device is limited to six months per lifetime. After the completion of 6 paid rentals the device is considered to be owned by the patient. The first rental month is considered to be a trial period (30 day trial). The trial period must be monitored and well documented by the physician to determine the effectiveness of the TENS unit in modulating the pain. If the physician determines the device is effective, then additional rentals will be approved (up to an additional 5 months) and the provider may continue to bill the device. A 4-lead TENS Unit (E0730) may be used with either 2 or 4 leads, depending on the characteristics of the beneficiary s pain. If it is ordered for use with 4 leads, the medical record must document why two (2) leads are not sufficient for the patient s needs. Supplies for TENS units are not separately payable as they are included in the rental of the device, and noncovered once the item is considered to be purchased (after 6 rentals). TENS Units are covered for the treatment of beneficiaries with, chronic, Intractable pain or acute post-operative pain Modification/Repairs (refer to Section 908) Rev. 01/09 Rev. 04/13 Rev. 01/09 Rev. 07/13 Rev. 01/14 Definition: A modification is an addition of a part(s) that was not included on the initial purchase of the base equipment. E1011 (Modification to pediatric size wheelchair, width adjustment package (not to be dispensed with initial chair), may be used to report modification but is on the CMS DMEPOS rate file and is therefore not separately reimbursable. For modifications eligible for reimbursement, use the appropriate HCPCS code that best defines the specific modification or accessory. A repair is a correction or replacement of the original part(s) of a purchased item. The labor component for repairs is coded K0739 U1 (Repair or non-routine service for durable medical equipment requiring the skill of a technician, labor component). K0739 U2 is reported in conjunction with K0739 U1 when repairs are for custom or

44 specialty parts that do not have a HCPCS code. If modifier U2 is used to report custom repairs/parts, then an itemized list must be submitted and the total price must be the submitted charge. **DO NOT report for parts that being replaced** If modifications/repairs are being requested for a complex or customized component of wheelchair, a recommendation from a physical or occupational therapist, actively involved in the member s care, must accompany the medical necessity statement. The therapist may be associated with a school, hospital, clinic or developmental center, but cannot be a vendor or be employed by a vendor. All labor, repairs and subsequent modifications of equipment requires prior authorization. The CMN must be signed and dated by the physician. The Division may request a copy of the manufacturer s warranty for all repairs requiring prior authorization. Copies of all warranties must be kept on file for audit purposes (see 902.4, 902.5). ALL REPAIRS ARE SUBJECT TO POST PAYMENT REVIEW. Providers must keep on file a complete record of the description and justification of all repairs and labor charges submitted for reimbursement. The Division reserves the right to request this information. There is no reimbursement for delivery. Rev. 04/13 The procedure for obtaining a prior approval must include a submitted Prior Authorization Request form DMA-610). Refer to Appendix G for required procedure codes. When completing the Prior Authorization Request form, DMA-610 for modifications, list the purchase procedure code for the based equipment being modified on line one (1) with a 0.00 dollar amount followed by the modification(s) procedure code(s), one modification per line, on the following lines. List no more than a total of six (6) items on any Prior Authorization Request form. If additional forms, DMA-610 are necessary to include further modifications, the purchase procedure code with a billed amount of zero dollars ($0.00) is required on the first line followed by the modifications one per line. When completing any Prior Authorization Request form, DMA-610 for repair(s), list the purchase procedure code with a billed amount of zero dollars ($0.00) on line one (1) followed by the repair procedure code on line two (2). If additional prior authorization forms are required, refer to the above paragraph for specific instructions. Rev. 04/13 This method insures that the Prior Authorization Request form DMA-610 and the Claim Form CMS-1500 will be identical for processing purposes. The detailed written order for repairs of wheelchairs must be signed by the physician who is actively involved in the member s plan of care for the indications necessitating the need for the equipment. (refer to ) Wheelchair Batteries

45 Rev. 01/10 Select wheelchair batteries require prior authorization if the line item charge exceeds $200. These codes include E2361, E2363, E2367, and E2371. Code E2372, located in Appendix D, should be billed by report (BR) with a provider quote and always requires a PA Catastrophic Needs The physician must document the medical necessity in a letter of request, this must be attached to the Prior Authorization Request form (DMA-610) and submitted for review to the Alliant GMCF (Georgia Medical Care Foundation). The Authorization Request Unit will notify the provider of the review decision. The assigned code and any special billing instructions be used when billing Enteral Nutrition Therapy Rev. 04/13 The Division will reimburse for enteral nutrition therapy prescribed by a physician for members under 21 years of age if it is medically necessary due to major impairment of the gastrointestinal tract or associated structures which prevents food digestion or assimilation. Major impairment is defined as any condition of the gastrointestinal tract lasting ninety (90) days or greater. All enteral nutrition therapy must be prior approved for coverage. Enteral formulas are non-covered for individuals who can consume nutrients by mouth (orally) i.e. failure to thrive, autism. If oral nutrition is permitted, the physician must document that the member has an inborn metabolic or genetic disorder i.e. PKU disease, or is unable to tolerate common food products, including liquid food in a can, in sufficient amounts to prevent mental retardation or death. Enteral therapy may be given via nasogastric, jejunostomy or gastrostomy tubes by a caregiver who is capable, able and willing to administer the therapy following appropriate educational training by the provider. Enteral feedings initiated for the convenience of the caregiver, using either pureed foods or equivalent commercial food products are non-covered. Documentation must be provided to indicate that the member s family has exhausted all avenues of coverage available prior to requesting approval for enteral therapy through the DME program. Examples are as follows: WIC funding is depleted; or The number of ounces required per month exceeds the WIC number of ounces allowed. WIC allows 806 ounces per month for infants and 910 ounces per month for children (up to the age of five (5) years) and pregnant women with special dietary needs. All nutritional product requests must be submitted with daily caloric intake needs noted on the Certificate of Medical Necessity (CMN) or prescription as well as the route to be

46 administered (oral/enteral), diagnosis, length of time needed, signature of physician, and the date the physician signed the detailed written order or CMN. Please note all requested information listed above is required on the detailed written order or CMN and not on the prior approval request form (DMA-610). Rev. 04/13 N Rev. 04/13 Nutritional formulas are reimbursed on a per unit basis. Use the following formula to calculate units: Number of calories per day /100 X number of days billed = units. (e.g., A patient received 1450 calories per day, during the month of March /100 X 31 days = or 450 units (fraction of a unit should be rounded. 1/2 or 5/10 (.5) is rounded up to the next whole unit). The detailed written order/medical necessity that is attached to the prior approval for nutritional formulas must include the number of calories per day the member will receive. The Division will determine the number of units to be used per month on the PA, not to exceed 900 per month. Coverage for enteral therapy will be approved initially for three (3) months, and then at periodic intervals of six (6) months and one (1) year. Further requests received following the initial three-month approval must indicate progress of member s growth and development, height and weight and what steps are being taken to wean the member from formula or that removal of formula will never occur due to the specific diagnosis. Formula that is not listed on the Schedule of Maximum Allowable Payments/Units should be sent to the Division on a prior approval form with medical necessity documentation attached and will be coded and priced based on the specific needs of the patient and description of the items provided, on a case by case basis. Additional supplies may be requested through prior approval. These include: B4088 NU (Mic-Key Kit), B4087 NU (other gastrostomy/ jejunostomy tube), B9998 NU (Mic-Key Extensions), B9998 is a NOS code B4081 NU (NG tube w/ stylet), B4082 NU (NG tube w/o stylet), B4083 NU (stomach tube/levine type/feeding tube). These supplies are approved only if the caregiver is changing the tube. A home health company may not bill for the same service. Supplies are not age restricted with the exception of B9998-U1 (up to 36 months of age). Rev. 01/14 B9998- U1 MIC-KEY Low-Profile Gastrostomy Tube Kit This kit will be covered at one unit per month for members ages 0-3 years (36 months). If the kit is billed, then no separate supplies may be reported during the same 30 day period unless they are not included in the components listed below. This kit must be approved through the prior authorization process, and all policy requirements for the coverage of enteral nutrition must be met. MIC-KEY Gastrostomy Feeding Tube Kit Components Low Profile Feeding Tube. Low-profile feeding tube Connectors/clamps Bolus extension set Syringe and cap tip syringe Gauze

47 Electric Breast Pump Coverage (E0603-NU, E0604-RR) Rev. 07/14 Coverage for breast pumps through Georgia Medicaid is limited to instances where there is a medical condition, pre-term birth or low birth weight resulting in extended NICU stay or neurological or congenital anomalies affecting the ability of the baby to breastfeed naturally in the home. Hospital grade electric breast pumps (E0604) are considered reasonable and necessary for infants who are separated from a breast feeding mother due to a critical situation related to an underlying medical condition. During this period, the baby would remain hospitalized in the NICU unit, and the mother would be discharged. In this case, a rental period of up to three (3) months would be considered for coverage, and the pump must be returned to the provider. NOTE: If the medical condition requiring the use of a breast pump is expected to continue after the baby is discharged to the home due to a neurological or congenital anomaly or oral deformity, then the physician should order the home use pump prior to or at the time of discharge. The hospital grade breast pump is rented during the inpatient stay and the home use pump is used after discharge. The DME provider should report the device using the baby s Medicaid ID number effective July 1, Coverage Guidelines E0604-RR: A) Prolonged infant hospitalization (NICU) after the mother is discharged due to pre-term birth, low birth weight or other congenital anomaly B) Infants readmitted to the hospital during the first three (3) months of life Home use electric breast pumps (E0603) are covered for babies with medical conditions that prevent natural breastfeeding abilities who have been discharged to the home. In this case, an electric breast pump would be purchased for use in the home for the duration of need, and the member retains ownership of the device. Coverage Guidelines E0603-NU: A) Baby has a congenital anomaly that interferes with the ability to breastfeed (Example: Cleft lip or palate, Down Syndrome, Pierre-Robin Syndrome, Oral deformity) B) Baby has neurological issues (Example: Cerebral or Facial Palsy) C) Long-term conditions causing sickness or weakness preventing the ability to breastfeed

48 D) NICU baby that is discharged to the home from a prolonged infant hospitalization requiring the use of a hospital grade rental pump Billing Guidelines: Effective 07/01/2014- Breast pumps must be reported using the baby s Medicaid ID to purchase a breast pump after discharge when medically necessary. No prior authorization is required for the rental or purchase of a covered breast pump as these items are subject to post payment review unless the infant is admitted for greater than 3 months. Providers must keep all supporting medical documentation on file for a minimum of five (5) years. All unsatisfied requests for documentation or documentation submitted that does not support the coverage criteria for the device provided will be subject to recoupment. Limitations E0604-RR maximum of three months rentals, per qualifying baby E0603-NU maximum of one purchase, per qualifying baby (additional kits are not covered as the pump may be replaced if an additional pregnancy results in another baby that meets coverage criteria) Breast pumps for healthy babies are not a covered benefit through the DME program. Providers should refer requests for these devices to the WIC Program at Georgia WIC Benefits Research has shown that there is no better food than breast milk for a baby's first year of life. Breastfeeding provides many health, nutritional, economical and emotional benefits to mother and baby. Since a major goal of the WIC Program is to improve the nutritional status of infants, WIC mothers are encouraged to breastfeed their infants. WIC has historically promoted breastfeeding to all pregnant women as the optimal infant feeding choice, unless medically contraindicated. WIC mothers choosing to breastfeed are provided information through counseling and breastfeeding educational materials. Breastfeeding mothers receive follow-up support through peer counselors. Breastfeeding mothers are eligible to participate in WIC longer than non-breastfeeding mothers. Mothers who exclusively breastfeed their infants receive an enhanced food package. Breastfeeding mothers can receive breast pumps, breast shells or nursing supplements to help support the initiation and continuation of breastfeeding Home Phototherapy (E0202) The Division will reimburse for home phototherapy for members with neonatal jaundice (hyperbilirubinemia) for use within the first thirty (30) days of life. The

