Benefit Criteria for Diabetic Equipment and Supplies Home Health Services Changing July 1, 2011

Transcription

1 Benefit Criteria for Diabetic Equipment and Supplies Home Health Services Changing July 1, 2011 Information posted May 13, 2011 Effective for dates of service on or after July 1, 2011, the benefit criteria for diabetic equipment and supplies home health services will change for Texas Medicaid. The diabetic equipment and supplies that are addressed in this article may be obtained through one of the following methods: Providers can use a Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form to prescribe the DME or medical supplies. The Title XIX Form must be signed and dated by the prescribing physician who must be familiar with the client prior to supplying any medical equipment or supplies. All signatures and dates must be current, unaltered, original, and handwritten. Computerized or stamped signatures and dates will not be accepted. Providers can use a verbal or a detailed written order that has been signed and dated by a physician, physician assistant, nurse practitioner, clinical nurse specialist, or a certified nurse midwife. The completed Title XIX form must be maintained by the dispensing provider and the prescribing physician in the client s medical record. The prescribing physician must maintain the original signed and dated copy of the Title XIX form. The completed Title XIX form is valid for a period of six months from the physician s signature date. The detailed written order must be received by the DME supplier within 90 days of the date of the prescribing provider s signature. Detailed written orders are valid for six months as follows: For initial orders, the detailed written order is valid for six months from the date of the order or the date of the prescribing provider s signature, whichever occurs first. For renewal orders, the detailed written order is valid for six months from the renewal start date. In the absence of a renewal start date, the date of the authorized prescribing provider s signature is the beginning date of service. The prescribing provider s order may be a written, faxed, electronic, or verbal order and must include: A description of the items. The recipient's name. The name of the physician or authorized prescribing provider. The date of the order. A completed, detailed written order must be signed and dated by the authorized prescribing provider. The prescribing provider is required to retain a copy of the signed and dated detailed written order in the client's medical record. The DME provider must retain the original, faxed, photocopied, or electronic signed and dated detailed written order in the client s medical record. A completed detailed written order must contain all the following components: Client s name.

2 The date of the verbal order if different from the date the authorized prescribing provider signed the written order. Description of item(s) to be provided. Quantity to dispense (quantity required per day or month). Diagnosis code or description supporting the medical necessity. Prior Authorization of Diabetic Equipment and Supplies Prior authorization is required for the following items and must be submitted to the Health and Human Services Commission (HHSC) within three business days of the date of service: Glucose tablets or gel. Blood glucose monitors with integrated voice synthesizers. Blood glucose monitors with integrated lancing blood sample. External insulin pumps. Quantities of supplies beyond the stated benefit limits. Any equipment or supply prescribed for a diagnosis that is not listed in the following table: Diagnosis Codes Prior authorization may be considered with documentation of medical necessity, which must include one of the following:

3 A completed Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form that has been signed and dated by the physician familiar with the client. A detailed written order that has been signed and dated by the prescribing provider familiar with the client and a Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form with section A completed. Note: Unless otherwise specified, documentation of medical necessity is required to explain the need for diabetic supplies for a diagnosis that is not listed in the diagnosis code table above or for quantities that exceed the stated benefit limitation. A determination will be made by HHSC as to whether the equipment will be rented, purchased, repaired, or modified based on the client s needs, duration of use, and age of equipment. Glucose Testing Equipment and Other Supplies When applicable, the prescribing provider must indicate on either a completed, signed, and dated Title XIX form or a signed and dated detailed written order how many times a day the client is required to test blood glucose or ketone levels (not all supplies are related to testing glucose or urine, e.g., batteries). Alcohol wipes (procedure code A4245) and urine test or reagent strips or tablets (procedure code A4250) are a benefit of Texas Medicaid when they are necessary for the treatment of some diabetic conditions or other conditions and therefore are not limited to the diagnoses listed in the diagnosis code table above. Procedure code A4245 is limited to four boxes per month and procedure code A4250 is limited to two per year. Prior authorization is not required for these procedure codes up to the quantities listed. For quantities beyond those listed in this article, prior authorization may be considered with documentation of medical necessity related to the number of tests the provider ordered per day. Blood Glucose Monitors Standard home glucose monitors (procedure code E0607): Do not require prior authorization. Are limited to the diagnoses listed in the diagnosis code table above. Diagnoses not listed in the diagnosis code table above may be considered for prior authorization with supporting documentation of medical necessity. External Insulin Pump and Supplies An external insulin pump and related supplies are a benefit of Texas Medicaid through Title XIX Home Health Services. Note: External insulin pumps that do not require tubing may be considered for clients who are birth through 20 years of age through the Comprehensive Care Program (CCP). An external insulin pump (procedure code E0784) must be ordered by, and the client's follow-up care must be managed by, a prescribing provider who has experience

4 managing clients with insulin infusion pumps and who is knowledgeable in the use of insulin infusion pumps. To request prior authorization for an external insulin pump, submit one of the following forms: For an external insulin pump rental, submit the External Insulin Pump form. For an external insulin pump purchase, submit the Title XIX form. All requests for prior authorization must include documentation of medical necessity. The External Insulin Pump form has been updated to incorporate the required prior authorization criteria for the rental of the external insulin pump. An external insulin pump rental is limited to one per month and an external insulin pump purchase is limited to one every three years. Providers must bill with the most appropriate battery codes (procedure codes K0601, K0602, K0603, K0604, or K0605) and the U1 modifier for the external insulin pump. The following procedure codes for external insulin pump supplies do not require prior authorization up to the maximum quantities allowed: Procedure Codes A4230 A4231 A4232 A4601 A6257 A6258 A6259 K0601 K0602 K0603 K0604 K0605 Limitations 10 per month Additional quantities may be considered with prior authorization and documentation of medical necessity. When there is not an appropriate procedure code to use for supplies, providers may request prior authorization using miscellaneous procedure code A9900. The external insulin pump extension tubing supplies (procedure codes A4230 and A4231) are limited to clients who have a previously billed external insulin pump device (procedure code E0784) or supply. External Insulin Pump Rental

5 An external insulin pump rental may be considered for prior authorization with the submission of clinical documentation that indicates one of the following: The client has a diagnosis of type 1 or type 2 diabetes must meet at least two of the following criteria while on multiple daily injections of insulin: o Elevated glycosylated hemoglobin level (HbA1c ) > 7.0 percent. o A history of dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dl. o A history of severe glycemic excursions with wide fluctuations in blood glucose. o A history of recurring hypoglycemia (less than 60 mg/dl) with or without hypoglycemic unawareness. o Anticipates becoming pregnant within three months. The client has a diagnosis of gestational diabetes and meets at least one of the following criteria: o Erratic blood sugars in spite of maximal compliance and split dosing. o Other evidence that adequate control is not being achieved by current methods. In