49 physician is responsible for assessing the appropriateness of home phototherapy each day. The physician determines each treatment and the length of time the infant is to be under the lights based on the serum bilirubin levels and clinical condition of the infant. There must be a separate detailed written order and bilirubin level for each treatment. Rev. 04/13 Rev. 10/14 Any FDA approved home phototherapy system, as prescribed, may be used. The maximum fee is a daily rental rate, all inclusive of equipment, related supplies, and a certified nurse or technician to collect a daily bilirubin level. The bilirubin may be obtained by a certified lab. Home phototherapy is covered for a maximum of five (5) consecutive days and includes all related services (equipment rental, nursing services, blood draw, supplies, and other services, per diem). Prior authorization is not required and no modifier should be reported. The provider must keep the daily prescription and bilirubin levels on file. (See Section 903 d). Home visits and associated professional services must be performed by a current licensed registered nurse or a person currently certified to perform the related services (i.e., certified laboratory technician). A skilled nursing visit may not be billed in the Home Health program for this service. The DME provider must assure that the parent or caregiver has been trained/educated in the safe and effective use of the home phototherapy equipment. The Division does not reimburse for home phototherapy until the member is discharged from the hospital. Rev. 07/13 Phototherapy services may not be billed through the Durable Medical Equipment program when provided for use of a patient who is currently receiving Home Health Services. The home health agency must assure that the parent or caregiver is trained in the safe and effective use of the home phototherapy equipment and guidelines for home health reimbursement must be followed. Refer to the Part II Manual for Policies and Procedures for Home Health Services, Chapter 901.2, Section E Insulin Infusion Pump (E0784) and Supplies (A4230, A4231, A4232, A9276, K0601, K0602, K0603 and K0604) The following criteria for medical necessity must be met: Rev. 01/10 Please note: If the member has purchased an insulin infusion pump, #3 is excluded from the criteria. (1) The member has a diagnosis of insulin dependent type I diabetes mellitus (diagnosed insulin dependent prior to age thirty (30) or gestational diabetes; AND (2) An endocrinologist or physician experienced in providing insulin infusion Therapy orders the insulin pump and states that he/she will monitor the members status while he/she uses the pump AND (3) The physician documents a history of poor glycemic control on multiple daily

50 injections of insulin, including a persistently elevated glycosylated hemoglobin level (HBA1C>7.0%); AND (4) The physician documents additional history of poor control, such as: a) Widely fluctuating blood glucose levels before bedtime, or b) History of severe hypoglycemia (<60 mg/dl) or hyperglycemia (>300 mg/dl), or c) Treatment of secondary diabetic complications requiring more extensive blood glucose control; and (5) The patient has demonstrated the ability and commitment to comply with the regimen of pump care, frequent self-monitoring of blood glucose, and careful attention to diet and exercise, and has received appropriate training on pump usage. Rev.10/13 (6) Insulin pumps must have a total coverage repair or replacement Warranty for four years. After four (4) years Medicaid will allow a request for a replacement Continuous Glucose Monitor (A9276 [sensor], A9277 [transmitter], A9278 [receiver]) A Continuous Glucose Monitoring System (CGM) is a device with three components (transmitter, receiver and sensors) used by placement of a sensor, subcutaneously, to continuously monitor and record glucose levels obtained from interstitial fluid. Realtime readings allow the member to monitor alerts indicating glucose issues and take immediate corrective action. This device does not replace finger stick readings. A CGM ordered for in-home use requires prior authorization and must be prescribed by the endocrinologist who is treating the condition for which the device is ordered. Short-term use of CGM is not covered through the DME program as it is part of a clinical service. Long-term usage (>30 days) requires the submission of a prior approval for the purchase of the transmitter and receiver and the appropriate number of refills for supplies (sensors). Coverage will be considered for members under 21 years of age if: The member has uncontrolled Type 1 Diabetes requiring the use of insulin 3 or more times a day or an insulin pump AND Recurring episodes of at least moderately severe hypoglycemia (<50mg/dl) Hypoglycemic unawareness: patient is not aware of symptom but it may be witnesses by others Poor glycemic control despite at least 4 finger-sticks per day Hypoglycemia overnight Recurring diabetic ketoacidosis (DKA) Specific indications will be considered on a case by case basis when appropriate. Insulin pump usage with poor control

51 Specific cases where CGM use led to improvement in control and the clinician feels that prolonged monitoring is needed for insulin dependent diabetic under 21 CGM is noncovered for: Short-term use Items ordered for convenience CGM may be prior authorized for clients with Type I diabetes that require the use of insulin. The patient must be compliant with his or her current medical regimen, use insulin injections three or more times per day or be on an insulin pump, and have documented self-blood glucose monitoring at least four times per day. To avoid unnecessary denials, the physician must provide correct and complete information, including documentation of medical necessity for the requested services, a prescription for the CGM device, number sensors requested per month, and length of need. Coding Guidelines All components of the CGM require prior approval. The reasonable useful lifetime of the monitor and transmitter is two (2) years, and these items will not be covered for replacement prior to this time. The sensors are designed to be replaced every 5-7 days and will be covered at a standard maximum allowed quantity of four (4) units per month. Refer to the Schedule of Maximum Allowable Payments (SMAP) for for reimbursement rates Communication Devices (L8500) Rev. 04/13 Rev. 04/13 (1) Speech Aid (L8500 NU) Is reimbursable only if the member has had a laryngectomy or the larynx is permanently inoperative. (2) Augmentative and Alternative Communication Device (AAC) Requires the PA and attachments to be submitted for review directly to: Alliant GMCF (Georgia Medical Care Foundation). See Chapter 1100 Part B for all policies and procedure requirements for prior approval. AAC device repairs will follow the criteria of 806.9, 908 and 909. Batteries do not require prior approval unless the item exceeds $200. Prior approval for repairs must be submitted to Alliant GMCF (Georgia Medical Care Foundation) Parenteral Infusion Pump Parenteral infusion pumps and/or supplies are a covered service if the member or caregiver is responsible for the infusion therapy. If a skilled nursing visit has been approved in the Home Health Services Program, the home health agency must supply the pump and/or supplies. A skilled nursing visit may not be billed for this service Home Blood Glucose Monitor

52 Durable Medical Equipment (DME) Diabetic Supply Transition Effective November 1, 2011, The Georgia Department of Community Health (DCH) transitioned the following Durable Medical Equipment (DME) diabetic supplies: insulin syringes, pen needles, lancing device, lancets, blood glucose monitoring strips, and blood glucose monitors to the Georgia Medicaid Fee-For- Service (FFS) Outpatient Pharmacy Program. The following supplies are no longer reimbursable under the DME Program Category of Service (COS) 320: DME SUPPLY CODE Lancet A4259 Glucose Strips A4253 Monitor E2100 (w/integrated voice synthesizer) Only the insulin infusion pump (E0784) and its supplies (A4230, A4231, A4232, K0101, K0602, K0603 and K0604) continue to be reimbursed under the DME program Diabetic supplies are only available through enrolled Georgia Medicaid FFS Outpatient Pharmacies when prescribed by a physician. Georgia licensed pharmacies, when enrolled, are simultaneously assigned to COS 300 and 321. Only providers eligible to enroll in COS 300 and 321 are eligible to dispense approved FFS insulin syringes, pen needles, lancing device, lancets, blood glucose monitoring strips, and blood glucose monitors to non-nursing home Medicaid PeachCare diabetic patients. Claims submitted by pharmacies for FFS members are processed by the Pharmacy Benefit Manager (PBM), SXC Health Solutions, Inc. (COS 300), except for blood glucose monitors which are processed directly through the manufacturer. All claims(including blood glucose monitors)submitted by pharmacies for crossover members (dual eligible) are processed by Hewlett Packard (HP) Enterprises Services through the Medicaid Management Information System (MMIS) (COS 321). Only dual eligible members are eligible to continue to receive services from DME suppliers Intermittent Urinary Catheter (A4353 NU) Intermittent catheterization using a sterile technique is covered when the patient requires catheterization and the patient meets one of the following criteria (1-4). Rev. 04/13 1. The member is immunosuppressed, for example (not inclusive) on a regimen of immunosuppressive drugs post-transplant on cancer chemotherapy has AIDS has a drug-induced state as chronic oral corticosteroid use 2. The member has radiological documentation of vesico-ureteral reflux while on a program or intermittent catheterization.

53 3. The member is a spinal-cord injured female with neurogenic bladder that is pregnant (covered for duration of pregnancy only). 4. The member has had distinct, recurrent urinary tract infections while on a program of clean intermittent catheterization, which has been documented at least twice within the 12-month period prior to the initiation of sterile intermittent catheterization. A urinary tract infection is considered if the member has a urine culture with greater than 10,000 colony forming units of a urinary pathogen AND concurrent presence of one or more of the following signs, symptoms or laboratory findings: Fever (oral temperature > 38 o C (100.4 o F) Systemic leukocytosis Change in urinary urgency, frequency or incontinence Appearance of new or increase in automatic dysreflexia (sweating, bradycardia, blood pressure elevation) Physical signs of prostatitis, epididymitis, orchitis Increased muscle spasms Pyuria (greater than 5 white blood cells (WBCs) per high powered fie Note: Prior Approval requests must have copies of cultures, urinalysis and documented signs and symptoms. Prior Approval requests must be renewed every six (6) months. Rev. 04/ Osteogenesis Stimulators (E0747, E0748 and E0760) Bone growth stimulators are covered on a case by case basis through prior approval. The review staff will utilize the medical necessity coverage criteria developed by Medicare, other Payers, and Inter Qual. Bone Growth Stimulators are reimbursed as new purchased equipment only. Refer to the DME-SMAP for schedule of maximum allowed fees. Refer to: Wound Care Devices (E2402/K0743) Provider limitations: Must have qualified knowledgeable staff able to trouble shoot 24/7 Must have a repair center and qualified repair technicians Must provide quality reliable products with warranties Must be liable to replace products or repair prior to the warranty and cannot replace before the specified lifespan of the product. Must repair products up to specified life of the product Must use accredited Home Health Agencies with Certified Wound Care experts The DME wound equipment expert must collaborate with the certified wound care expert to recommend the appropriate equipment after the assessment

54 Devices and supplies are only covered for members under 21 years of age Assessment: Members must be assessed by a certified wound care specialist. The following are the accepted certified wound care professionals: 1) Licensed Physical Therapist (PT) 2) Enterstomal and Treatment Nurse (ET) 3) Certified Wound, Ostomy and Continence Nurse (CWOCN) 4) Certified Wound Care Nurse (CWCN) 5) Certified Wound Ostomy Nurse (CWON) Wounds must be assessed monthly for medical necessity to continue monthly rental of a Group II or III product and the Negative Pressure Wound Device/supplies. The PA Review Team may reduce the type of surface as per medical necessity as the wound heals. The surface will cap at 10 months Only accredited Home Health Agencies and Centers listed below may provide assessment/recommendation services in the home or in the specified Centers using certified wound care experts (see list above) Wound Care Centers may provide wound care assessment/recommendations Hospital Wound Care Teams may provide assessments/recommendations CMN must be signed and dated by the physician managing the wounds (i.e. plastic surgeon), the certified wound care expert and the DME equipment expert. The certified wound care expert must submit a copy of their certification for wound care and name the Accredited Home Health Agency for whom they are employed Rev. 04/13 A. Pressure Reducing Support Surfaces (PRSS): Pressure Reducing Support Surfaces are capped rental items and are considered to be purchased (patient owned) after ten (10) monthly rental payments. The PRSS must be new equipment. Warranty and life expectancy commences at the date of purchase. Group I: Preventative Surfaces (E0184 NU, E0185 NU, E0197 NU) Group II: Non-powered Advanced Pressure-Reducing Overlay, powered air overlay and non-powered advanced pressure reducing mattress (E0371 RR, E0372 RR, E0373 RR) Group III: Powered Pressure-Reducing Air Mattress (E0277 RR) Low air loss and alternating pressure and combination low air, alternating pressure B. Negative Pressure Wound Therapy Device Negative Pressure Wound Therapy Electrical Pump, stationary or

55 portable (E2402) Wound Care Set for the Negative Pressure Wound Therapy Pump (A6550) Rev. 04/13 Rev. 07/13 (Device and supplies are approved on a monthly basis for the duration of medical necessity. Please note: In addition to DCH Policy, Medical necessity reviews will follow the criteria/guidelines of InterQual, Medicare and other accepted medical necessity standards Wound Care Supplies (A4217, A4371, A4432, A4450, A4452, A5120, A5122, A6021, A6154, A6196, A6197, A6216, A6252, A6402, A6403, A6446) Coverage for wound care supplies is appropriate for the care of acute and chronic wounds, which includes but is not limited to: open ulcers (venous pressure or diabetic ulcers), fistulas, or erosion of the skin due to cancer or related illnesses. Wounds are defined as the following: Acute wounds: Wounds taking less than 30 days for complete healing Chronic wounds: Wounds taking more than 30 days for complete healing These items are covered for use in the home for patients who require wound care supplies in excess of what is provided during Home Care visits by Home Health Providers. The patient or caregiver must be trained in the usage of these supplies and be willing to change these items in the home setting in order for coverage to be considered through the DME Program. No prior authorization is required, however, the diagnoses on the claim and documentation in the medical record must support the medical necessity of the items requested. Please refer to the Schedule of Maximum Allowed Fees for for the maximum allowed units and associated fees. Any item billed in excess of the maximum allowed amount will be denied unless they are listed on the Schedule of Maximum Allowed Fees as requiring a PA if submitted for greater than the maximum allowed. The maximum units for these items are based on a monthly allowance Equipment Rental In reviewing requests for prior approval of equipment rental (RR) services, the Division will take one of the actions listed below: a) Approve the months requested and return the request to the provider. b) Approve an alternate number of months and return the request to the provider.

56 c) Modify the prior approval request and approve the equipment as a purchase. d) Deny the prior approval request and notify the provider of this action. e) In those cases, in which the member s medical need dictates purchase rather than continued rental of equipment, the Division will reimburse the provider for the balance between the rental months previously billed (and/or paid) and any remaining months up to ten months. f) After ten months rental, equipment is considered purchased (except for the items noted in 807(h). Under no circumstances will the provider be reimbursed for more than the ten (10) months rental or for more than the maximum allowable amount for the purchase of the equipment. Approvals will not be given for rentals beyond ten months. When the rental option is chosen, the provider must agree to accept the rental reimbursement as payment in full once the total charges paid by the Division equals the Division s maximum allowed purchase price for the item(s). This requirement does not apply to equipment that may be rented indefinitely. g) Any rental for less than a full month, with a reimbursement allowable greater than $200.00, will be prorated to a daily rate based on the maximum allowable. This amount is submitted to the Division on the DMA For example, rental of E0791 RR (parenteral infusion pump) for ten (10) days will be calculated by dividing the Division s monthly allowable by 30 and multiplying the result by 10. h) Certain kinds of equipment may be rented indefinitely. All supplies are included in the rental fee of the base equipment (tubing, probes, masks etc.) This equipment includes: Liquid oxygen system (E0439) Oxygen concentrators (E1390, E1392) Portable oxygen systems/contents, gaseous and liquid (E0431, E0433, E0434, E0441, E0442) Apnea monitors (E0619)-refer to for criteria and coverage time. Volume ventilator (E0450) pressure control ventilator (E0463 and E0464) Prior authorization must be submitted timely (see 803.1) and must be accompanied by the required documentation (see 803.3). If a request is not submitted timely, the Division will deny the authorization. Providers are not permitted to charge members for durable medical equipment rental while the provider is awaiting a response to a prior authorization purchase request. However, the provider may charge the member for any non-covered durable medical equipment services.

57 Providers are not permitted to bill for rental and purchase of the same piece of equipment in the same month. Rev. 07/13 Providers are not permitted to bill for the rental or purchase of two different pieces of equipment that are considered to be same or similar (i.e., E0100 and E0105 canes, E0176 and E2609 cushions, E0305 and E0310 bed side rails, etc.) during the same rental month for rental items and during the reasonable useful lifetime for purchased items (approved upgrades due to a change in medical condition are excluded). This type of billing will result in claim denials or recoupment of payments.

58 Rev. 04/13 CHAPTER 900 SCOPE OF SERVICES 901. General The Durable Medical Equipment Program reimburses for the purchase or rental of certain medical equipment and accessories and the purchase of certain medical supplies for a patient s use in a non-institutional setting. The items must be prescribed by the attending physician and generally do not have value to patients in the absence of illness or injury. Rev. 01/14 Durable Medical Equipment is covered for members in a hospice for nonhospice related conditions. The hospice agency is responsible for all services related to the terminal illness and any condition related to the terminal illness, including inpatient care and outpatient services. If care/services are required by a hospice patient that is unrelated to the hospice diagnosis, the provider of that care/service must first contact the hospice agency to obtain the hospice diagnosis of the patient before submitting prior authorization for the care/service. Diagnosis codes in the same family of codes will not qualify for separate payment of equipment. Example: Hospice Dx is-respiratory failure, then DME is not separately payable for any equipment that is ordered for the treatment of respiratory related conditions. A DMA-521 Hospice Referral form must be attached to the Prior Authorization Request and the claim. (Refer to Section IV-11 of the Billing Manual for.) 902. Coverage for Durable Medical Equipment The Division will reimburse for equipment in accordance with the following conditions: The equipment must be appropriate for home use. Home is defined as a member s own residence or a relative s home. And, it may not be considered a member s home if it functions primarily as a hospital or nursing facility for inpatients. The Division does not reimburse under the DME program for equipment that is rented, purchased or repaired for members residing in a nursing home or other institution. See for Members who Transition to the Community. Rev. 10/ Coverage for DMEPOS items will be considered if the place of service is: X-1

59 01 Pharmacy 04 Homeless Shelter 09 Prison/Correctional Facility 12 Home 13 Assisted Living Facility 14 Group Home 33 Custodial Care Facility 54 Intermediate Care Facility/Mentally Retarded 55 Residential Substance Abuse Treatment Facility 56 Psychiatric Residential Treatment Center 65 End Stage Renal Disease (ESRD) Treatment Facility (valid POS for Parenteral Nutritional Therapy ONLY) Coverage consideration for DME items in a Skilled Nursing Facility (31) or Nursing Facility (32) is limited to the following: Prosthetics, orthotics and related supplies Urinary incontinence supplies Ostomy supplies Surgical dressings Therapeutic shoes for diabetics Parenteral/Enteral nutrition Custom Wheelchairs (case by case basis under 21 only*) The equipment must be able to withstand repeated use. Rev. 04/13 Rev. 04/14 Rev. 04/ The equipment must be medically necessary. Medical necessity for equipment is established by the physician s detailed written order or Certificate of Medical Necessity (CMN) based on the results of a face to face encounter with the physician treating the condition for which the equipment is needed. The detailed written order must document the member s diagnosis, physical limitations, height and weight if required, prognosis, and it must include an estimate of the length of time that the equipment will be reasonable and necessary The equipment must have a warranty. Providers must honor all warranties expressed or implied under applicable law. Providers must honor manufacturer s warranties. The warranty begins on the date of delivery (date of service) to the member as indicated on the delivery ticket signed by the member or member s authorized representative. A copy of the original warranty must be kept by the provider for audit review by the Division, and the original warranty is given to the member. The Division may request a copy of the warranty. (See 909 for situations not covered by warranty). X-2

60 902.6 Warranty of Custom Seating and Wheeled Mobility Systems: Providers must stand behind a two year warranty of the major components for custom wheelchairs. Rev. 04/13 Rev. 04/13 Rev. 04/11 Rev. 10/13 1.) Manual wheeled mobility base: must have a lifetime warranty on the frame of the wheelchair against defects in material and workmanship for the reasonable useful lifetime of the equipment. i. Excludes tires, casters, upholstery and other consumables ii. Excludes damage caused by neglect, misuse or improper installation, adjustment or repair done by the member, their family or another provider 2.) Powered mobility base: must have a lifetime warranty on the frame against defects in materials and workmanship for the lifetime of the equipment. Additional Warranty: i. Main electronic controller must have a two year warranty from the date of delivery ii. Motors, gear boxes and remote joystick must have a two year warranty from the date of delivery iii. Cushions and seating systems must have a two year warranty or full replacement for manufacturer defects or the surface does not remain intact due to normal wear Face to Face Encounter Requirement: The Georgia Department of Community Health (the Department) in accordance with the Affordable Health Care for All Americans Act, Section 6407, and in addition to compliance with other applicable Policy requires a face to face encounter with patients before physicians May certify eligibility for the initial issuance of base durable medical equipment (DME) under the Georgia Medicaid program. It is a condition of reimbursement that providers evaluating, prescribing, providing, or in any other manner supplying durable medical equipment must comply with the Medicaid policy requirements and documentation standards for face to face encounters for initial and replacement equipment, supplies and modifications. This banner message supplements the December 8, 2010, banner message to DME providers about the face to face encounter requirements. A face-to-face evaluation is defined as a visit during which the patient is seen by a treating physician, nurse practitioner or clinical nurse specialist working in collaboration with the physician, or a physician assistant under the supervision of the physician during which the X-3

61 specific need for the equipment is addressed. The face to face encounter must occur during the six months preceding the written order for DME and the examination must be completed prior to any examination performed by a DME provider. The face-to-face encounter may be made through the use of telehealth technology with billing the appropriate Evaluation and Management (E&M) code. Rev. 04/13 Rev. 04/13 Rev. 10/14 The history and physical examination by the physician or other medical professional and the results of the face to face evaluation must be recorded in the patient s medical record including associated medical and diagnosis information which supports the need for the requested product and/or services. A detailed written order for DME cannot be reimbursed by the Department unless it is written after the face to face evaluation has occurred and the medical evaluation is completed. The detailed written order and attestation statement documenting the face to face encounter must be sent to the equipment supplier within 30 days after the completion of the evaluation. The DME supplier must complete all necessary steps to obtain documentation that the face to face encounter has occurred as a part of the confirmation of the order. The date of the face to face encounter must be specifically set forth in the documentation in the member file with the DME supplier. All documentation must be retained in the member s record for a minimum of five (5) years and made available to the Department upon request. Through Alliant Georgia Medical Care Foundation (GMCF), the Department s quality improvement organization, providers must attest to a face-to-face encounter on all prior authorization requests. An attestation statement must be submitted which requires a Yes or No response and the date of the patient s last office visit. Prior authorizations may be approved for 12 months. A face-to- face encounter must occur between the beneficiary and their treating physician to specifically document that the member was evaluated and/or treated for a condition that supports the need for the item(s) ordered. The face-to-face evaluation must occur within six (6) months prior to prescribing any item that is considered base equipment whether it is rented or purchased. Long-term rentals require a new face-to-face encounter within the six (6) months prior to an initial order and prior to any revision or recertification CMN to establish that the medical need still exists. There are no exceptions. A separate face-to-face examination for each subsequent DME item prescribed (accessories, additions, supplies) is not necessary if the medical justification for the item that is ordered is directly related and X-4 Rev. 07/14

62 Rev. 10/14 has been previously established in the clinical findings of the prescriber through a face to face encounter that was conducted within the previous six months by the prescriber. An example of this would be a headrest order issued for a previously purchased power wheelchair that was approved through the prior authorization process, at which time, the face-to-face was completed. The order for the headrest would not require an additional face-to-face evaluation, but does require prior approval if stated in the policy or SMAP. Standard and customary repairs associated with the regular usage of equipment are excluded from the face to face requirement. Enteral Nutrition providers must follow the standard Face to Face requirements for items that are approved on a 12 month basis and must have evidence of a face to face visit within 6 months of the initial or recertification order for these items. The Department announced the face to face to face encounter requirement in a banner message published in December 2010 which has allowed providers time to establish internal processes for compliance with this requirement The Department will look for appropriate documentation of the encounter by July 1, Coverage for Medical Supplies a) Reimbursement can be made for medical supplies when prescribed by a physician. Supplies for care of a colostomy, ureterostomy, gastrostomy or surgical dressings can be reimbursed. Surgical dressings are defined as the primary therapeutic and protective covering for a surgical lesion of the skin or opening of the skin required as the result of a surgical procedure performed by a physician. Items such as ace bandages, spank boots, knee supports, surgical leggings, gauntlets and pressure garments for the hand and arm are generally used as secondary coverings and would not qualify as surgical dressings. Rev. 04/13 b) DME supplies are limited in the quantity to be dispensed per month. The monthly maximums are stated on the fee schedule. Quantities within the maximum limits do not require prior approval except A4353 NU, intermittent urinary catheters. (See Section ) If it is necessary to exceed the monthly maximum units, prior approval must be obtained and the detailed written order must include justification for exceeding the monthly maximum allowed. The Division will not pay for supplies exceeding the maximum unless prior approval is obtained. Please refer to Section for detailed explanation of this process. X-5

63 c) A prior approval for twelve months may be submitted for members who are permanent or long term users of supplies, (e.g., ostomy bags or urinary catheters for quadriplegics with a neurogenic bladder). Rev. 04/13 Rev. 07/12 Rev. 10/14 Rev. 07/12 d) The current list is set up and priced on a per item basis. Copies of all detailed written orders or letters of medical necessity must be kept on file by the provider for at least five years and renewed every twelve (12) months (or less if the duration on the order is less). e) The provider must prorate and calculate reimbursement based on the division s maximum allowable if providing less than a monthly supply amount. Prescriptions for supplies must be recertified upon expiration or annually (twelve (12) months) whichever comes first, and kept on file. No delivery mileage will be paid on medical supplies. All supplies require prior authorization if the request exceeds maximum units allowed, unless otherwise noted. f) Prescription refills shall be performed and recorded in a manner consistent with existent State and Federal Laws, Rules and Regulations. Automatic refills and automatic shipping are not allowed. Rev. 04/13 Rev. 01/11 All prescriptions for refills shall be initiated by a request from the physician, member, or caregiver/guardian acting on behalf of the member, i.e., family member. g) Providers may not bill for supplies used to provide Home Health Services Prior Authorization Criteria for subcutaneous injection port (I-port) Rev. 07/10 The injection port (I-port) functions as a medication delivery channel directly into the subcutaneous tissue. When applying the I-port, an insertion needle guides a soft cannula (a small, flexible tube) under the skin. Once applied, the insertion needle is removed and only the soft cannula remains below the skin, acting as the gateway into the subcutaneous tissue. The I-port is a single use product cleared for up to 72 hour use and 75 individual injections. This results in approximately ten devices for each thirty days of use. The I-port is packaged in boxes of ten (a one month supply). It is indicated for patients who administer, or to whom is administered, multiple daily subcutaneous injections of physician prescribed medication, including insulin. The use of the I-port is designed to increase the patient comfort where multiple daily insulin injections are required. X-6

64 The I-port is not a benefit of Georgia Medicaid as an item of convenience or for clients already receiving the medication through an ambulatory infusion pump. The device is considered an item of convenience if the client does not meet the criteria for medical necessity that are outlined: Age less than 21 years Does the client have a medical condition that requires multiple (i.e., 2 or more) subcutaneous, self-administered injections on a daily basis and have a current prescription for the injectable medication? AND Indicate which medication is being administered. Medication must be appropriate for this type of administration AND Client or the caregiver been has unsuccessful with the selfadministration of injections using a standard needle and syringe because the client demonstrates a significant needle phobia or reaction, as evidenced by documented physical or psychological symptoms. Documented symptoms may include, but are not limited to, the following: Physical symptoms such as changes in blood pressure, syncope, sweating, nausea, pallor, and tinnitus; psychological symptoms such as extreme anxiety, insomnia, and panic attacks; signs and symptoms such as combativeness, elevated heart rate, and resistance to procedures involving needles or injections. AND CMN required Initial approval for 3 months (1 box of 10 devices per month) Re-approval for 1 year Requirements for re-approval Above, plus- Has the patient experienced improved control of their medical condition through the use of this device? Has the client s demonstrated significant needle phobia or reaction, as evidenced by documented physical or psychological symptoms, improved with the use of this device? New LMN for patients >21 years old Prior Authorization Criteria for Bioengineered Skin Substitutes (Q4101-Q4111) X-7

65 Rev. 07/10 Medicaid covers bioengineered skin substitute when the procedure is medically necessary and: a. The procedure is individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the recipient s needs; b. The level of service can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide; c. The service is furnished in a manner not primarily intended for the convenience of the recipient, the recipient s caretaker, or the provider; and d. The product used has FDA approval for the specified usage. Review criteria for non-infected partial to full thickness skin ulcers due to venous insufficiency OR neuropathic diabetic foot ulcer. Rev. 04/13 I. Venous Stasis Ulcers: 1. Wound must be a partial to full thickness ulcer and > 3 months old. 2. The member must have failed to respond to documented conservative measures. List what measures have been tried, the duration of treatment and result or outcome of the trial. 3. Submit a wound assessment including measurement of the wound at the start of conservative measures as well as measurement on the most recent assessment. 4. Documentation must be submitted that the wound is free from infection and any underlying osteomyelitis. 5. Any treatment of the underlying vascular disease in conjunction with the bioengineered skin substitute treatment must be documented. 6. There must be at least 6 weeks between applications; two applications are indicated. A third application will be considered with detailed documentation of medical necessity. 7. Only enough bioengineered skin substitute should be requested to cover the surface area of the specified wound being treated. II. Neuropathic Diabetic Ulcers: 1. Wound must be a partial to full thickness ulcer and >8 weeks old. 2. The member must have failed to respond to documented conservative measures. List what measures have been tried, the duration of treatment and result or outcome of the trial. 3. Submit a wound assessment including measurement of the wound at start of conservative measures as well as measurement on the most recent assessment. 4. Documentation must be submitted that the wound is free from infection and any underlying osteomyelitis. 5. Documentation must be submitted that appropriate steps have been taken to off-load pressure from the ulcer during treatment. X-8

66 6. There must be at least 3 weeks between applications. Reapplication of a skin substitute is not recommended after 3 applications. 7. Only enough bioengineered skin substitute should be requested to cover the surface area of the specified wound being treated Face-to-Face Encounters Rev. 01/11 Rev. 04/13 Rev.04/13 The Department of Community Health, in accordance with the Affordable Health Care for All Americans Act, Section 6407, requires a face-to-face encounter with patients before physicians may certify eligibility for durable medical equipment (DME) under the Georgia Medicaid program. To ensure compliance with the federal requirement there must be: 1) A face-to-face encounter by a treating physician, nurse practitioner or clinical nurse specialist working in collaboration with the physician, or a certified nurse-midwife; or a physician assistant under the supervision of the physician during the 6-month period preceding a written order for DME; and 2) Providers must obtain a signed, detailed written order certifying that the patient received an office visit prior to obtaining any DME. Providers are to continue to adhere to the DME policies and procedures currently in place, in addition to this federal requirement. These conditions apply to ALL DME services. Alliant Georgia Medical Care Foundation (GMCF), the Department s quality improvement organization, requires providers to attest to a face-to-face encounter on all prior authorization requests. An Attestation Statement must be submitted, which requires a Yes or No response and the date of the patient s last office visit. The face-to-face encounter may also be made through the use of telehealth technology by reporting the appropriate Evaluation and Management (E&M) code. All documentation must be retained in the patient s record for a minimum of five (5) years and made available to the Department upon request. For more information on the Affordable Health Care for All Americans Act, refer to the following website: Coverage for Nebulizer Accessories Rev. 04/13 Reimbursement may be made for nebulizer supplies essential to the effective use of the nebulizer device. On line billing requires: one (1) the provider must enter the HCPCS code for the nebulizer at $0.00. The provider must use HCPCS code A7015 NU Line three (3) and A7005 NU (line 4). X-9

67 906. Non-Covered Services Devices and equipment that are primarily and customarily used for non-medical purposes are not covered. A partial list of non-covered items is listed below: Rev. 10/13 Equipment that is useful in the absence of illness or injury (walker/stander, diapers, bath seats for infants etc.) or equipment that is not age appropriate (power wheelchairs for toddlers) and causes concern for the safety of the patient is not covered by Georgia Medicaid, and will be denied. a) Environmental control equipment (e.g., air conditioners, dehumidifiers, air filters or purifiers); b) Comfort or convenience equipment (e.g., vibrating beds, over-the-bed trays, chair lifts, or bathtub lifts); c) Institutional-type equipment (e.g., cardiac or breathing monitors except infant apnea monitors and ventilators); d) Equipment designed specifically for use by a physician and trained medical personnel (e.g., EKG monitor, oscillating bed and laboratory testing equipment); e) Physical fitness equipment (e.g., exercise cycle, Moore Wheel and exercise treadmill); f) Most self-help devices (e.g., Braille teaching texts); g) Training equipment; h) Precautionary-type equipment (e.g., preset portable oxygen units); i) Furnishing-type equipment (e.g., infant cribs); j) Incontinence items (e.g., diapers, pads and adult briefs); k) Nutritional supplements and formula for members who eat by mouth (see exceptions under Section ); X-10

68 l) Reimbursement for delivery or delivery mileage of medical supplies; m) Equipment considered experimental or under investigation by Public Health Service; Rev. 01/10 n) Infant and child car seats, activity chairs, corner chairs, tripp trapp chairs, floor sitters, feeder seats, hi or low seats, etc.; o) Blood pressure monitors and weight scales; p) Safety alarms and alert systems; Rev. 10/09 q) All procedures listed in the HCPCS or CPT description as unlisted, unspecified and/or miscellaneous that have not been designated as Covered by a specific code or modifier, per Georgia Medicaid ( etc.) r) Services billed using non-covered HCPCS or CPT codes Rev. 04/13 Rev. 04/14 s) Durable Medical Equipment that is not intended to be used primarily inside the patient s home (i.e. wheelchairs for outdoor use only) excludes portable oxygen and wheelchairs etc. that are required for use inside and outside the home (school, physician visits, community based ADL). t) Services billed with a miscellaneous code when there is a designated code that meets the description of the item provided. u) Code combinations contained on the NCCI Table as invalid code combinations for any reason, and codes that exceed the maximum number of units as established on the MUE tables or listed on the DME SMAP or in specific policy criteria. If coverage is uncertain, the provider should contact the Division prior to dispensing the item. Telephone numbers are listed in Section Purchasing Guidelines Rev. 04/13 The Division will purchase equipment when purchasing appears more economical than renting. When the period of need is estimated by the physician to be ten or more months, the provider should request prior authorization for purchase instead of rental. The original detailed written order must be kept on file by the provider for at least five years. The Division will purchase only new equipment. When equipment has been rented for ten months and thus considered purchased by the Division, the provider must replace the rental equipment with comparable equipment if the item must be replaced during the reasonable useful lifetime. X-11

69 908. Rental Guidelines The provider must submit a Prior Authorization Request form (see Chapter 800) for rental approval covering the anticipated months. Rev. 04/13 Rev. 01/14 Rental reimbursement is based on the reasonable cost for the equipment that meets the member s medical needs. The provider may not charge for features on equipment that are not reasonable and necessary to meet the needs required by the member s condition as noted on the detailed written order. The standard rental period for capped rental items is 10 months unless the policy states otherwise (example: TENS units are purchased after 6 rentals) Repairs and Maintenance Rev. 10/14 Table of Repairs with Allowed Units of Service Effective for dates of service on or after October 1, 2014, Georgia Medicaid is implementing payment policy for common repairs based on standardized labor times. This applies to non-rented and out-of-warranty items that are owned by the member. This applies to providers who report K0739 (REPAIR OR NONROUTINE SERVICE FOR DURABLE MEDICAL EQUIPMENT OTHER THAN OXYGEN REQUIRING THE SKILL OF A TECHNICIAN, LABOR COMPONENT, PER 15 MINUTES) for prior authorization and claims reimbursement. One unit of service = 15 minutes. The following table contains repair units of service allowances for commonly repaired items. Units of service include basic troubleshooting and problem diagnosis. Suppliers are reminded that there is no Medicaid payment for travel time or equipment pick-up and/or delivery, and providers are prohibited from billing Medicaid members from these services Suppliers may only bill up to the maximum allowable units of service listed in the table for each repair. Prior authorization for repairs, including any repairs not listed above, must contain information itemizing each repair and the time taken for each repair. Suppliers are also reminded that Medicaid does not pay for repairs to items during the rental period (capped or indefinite) or items under warranty. Type of Equipment Part Being Repaired/Replaced K0739-Allowed Units of Service (UOS) Power Wheelchair Batteries (includes cleaning and testing) 2 Power Wheelchair Joystick (includes programming) 3 X-12

70 Power Wheelchair Charger 1 Power Wheelchair Drive wheel motors (single/pair) 3 Routine maintenance, repairs, and replacement of rented equipment are the sole responsibility Power or Manual Wheelchair Wheel/Tire (all types, per wheel) 1 Power or Manual Wheelchair Armrests or arm pads (pair) 2 Power Wheelchair Shroud/cowling 2 Manual Wheelchair Anti-tipping device 1 Hospital Bed Pendant 2 Hospital Bed Headboard/footboard 2 Routine maintenance, repairs, and replacement of rented equipment are the sole responsibility o p a y m e n t and should not be submitted for separate reimbursement. Repairs to purchased equipment are covered when a repair is necessary to make the equipment serviceable and the warranty has expired. (Refer to Section ) All repairs for purchased equipment require prior authorization. A detailed written order or certificate of medical necessity (CMN) for repairs requiring prior authorization must be signed by the physician. CPAP Blower Assembly 2 Seat Lift Hand Control 2 Seat Lift Scissor mechanism 3 Stander Leg straps, Harnesses, Slings, any type 1 Patient Lift Hydraulic Pump 2 All Other Approved Repairs N/A 1-8 depending on PA decision REPAIRS WILL BE SUBJECT TO POST PAYMENT REVIEW. Routine periodic servicing of equipment is not covered. Equipment will not be repaired due to the member s negligence or abuse. Providers must keep on file a complete record of the description and justification of all repairs and labor charges submitted for reimbursement. The Division reserves the right to request this information. Providers must have the capability to repair and perform routine maintenance on purchased equipment placed for Medicaid members. All repairs and routine servicing of equipment must be performed in a reasonable length of time. The provider also must be available to answer questions by Medicaid members about the equipment. If the expense for the repairs exceeds the expense of the purchase or rental of another like item, the amount for repairs cannot be reimbursed. Repair estimates and the retail price quote of the equipment must accompany a PA for new equipment. Repairs and modifications must be prior authorized by the Division on Form DMA-610 (See 806.9). Extensive or periodic maintenance recommended by the manufacturer, performed by an authorized technician is covered. When the manufacturer s warranty expires, quadriplegics unable to service their wheelchairs may take them to an enrolled provider for routine servicing X-13

71 twice each calendar year. Prior authorization is required for this servicing, including labor Replacing or Repairing Purchased Equipment Rev. 01/14 Replacement or repair of equipment is covered in cases of occurrences (e.g., from fire), or when the member s condition changes. Equipment will not be replaced due to the member s negligence and/or abuse (e.g., a wheelchair left outside, struck by vehicle, lost/abandoned). Equipment will not be replaced before its normal life expectancy has been attained (see following list) unless supporting medical documentation of a change in the physical condition of the member is submitted for prior approval. In addition, a purchase estimate and supporting documentation must be submitted as to the reason for replacement of purchased equipment (e.g., fire report). A new CMN (if required) or order for the replacement equipment must accompany the fire report when submitting a prior authorization. You will not be required to submit PT evaluations in this circumstance, but note that if the equipment was not on file prior to the fire, then you must submit a PA and follow all policy guidelines for documentation as this would be considered an initial order and not a replacement due a fire. The following is a list of the life expectancy for certain equipment that the Division considers reasonable: Revision Dates Durable Medical Equipment Air Compressor/Generator Reasonable Useful Lifetime 10 Years Adult Wheelchair (21 or older) Power or Manual 5 Years 10/13 Wheelchair Power or Manual (under 21) 3-5 Years (case by case) 01/14 Pediatric Wheelchairs (KidKart etc.) 2-3 Years Breast Pumps 3 Years Hospital Bed 8-10 Years Hospital Bed Mattresses 4-6 Years 04/08 Group I Pressure Reducing Support Surfaces 3 Years 04/08 Group II/III Pressure Reducing Support Surfaces 5 Years Hoyer Lift 6-8 Years Oxygen Equipment (indefinite Rental) 5 Years (or as needed) Respiratory and Other Breathing Equipment 6-8 Years 07/13 CPAP/BIPAP 4-5 Years Suction Pumps 3-5 Years 10/13 Inexpensive Routinely Purchased Equipment 2-5 Years (Nebulizer/Walker/Bedside Commode, etc.) Crutches 1-3 Years PEN Infusion Pump 8 Years 01/08 Insulin Infusion Pump 4 Years 01/11 Speech Generating Devices 3-5 Years 07/14 Stander 3-5 Years X-14

72 Rev. 01/14 Base Equipment without a designated reasonable useful lifetime 3-5 Years 10/14 For replacement guidelines of supplies refer to the SMAP See SMAP Base Equipment without a designated reasonable useful lifetime may be replaced every 3-5 years if it is medically necessary. Replacement wheelchairs purchased for growing children will continue to be evaluated on the medical documentation submitted for each individual child. When durable medical equipment is damaged or destroyed by a third party (e.g., a car accident), the third party is liable for repairs or replacement when the third party is at fault. Attempts should be made to collect the full or partial payment from the third party s insurance company. The Division may require documentation regarding liability insurance (e.g., homeowner s fire insurance) Out-of-SOut Of State Providers and Service Limitations Out-of-state providers not enrolled in the Georgia Medicaid program may be temporarily enrolled as Participating Providers and will be reimbursed for covered services provided to eligible Georgia members while out-of-state if the claim is received within twelve (12) months from the month of service and if at least one of the following conditions are met: A) The service(s) was prior authorized by the (Alliant GMCF) Division and the provider is enrolled as a Temporary Georgia provider in the DME Program. B) The service(s) was provided as a result of an emergency or lifethreatening situation occurring out of state and the Provider is enrolled as a Georgia Temporary Provider in the DME Program. Rev. 10/09 The Division will enroll DME providers outside the State of Georgia only if the following criteria are met: A) The DME provider is supplying products with limited or exclusive distribution channels for which there is no such potential provider within the State of Georgia. B) Other exceptions due to extenuating circumstances which may impair access to. Such exceptions are solely at the discretion of the Georgia Department of Community Health. Reimbursement and coverage for of out-of-state services are determined through prior approval and the rate will be based on the policies and procedures and/or rates established in the Georgia DME Program. X-15

73 PLEASE NOTE: Requests for prior approval or questions regarding out-ofstate services must be directed to: Alliant GMCF PA/UM Department PO Box Atlanta, GA Fax (678) The web address is the DME can be submitted by web, fax or mail. Out-of-state claims must have a copy of the authorization letter attached if services were prior approved or the medical justification of the services was due to an emergency. PART II - CHAPTER 1000 BASIS FOR REIMBURSEMENT The maximum reimbursement for providers of durable medical equipment is limited to the lower of: a. The actual charges for the item; or b. 80% of the 2007 CMS DMEPOS rate Rev. 10/13 1) Member co-payment: Effective for dates of service July, 1, 1994 and after, for members 21 years of age and older, a $3.00 co-payment will be applied to all DME services with the modifier NU except for DME supply procedure codes ( A codes). Procedure codes E0441 and E0442 are exempt from co-payment. A $3.00 co-payment will be applied to the following rental procedure codes: E1390 RR, E0431 RR, E0434 RR, E0439 RR, E0439 QE, E0439 QF, E0450 RR, E0463 RR, E0464 RR, E0470 RR and E0784 RR. A $1.00 co-payment will be applied to all other procedure codes that have a modifier of RR. ILLUSTRATIVE CO-PAYMENTS X-16

74 Durable Medical Equipment Rentals (RR) (excludes oxygen Per Month Durable Medical Equipment Purchases (NU) Per item Durable Medical Equipment- Portable or Stationary Oxygen Rentals (RR) Oxygen Contents- E0441 and E0442 Durable Medical Equipment-Supplies ( A ) codes $1.00 $3.00 $3.00 No co-pay No co-pay X-17

75 CO-PAYMENTS FOR PEACHCARE FOR KIDS Effective for services provided on or after April 1, 2012, the Department of Community Health will implement co-payments for covered services to PeachCare for Kids members six years of age and older. The co-payments are subject to fee-for-service rates. They will be deducted from the amount paid on each claim filed. Co-pays are not required for children who are American Indians or are Alaska Natives. The provider cannot deny services to any eligible PeachCare for Kids member because of the member's inability to pay the co-payment. The provider should check member eligibility In order to identify those individuals who may be responsible for the co-payment. If you have questions, contact HP Enterprise Services Contact Center at (770) or (800) Listed below are the PeachCare for Kids co-payment amounts: ILLUSTRATIVE CO-PAYMENTS Durable Medical Equipment Rentals (excludes oxygen Per Month Durable Medical Equipment Purchases Per item Durable Medical Equipment- Portable or Stationary Oxygen Rentals Oxygen Contents- E0441 and E0442 Durable Medical Equipment-Supplies ( A ) codes $1.00 $3.00 $3.00 No co-pay No co-pay XI-1

76 CHAPTER 1100 PART A Complex Custom Wheeled Mobility and Other Rehab Equipment 1101 SUPPLIERS: Rev. 01/09 Rev. 07/13 1. Effective September 1, 2009, Complex Custom Rehab Suppliers must be accredited by one of the following accepted Accreditation Companies for the service of Complex Custom Assistive Technology: i. Joint Commission on Accreditation of Healthcare Organizations (JCAHO) ii. Commission on Accreditation of Rehabilitation Facilities (CARF) iii. Community Health Accreditation Program (CHAP) iv. Healthcare Quality Association on Accreditation (HQAA) v. Accreditation Commission for Healthcare (ACHC) vi. American Board for Certification in Orthotics & Prosthetics, Inc. (ABC) vii. Board of Certification/Accreditation, International (BOC) 2. Complex Respiratory Providers must be accredited through one of the following approved Accreditation Companies: i. The Joint Commission (TJC) formerly Joint Commission on Accreditation of Healthcare Organizations (JCAHO) ii. Commission on Accreditation of Rehabilitation Facilities (CARF) iii. Community Health Accreditation Program (CHAP) iv. Healthcare Quality Association on Accreditation (HQAA) v. Accreditation Commission for Healthcare (ACHC) vi. American Board for Certification in Orthotics & Prosthetics, Inc. (ABC), vii. Board of Certification/Accreditation, International (BOC), or viii. The Compliance Team All other Durable Medical Equipment Providers (excluding Complex Custom Rehab Suppliers and Custom Respiratory) must be or be in the process of being accredited by one of the following Medicare approved Accreditation Companies: JCAHO, CARF, CHAP, HQAA, ACHC, BOC, ABC, the Compliance Team/Exemplary Provider, and NABP Rev. 01/09 Rev. 07/13 3. Individuals working for suppliers who are providing custom wheelchairs, extensive modifications, and seating systems must be a registrant of NRRTS (National Registry of Rehab Technology Suppliers). They may then refer to themselves as a Rehab Technology Supplier (RTS) registrant. RTS is not a title, but a description of a supplier XI-2

77 who provides enabling technology in the areas of wheeled mobility, seating and alternate positioning, ambulation assistance, environmental controls and activities of daily living.) In addition, the registrant of NRRTS must be RESNA certified (ATP). Once a registrant of NRRTS for two years, and an ATP, the individual will be CRTS (Certified Rehabilitation Technology Supplier). Effective January 1, 2007, all rehab suppliers must be or have an employee(s) working for them that is RESNA (Rehabilitation, Engineering and Assistive Technology Society of North America) ATP (Assistive Technology Professional) certified and that is a registrant of NRRTS. Please note: THERE WILL BE NO EXCEPTIONS. Rev. 01/09 Effective January 1, 2009, the former ATP and ATS certification designations will be consolidated into the designation of Assistive Technology Professional (ATP). The CRTS must be employed by one employer and the CRTS may not work for a second employer. Assistive Technology Review Courses Available for Fundamental Course: a. Permobil ATS/ATP Review Course b. University of Pittsburgh, CSUN Review Course. Note: NRRTS registration is required at minimum for Sit and Go type power vehicles and without extensive modifications. The Division is evaluating extending the requirement that all power codes will be provided by providers who are NRRTS members and RESNA certified only. The Division strongly suggests that providers with NRRTS only obtain RESNA certification. 4. Custom wheelchair codes include all codes with the exception of the Manual Standard codes. Custom codes may include: E1161 NU, E1220 NU, E1002, E1003, E1008, E2603, E2607. Rev. 07/13 5. Suppliers must obtain a complete face-to-face wheelchair evaluation and recommendation by a Georgia licensed PT/OT for all members under the age of twenty-one (21) and all member requests for custom seating and custom wheelchairs. A RESNA- certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the beneficiary must be present at the seating evaluation and must sign and date the OT/PT evaluation. The Division has the right to verify credentials, therefore, a copy of eligible credentials (ATP/RTS/CRTS) MUST be submitted during XI-3

78 Rev. 01/09 Rev. 07/13 the prior authorization process for any patient evaluated for a power mobility device beginning July 2013 **Wheelchairs are not approved for members who are ambulatory.** 6. ALL wheelchair requests (purchase, rental and modifications) MUST INCLUDE the MANUFACTURER S RETAIL QUOTE CONFIRMATION. The actual wheelchair provided MUST contain all components listed in the retail quote and must be NEW equipment. Used equipment or equipment identified as a Demo is not covered. The equipment Must have a 2 year warranty on all major parts and components. 7. Prices listed for wheelchairs are located in the companion Schedule of Maximum Allowable Payments for DME Services, for all sized wheelchairs (i.e., child and adult are listed at the same price). The Division will not pay more than the retail price quote or the capped rate, whichever is lower. The Division may ask for invoice and cost price when questioning submitted quotes. 8. The manufacturer s name and model number must be listed in field 19 of the PA or the PA will be denied. 9. The member s height and weight must be on the CMN for all wheelchair requests. 10. Serial numbers of all wheelchairs must be entered in the appropriate field when the initial claim is submitted for the purchase of the item. For rentals, enter the serial number on the tenth month when the wheelchair is considered purchased. 11. Wheelchair delivery and pick-up records must be dated and signed by the member or caregiver and the vendor. The delivery record must be kept in the member s file. 12. Wheelchair suppliers may not bill the Division until the wheelchair is delivered to the member. 13. Wheelchair providers must stand behind a two (2) year warranty on the major components of all custom wheelchairs. See The CMN or detailed written order for repairs must be signed by the physician. 15. Suppliers must have a physical location in the State of Georgia or within fifty (50) miles of the State border. This location must have a XI-4

79 working land line telephone and a designated repair and service department. 16. Suppliers providing custom wheelchairs, specialty and/or alternative controls for wheelchairs, extensive modifications and seating and positioning systems must have a designated repair and service department, with a technician available during normal business hours, between 8am and 6pm. Each technician must keep on file records of attending continuing education courses or seminars to establish, maintain and upgrade their knowledge base. 17. Suppliers may not deliver equipment that has been approved for members transitioning from nursing homes to the community until the patient has been discharged. The equipment must be delivered to the patient s community address once the member has moved. (See and 902.1) Rev. 07/ PHYSICAL OR OCCUPATIONAL THERAPIST (PT/OT) **The PT/OT evaluation must be kept in the member s file For auditing and quality control purposes. ** 1. The certificate or medical necessity (CMN) for a wheelchair must be accompanied by an evaluation / detailed written order from a physical or occupational therapist for: Rev. 04/13 a) all members under the age of twenty-one (21) years. b) all members receiving a custom or power chair or a chair with extensive modifications and seating/positioning system. c) The OT/PT must have a face-to-face evaluation with the member. The evaluation / detailed written order may be signed and dated by the physician and the PT/OT and serve as the CMN. The PT/OT must include the license number. 2. The PT/OT must be licensed in the State of Georgia and include the license number on the CMN. 3. The PT/OT must be experienced with rehab technology, wheelchair and seating evaluations and recommendations. Rev. 10/13 4. The PT/OT may be associated with a school, hospital, clinic or developmental center, but cannot be a supplier or be employed by a supplier or accept any payment for evaluation services from a supplier. Suppliers MAY NOT generate or fill out any portion of the PT/OT evaluation. 5. The PT/OT must be actively involved in the member s care. XI-5

80 Rev. 07/13 Rev. 04/13 6. Include the PT/OT license number on the evaluation / recommendation. The RTS/CRTS and ATP provider should be present at the evaluation, sign off on the recommendation, and must submit a copy of their certification when the prior authorization request is submitted. 7. The PT/OT must submit the address and telephone number where they are employed and where they may be contacted. The PT/OT must submit their seating and positioning experience for wheeled mobility and rehab equipment. 8. The physician must sign and date the CMN or detailed written order for all repairs. XI-6

81 1103 EQUIPMENT (SEE Section for warranty policy) Extra-Wide or Heavy Duty Wheelchairs Wheelchairs must accommodate the physical characteristics of the member. The warranty must cover the weight of the member and allow for weight increase. Wheelchairs must also accommodate the home environment (i.e., apartment and mobile home doorways). (See ) If the member is homebound or without transportation the provider should still obtain the measurements. Examples of methods the provider could use toward this end are: a) The County Division of Family and Children Services caseworker could arrange non-emergency transportation for the member to go to the provider for measurements. b) A nurse or physical therapist from a home health agency or from a health department in that county could measure the member. Rev. 01/09 Rev. 07/13 c) The provider could request height and weight from the member s attending medical physician s office. 2. Power Mobility Rev. 07/13 When requesting power wheelchairs, the physician and PT/OT must document the specific medical and physical limitations and daily activity level (work, school, etc.) of the member that necessitates the use of a power wheelchair. Power vehicles will not be approved for ambulatory members as an assistive/helpful device. The physician, PT/OT, RTS/CRTS member and the ATP must collaborate and sign and date the same assessment/ detailed written order. This assessment/detailed written order may also be referred to as the CMN. Power wheelchairs must accommodate the home environment (i.e., doorways). Suppliers must document the home assessment for appropriateness. If the home environment cannot accommodate the recommended wheelchair, it will not be approved. This assessment must be detailed on the CMN or submitted as an additional attachment with the request. i.e. doorway width, size of home, accessibility to home (ramp, elevator). Medical physician s office. Power chairs will not be allowed for the convenience of the caregiver, ambulatory members, and non-compliant members. CMN / Detailed Written Order Requirements- PMD: (Commonly referred to at the 7 element order) a) Beneficiary s name, Height, and Weight XI-7

82 b) Description of the item(s) ordered- /Detailed Product Description (regardless of the form of the description, there must be sufficient detail to identify the item(s) in order to determine that the item(s) dispensed are properly coded) c) Date of the face-to-face examination d) Pertinent diagnoses/conditions that relate to the need of the PMD e) Length of need f) Required Signatures: Physician s signature, OT/PT Signature with License #, NRRTS Member s Signature with License/Certification Number (with copy of license/certification) g) Date of Signatures: physician signature, OT/PT, and NRRTS member must date all signatures Attestation statement PMD: Prior to the delivery of a PMD, the supplier/practitioner must have performed an on-site evaluation of the beneficiary s home to verify that the beneficiary can adequately maneuver the device that is provided considering the doorway width, doorway thresholds, surfaces, and other dimensions of the physical layout of the home. There must be a written report of this evaluation in the patient s medical record and available upon request. Rev. 07/13 Specialty Assessment (Custom, or Push rim activated) PMD: a) Performed by licensed/certified medical professional having specific training and experience in rehabilitation wheelchair evaluations b) Provides detailed information explaining the need for each option or accessory: -Power seating system -Alternate drive control interface - Push-rim activated power assist c) Done in addition to the requirement for a face-to-face examination. Attestation statement PMD: a) For PMDs requiring a specialty assessment this document must be submitted to affirm the medical professional performing the specialty assessment has no financial relationship with the supplier. Proof of Delivery MUST include the following: XI-8

83 a) Beneficiary s Name b) Delivery Address c) Detailed Description of Items (sufficient information to identify the items delivered including brand names, serial numbers, and narrative descriptions for ALL miscellaneous codes such as etc.) d) Quantities Delivered e) Date Delivered f) Beneficiary or Designee Signature and Date of Signature g) Relationship of anyone signing the delivery ticket as a representative of the patient Rev. 10/13 DME Suppliers are required to maintain POD documentation in their files for medical review purposes. Every element required for the approval of the POD (Invoice, Delivery Ticket, CMN, etc.) is considered to be part of the medical record and MUST be kept on file by the provider and available to the Division upon request for no less than five years. This documentation assists in determining correct billing and coding practices for claims submitted for Medicaid reimbursement, and ensures the items reimbursed are the actual items that were delivered to the patient. The reviewing agent must be able to determine from the delivery documentation that the supplier properly coded the item(s) that the item delivered are the same item(s) submitted to Medicaid for reimbursement, and that the items are intended for, and received by a specific Medicaid beneficiary. Suppliers, their employees, or anyone else having a financial interest in the delivery of the items are prohibited from signing or accepting the item(s) on behalf of a Medicaid beneficiary (i.e., acting as a designee on behalf of the beneficiary). The signatures and dates on the delivery ticket MUST be complete and legible to submit for and receive reimbursement from the Medicaid program. 3. Backup/Travel Wheelchairs Only standard wheelchairs with fixed arms will be allowed as travel wheelchairs for members with power wheelchairs, and only when the member s power wheelchair cannot be folded into a car. Separate documentation of need by the attending medical physician/pt/ot must accompany approval requests. Stroller type transporters (e.g., Pogon, Hogg, and McClaren) are reimbursed for children under the age of two years unless the physician documents that this equipment is appropriate for children over two. 4. Manual Wheelchairs When requesting approval for manual wheelchairs, the physician must document specific physical limitations and ambulatory status. If the member has had a stroke, the physician must document the date of the stroke and rehabilitation potential. XI-9

84 5. Power Chair Adaptable for Power Recliner When requesting approval for a power-chair with a power recliner, the physician must document a diagnosis of quadriplegia, dwarfism, or degenerative neuromuscular disease. Physicians must include physical limitations, weight and height. 6. Youth Wheelchairs Any Type For members under 21 years of age, the necessity must be accompanied by a recommendation from a physical or occupational therapist who is actively involved in the child s care. (See c.). The evaluation must be face-to-face. 7. Specialty Walker (E0147 NU) Rigid walker (E0147 NU) rollator, wheeled, with seat K-walker or other specialty walker: Requires an OT/PT evaluation and Requires the service to be provided by a Complex Rehab Provider (employees who are CRTS) Physician must document specific physical limitations. An OT/PT evaluation is required. Manufacturer s retail quote confirmation must be attached. Specify the make and model number and any serial number on the prior approval. 8. Shower/Bath Chair or Other Rehab Toilet Aids (E0240 NU) Rev. 01/09 Rev. 10/13 E0240-NU represents a shower/bath chair, with or without wheels, any size only. This code is listed in the DME-SMAP with standard pricing applied. E0240-U1 is applicable to other rehab toilet aids that are covered by Medicaid. This code MUST not be used for items that are noncovered by Medicaid (i.e. Bath lifts for patients over 21 etc.) see 906. Of this manual for the list of noncovered items (this includes items not specifically listed not listed as covered in the policy manual or DME- SMAP). Physician must document specific physical limitations. An OT/PT evaluation/recommendation is required. Supplier must be CRTS. Provider must submit the Provider Invoice price and the manufacturer s model number of the item with the PA request. Providers must submit separate PA requests for each item required in the member s individual home situation. i.e.) one PA for toilet needs and a 2 nd PA for bathtub needs. Each request submitted will be requested utilizing E0240 NU or U1 with the specific related medical necessity justification attached. 9. Standing Frame System (E0638) and Sit to Stand System/Multi Positional (E0637). XI-10

85 The multi positional standing system must position 3 way or more. An OT/PT evaluation is required. Internal review criteria are based on experienced OT/PT recommendations. Supplier must be CRTS. Repairs may be requested utilizing the same procedure as wheelchairs requests. 10. Gait Trainer (E8000, E8001, E8002 NU) An OT/PT evaluation is required. Internal review criteria are based on experienced OT/PT recommendations. Supplier must be CRTS. Manufacturer s retail price quote must be submitted. Repairs may be requested utilizing the same procedure as wheelchair requests. 11. Low Pressure and Positioning Equalization Pad for Wheelchairs E2607 NU Requires an OT/PT evaluation. Service restricted to Custom REHAB providers (CRTS only) 12. Skin Protection Cushion E2603 NU Supplier must be NRRTS or CRTS *PA Required XI-11

86 CHAPTER 1200 PART B SPEECH GENERATING DEVICES (SGD) FOR AUGMENTATIVE AND ALTERNATIVE COMMUNICATION (AAC) 1201 General Provisions a. Purchase, rental, replacement, and repair of a Speech Generating Device (SGD) use for Augmentative and Alternative Communication, (AAC) devices and accessories are reimbursed through the Durable Medical Equipment program, and are subject to the limitations set forth within. b. All Medicaid members shall be eligible to receive a speech generating device as prescribed by a physician in accordance with the requirements and limitations set forth herein. c. All requests for speech generating devices, software, applications, accessories and/or attachments shall be reviewed for medical necessity, as defined in Section 1102 herein, and the other requirements set forth herein. d. All required supporting documentation, as more clearly set forth herein, must be submitted prior to the Department s review of any claim for a speech gernating device Definitions a) Speech Generating Devices (SGD) for Augmentative and Alternative Communication (AAC): electronic or non-electronic aids, devices or systems that correct expressive communication disability that precludes effective communication of messages, in the form most appropriate to the beneficiary and meaningful participation in daily activities. Augmentative communication devices include both dedicated voice output communication devices as well as computerbased devices that have been modified so that they are dedicated to run only AAC software are covered. b) Accessories for Speech Generating Devices: device related components, including computer software, symbol sets, overlays, mounting devices, switches, cables and connectors (included in reimbursement for SGD), auditory, visual and tactile output devices, and related follow up training for the member to use the SGD device to effectively meet his or her communication needs. XI-12

87 c) Augmentative Communication Evaluation for a Speech Generating Device: An evaluation, provided in written form, acceptable to the Division that accompanies a prior authorization request for a SGD, accessory and/or service. The assessment shall be conducted by a speech-language pathologist (SLP) as defined in 42 C.F.R. Section , who also holds a Georgia license to practice. The assessment may be performed in conjunction with other appropriate licensed practitioners of the healing arts acting within the scope of their practice. d) Medical Necessity: All requests for speech generating devices (SGD), accessories or attachments shall be reviewed for Medical Necessity as the term shall be defined in Part I, Policies and Procedures, Section , applicable to all providers, and the requirements set forth herein. Section currently defines Medically Necessary services as those covered services which are reasonable and necessary in establishing a diagnosis and providing palliative, curative or restorative treatment for physical and/or mental health conditions. Services meeting professional standards are those which, in the opinion of a recognized peer, under usual circumstances, contribute to a satisfactory outcome in the health status of the member. The services provided, as well as the type of provider and setting must be appropriate to the specific medical needs of the member; and there must be no other equally effective, more conservative or substantially less costly course of treatment available. The determination of medical necessity shall be made in accordance with currently accepted standards for medical practice. Should the definition of medical necessity set forth in Section be changed or modified in any way, those changes or modifications shall apply to claims for speech generating devices, accessories and services Non-Covered Items The following equipment, items and services shall not be covered: a. Extended warranty and maintenance agreements (Excludes tablets or equivalent which require a 3 year loss insurance policy at time of purchase). b. Shipping and handling fees on purchased equipment. c. Computer equipment, software and applications, and accessories that are not specifically integral to use of the member s communication device. d. Replacement or repairs of equipment being rented. e. Replacement or repairs of tablets or equivalent covered as a SGD for AAC services. f. Equipment replacement or repair that is necessitated by member neglect, wrongful disposition, intentional misuse or abuse. XI-13

88 g. Equipment that is considered same or similar to equipment already funded by Medicaid either through the Early Intervention Screening and Diagnosis Program or through Medical Assistance Services provided by educational agencies, unless such equipment is required by clinical justification of needs and represents the least costly alternative in equipment options for the individual. h. Second speech generating device unless such devices are medically necessary, through justification of clinical needs in order to functionally communicate and represent the most appropriate, least costly alternative in equipment options for the member. i. Replacement of a member s existing speech generating device when the replacement is requested solely as a result of changing technology. Rev. 07/13 j. Equipment that is not NEW when provided to the Medicaid beneficiary. This includes demos or any equipment that is issued after the warranty has begun. (This does not apply to crossover claims where equipment may be billed as used). k. Tablets or equivalent that does not have a 3 year accidental loss insurance plan at the time of purchase. XI-14

89 Effective 04/ Mobile Devices with Qualifying Software covered as a Speech Generating Device (SGD) for Alternative Augmentative Communication (AAC) Therapy Due to emerging technology in speech therapy, Georgia Medicaid will consider coverage of Mobile Devices that have associated Alternative and Augmentative Communication Applications and Software available for use as a Speech Generating Device. All coverage requirements for standard speech generating devices listed in Chapter 1200, Part B apply to the coverage of this type of speech generating device as well as any additional requirements listed under section All codes associated with this type of Speech Generating Device must have a quote invoice submitted with the prior authorization request. -Patients must meet all the policy requirements for a speech generating device as specified in this policy (Chapter 1200, Part B). -The Mobile Device submitted must be the least costly alternative for that product category as this device should only support the application for speech therapy. -A Detailed Written Order for the specific device and software or application must be submitted for approval Covered Device HCPCS/Modifier Combinations for Mobile Device and Software Applications used for AAC Therapy: E2510- U1 (Mobile Device used as speech generating device for AAC therapy with 3 year loss insurance) manually priced 40% above invoice- up to $1, for the device with 3 year loss insurance. E2511- U1 (AAC Software Application for use with Mobile Device used as speech generating device) manually priced 40% above invoice- Up to $ Covered Accessories for Qualifying a Mobile Device used as a SGD for AAC: E2599- U1 (Heavy Duty protective case for Mobile Device used as a SGD) once per lifetime of device manually priced 40% above invoice- Up to $ E2599- U2 (Replacement Charger/adapter for Mobile Device used as a SGD) once per year beginning 12 months after the date of purchase manually priced 40% above invoice- Up to $70.00 Coverage Guidelines: Coverage for a Mobile Device and appropriate software application will be considered for patients who: XI-15

90 1- Had an assessment performed by a Speech Language Pathologist (SLP) for the use of this device/software application (SLPs must refer to the respective program manual for coding guidelines for this assessment U1) 2- Have a treatment plan for therapy services for this particular device/software (SLPs must refer to the respective program manual for coding guidelines U1) 3- Meet ALL coverage criteria for a standard speech generating device as referenced in this policy 4- Have a detailed written order from the treating physician for the device requested in the SLP s evaluation. Coding Guidelines for Mobile Devices used as Speech Generating Devices with Augmentative and Alternative Communication Software Applications: *The ordering provider must document the patient s willingness and ability to use this device.* If E2510-U1 is billed without the associated AAC software (speech therapy software/application) E2511-U1, it will be denied as a noncovered device. A mobile device that is not used as a dedicated device (a dedicated device is a device that is used solely for the purpose for which it is prescribed) for speech therapy and does not have the required augmentative and alternative communication (AAC) software installed does not meet the definition of a speech generating device. Augmentative and Alternative Communication software applications (E2511-U1) may be billed without a speech generating device (E2510-U1) for a patient owned mobile device (i.e., funded through grants). The mobile device and software application will be considered for coverage if they meet the needs of the patient as reported in the Speech Language Pathologist s assessment and have been ordered by the treating physician after reviewing the SLPs assessment. *Reasonable Useful Lifetime: The reasonable useful lifetime of equipment issued as an optionally dedicated (non-dedicated devices such as tablets that have been ordered with AAC software to allow them to function as a SGD) speech generating device is 3-5 years. Any additional speech generating device billed during the reasonable useful lifetime will be denied as same or similar equipment. Medicaid will not replace this type of device before the 3-5 year reasonable useful lifetime for any reason other than a change in the patient s medical condition which no longer permits the patient to use the current device as a functional speech generating device. *Replacement of the Device during the Reasonable Useful Lifetime: The DME provider MUST purchase a 3 year accidental loss/damage insurance policy (this is offered by some retailers at the time of purchase or through a private carrier). The provider must replace the device through the loss insurance policy if necessary XI-16

91 during the three year period for any reason including accidental loss/theft. *Reimbursement: The authorized payment for the device will be 40% above the combined cost of the device and the accidental loss/damage insurance policy. Invoices for both components must be included in the documentation that is submitted for reimbursement. If both pieces of information are not present at the time the prior authorization is submitted, the device will be denied as it does not meet policy guidelines. *Accessories: Heavy-duty carrying cases that include screen protection are covered during the initial purchase of the device only, and will not be covered again during the reasonable useful lifetime of the device. A charger and/or charger/adapter combo can be replaced 1 time per year beginning 12 months after the purchase of the device if necessary. * Device Requirements: This device must be used by the member as a dedicated device in order for the item to be considered for coverage. The software application for this device is covered once during the reasonable useful lifetime of the device and must be billed with the initial purchase of the qualifying mobile device. *Georgia Medicaid does not reimburse for the costs of any type of internet services required to operate these devices and software applications. The applications and software should be operational without requiring internet services. *The Speech Language Pathologist provides the initial setup, training on the usage of the device, and therapy services. This is the only time the ordered software application requires internet services. XI-17

92 1205 Prior Authorization a. Providers of speech generating devices shall request and obtain prior authorization from the Division of Medical Assistance for the purchase, rental, repair, replacement or modification of speech generating devices, accessories and attachments. 1) No prior authorization shall be required for the repair or replacement of the batteries of a speech generating device. b. Prior authorization for purchases and rentals of speech generating devices, accessories or attachments shall include the following: 1) A prescription from a physician that includes the information stated in 1105(b). 2) An evaluation for a speech generating device prepared by a Georgia licensed speech-language pathologist, as specified in c. Prior authorization requests for repair, replacement or modification of a speech generating device, accessories or attachments shall include the following: 1) The reason for the repair, modification or replacement, and if the speech generating device has been damaged, a letter from the speech-language pathologist explaining how the damage occurred; 2) When the request is for the repair of a speech generating device, or for its replacement with a same or similar device, a letter from a licensed speechlanguage pathologist establishing the member s prognosis for continued use of the current device. 3) When the request is for the replacement of an existing speech generating device with a same or similar device, in addition to the information required in 1102, a statement from a licensed speech-language pathologist of why replacement is required as compared to a repair of the existing device, and the replacement cost of the new device; 4) When the request is for the replacement of an existing speech generating device with a different type of speech generating device, a letter from a licensed speech-language pathologist establishing why both repair and replacement with the same type of device is not appropriate, what the member s prognosis with the requested replacement device will be, and the cost of the new device. A change in the device or upgrade is only approved if the medical condition has significantly changed and the current device is not capable of providing the alternative augmentative communication for which it was ordered or if the current device has reached the reasonable useful lifetime. XI-1

93 d. The Division shall issue a decision either approving or denying the request for the purchase, rental, repair, replacement, or modification of a speech generating device, accessory or attachment within thirty (30) days of receipt of the prior authorization request. 1) When it is determined by the Division that a prior authorization request is incomplete or that additional information is needed in order to make an informed decision on a request for a speech generating device, the Division will request the missing or needed information from the speech-language pathologist who conducted the assessment for the device. If the Division must request missing or additional information from the SLP in order to make a decision, the thirty (30) day time period shall not begin to run until the additional information is received by the Division Required Data a) A prior authorization request for a speech generating device, accessories or attachments must be supported by the information described in this section. b) Treating Physician Information The member s treating physician is required to submit the following information in support of prior authorization for a speech generating device, accessories or attachments: 1) A personally signed (not stamped) and dated prescription for all items. 2) The prescription must include the following information: i) a description of the member s specific physical limitations and significant medical history pertaining to communication abilities and limitations; ii) a complete description of the speech generating device, accessories and attachments being sought; iii) the anticipated duration of need for the speech generating device, accessories and attachments being sought; iv) the member s medical diagnosis or condition requiring the use of the speech generating device, accessories and attachments; v) a statement of concurrence with the recommendation of the evaluation for a speech generating device. c) Speech-Language Pathologist Information The SLP and all other practitioners who submit data in support of the prior authorization request shall describe his/her AAC services training and experience in XI-2

94 addition to establishing their licensure and other qualifications. The SLP must assert that he/she has no financial interest in the outcome of the assessment. 1) Evaluations for speech generating devices must contain, at a minimum, the following information: i) member s medical diagnosis, including the member s communication diagnosis (e.g., dysarthria, apraxia, aphasia); ii) member s communication prognosis with and without the aid of a speech generating device. iii) any previous treatments of communication problems and why those treatments are not effective to permit effective communication of messages, in the form most appropriate to the beneficiary and meaningful participation in daily activities. For members who previously or currently use or own a speech generating device, whether at home, school or work, a description of the device and an explanation as to why the device is not appropriate or available for the member s communication needs; iv) current and projected language comprehension, expressive language capabilities, oral and motor speech status, visual capabilities, hearing capabilities, and the limitation of impairments in these areas which impact the member s expressive communication and prognosis; v) current communication abilities, behaviors and skills, and the limitations or impairments in these areas that interfere with meaningful participation in current and projected daily activities; vi) communication environments and constraints which impact speech generating device selection and use; vii) communication partners and tasks, including limitations in partners communication abilities; viii) description of the member s postural, mobility and motor status, including optimal positioning and integration of the speech generating device; ix) a description of any trial period in which member utilized the speech generating device requested which demonstrates the member s ability and willingness to use the device effectively; x) a description of the manner in which the recommended speech generating device will meet the member s communication needs both at present and within the next two (3-5) years; xi) a description of the recommended speech generating device and all requested components; xii) an explanation of the medical necessity of the speech generating device; xiii) an explanation as to why the recommended device represents the least costly, most appropriate and equally effective treatment alternative; xiv) an Augmentative and Alternative Communication (AAC) therapy treatment plan for the member which includes the following: a. the party responsible for delivering and programming the speech generating device; b. a statement as to who will train the member and communication partners in the proper use, programming, care and maintenance of the speech generating device; XI-3

95 c. the short and long term goals and expected outcomes d. a description of the criteria to be used to measure the member s progress toward meeting both short and long-term communication goals and expected outcomes xv) when a speech therapy device is requested for an individual under the age of twenty-one (21) and the individual is attending school, a copy of the member s most current individualized educational plan, if applicable, must be submitted along with the AAC evaluation for the speech therapy device; and identification of the vendor providing the recommended speech therapy device and/or service and their cost (DME providers must provide a warranty for their products according to the Georgia Assistive Technology Act of 1993.) 2) The Alternative and Augmentative Communication assessment shall also include an assessment of the specific speech therapy device, accessories and services being recommended which shall contain the following information i) vocabulary requirements ii) representational systems iii) display organization and features iv) rate enhancement techniques v) message characteristics, speech synthesis, printed output, display characteristics, feedback, auditory and visual output; vi) access techniques and strategies vii) portability and durability issues viii) identify significant characteristics and features of the speech generating device, accessories and/or services; ix) cost of the recommended device, accessories and services; x) identification of alternative devices, accessories and/or interventions considered and an explanation of why the requested device, accessories and services are the least costly, most appropriate and equally effective alternative to permit effective communication by the member; and xi) determine whether purchase or rental is the most effective option Third Party Liability For individuals who are members of health services from third party funding sources in addition to Medicaid, the documentation submitted with a prior authorization request must include a written decision from each third party funding source regarding its willingness or refusal to pay for the speech generating device, accessory or attachment Trial Period XI-4

96 An SLP may request that a speech generating device, accessory or attachment be provided on a trial basis prior to making a recommendation for purchase. A request for a trial period must be prior authorized, and supported by an AAC evaluation for the device, as described in The duration of the trial period may be between 30 to 90 days, at the discretion of the SLP. Results of trial periods for the speech generating device, accessories or attachments are to be included with any request for purchase of these items Notice for Decision The Division shall provide written notice of every decision to approve or deny a prior authorization request for a speech generating device, accessories and/or services to the beneficiary, as well as to the speech-language pathologist who conducted the beneficiary s AAC assessment for the device. XI-5

97 APPENDIX A Sample Medicaid ID Card A-1

98 APPENDIX B STATEMENT OF PARTICIPATION The new Statement of Participation is available in the Provider Enrollment Application Package. Written request for copies should be forwarded to: Provider Enrollment P. O. Box , Tucker GA OR Phone your request to: 1 (800) and choose option (#4) B-1

99 Rev. 04/14 APPENDIX C INSTRUCTIONS FOR COMPLETING THE PRIOR AUTHORIZATION REQUEST FORM AND CMS-1500 (version 02/12) CLAIM FORM This section provides detailed instructions for completing the Prior Authorization Request Form and Detailed instructions for completing the CMS-1500 (version 02/12) claim form. This information is also found in the Billing Manual, Section pages 30 thru 34. Also see Section for specific instructions regarding serial numbers. The DMA-610 form is found on the web: A physician certification of medical necessity should always be attached to the completed form and both should be mailed, faxed, or submitted via the web. Please see the information below for contact information: Alliant GMCF PA/UM Department PO Box Atlanta, GA Fax (678) The web address is the DME can be submitted by web, fax or mail. A sample form and a brief explanation of data items follow: Item 1: Member Name Enter the name exactly as it appears on the Medical Assistance Eligibility Certification, last name first. Item 2: Member Case Number Enter the Medicaid number exactly as it appears on the Medical Assistance Eligibility Certification. (This number may change so it is imperative that you view the Certification during each month of service.) A valid member case number will be formatted in one of two ways as follows: a. ten digits ending with the alpha letter P or S (example: P) or b. thirteen digits (example: C-11) The entire number, including all zeros, must be placed on the form correctly or it will be rejected. Item 3: Nursing Home Yes or No must be indicated. C-1

100 Item 4-7: Birth date, Sex, Address, and Telephone Number This information is self-explanatory and should be entered for the member. Age is a requirement and must be filled in at all times. Item 8: Prescribing Physician/Practitioner Name and Address Enter name and address of physician who prescribed item being requested. Item 9: Prescribing Physician Provider Number Enter the ten-digit Medicaid Provider Number. If not enrolled in the Medicaid Program, the State license number should be entered and is the only other acceptable number. Item 10: Prescribing Physician s Telephone Number Enter the telephone number of the prescribing physician. Item 11: Provider of Service(s) Name and Address Enter current name and address of the durable medical equipment company. Item 12: Medicaid Provider Number Enter the ten-digit Provider Number. Item 13: Provider s Telephone Number Enter the provider s telephone number. Item 14: Authorization Period Rentals - Enter the date the equipment is placed. Purchases - Enter the date the provider signs this Prior Request Form as the beginning date. If equipment has been issued, enter the date of placement as the beginning date. The Prior Approval staff will enter the through date. Item 15: Description of Services Requested Enter the general name of the item requested, in this case such as wheelchair or hospital bed. Item 16: Primary Diagnosis Requiring Service(s) C-2

101 Rev. 04/14 Item 17: Item 18: Item 19: Item 20: Item 21: Item 22: Briefly list diagnosis and condition of the member as the physician has described on the prescription. Enter the ICD-9-CM (International Classification of Diseases) code(s) related to the service requested on or before 09/30/2015. On or after 10/01/2015 enter the ICD-10-CM code(s) related to the service requested. Justification and Circumstances for Required Services Enter the justification for the equipment, including any special features, length of time needed, and extraordinary circumstances. Description of Item List equipment and/or supplies for which authorization is being requested on the CMN and give manufacturer s name and model number. Use additional forms if necessary but do not exceed six (6) lines on one form. Mileage one-way charge must be included as a line item. Procedure Code or Equipment Code Enter the code number for the item or procedure. (Refer to Appendices D, E, F, and G). Modifications - List the purchase procedure code on line one (1) followed by modification procedure code(s) on the following lines. List no more than a total of six (6) procedure codes for any Prior Authorization Request form. If additional forms are necessary to include any remaining procedure code(s), a purchase procedure code with a billed amount of zero dollars is required on the first line of any additional Prior Authorization Request form(s) used. Repairs - List the purchase procedure code with a billed amount of zero dollars on line one (1) followed by the repair procedure code(s) on the following lines. If additional prior authorization forms are required, refer to the above paragraph about modifications for specific instructions. Staple all forms together to facilitate processing. Requested or Estimated Retail Price Per Unit Enter requested reimbursement amount. This amount must be the provider s usual and customary charge, not the Division s maximum reimbursement rate, unless specified in policy, and then enter the rate specified by policy (i.e., amounts that are prorated). Months or Units of Service Requested C-3

102 Enter the total number of units being claimed for the period of service covered by this prior approval authorization. E.g., a five month rental should be entered as 5 units; a wheelchair purchase should be entered as 1 unit; the purchase of 1200 units of gaseous oxygen per month for five months should be entered as 6000 units (5 X 1200 = 6000). Item 23: Units Per Claim Enter the number of units being requested per claim. For example, a rental should be entered as1unit, a purchase enter one unit, 1200 units of gaseous oxygen enter Item 24: Providers Signature The provider of services must sign the Prior Authorization Request form and attach a copy of the physician s prescription to it. Delegation of signature must be in writing and on file with the Division. Item 25: Date Enter the date the request is mailed from the provider s office. Item 26: Request (DIVISION S USE ONLY) Division action will be noted in this section upon receipt of the request. If Approved as Changed block is checked, please note any changes in the following areas: Item 14 - Item 20 - Item 21 - Authorization period may be adjusted. Procedure code may be changed Requested amount may be adjusted. Item 27: Signature (DIVISION S USE ONLY) Division of Medical Assistance authorized signature. Item 28: Date (DIVISION S USE ONLY) This date is the date that the request was approved and will be entered by the Division. Item 29: Explanation (DIVISION S USE ONLY) This area is provided for the Division to enter comments concerning the request. C-4

103 THE PRIOR AUTHORIZATION REQUEST FORM DMA-610 C-5

104 NEW CMS 1500 Claim Form (version 02/12) & ZFLD Locator Instructions General Instructions on filling out the 1500 claim form are found in the Billing Manual on the web: See Section for specific instructions for entering the serial number of required equipment. C-6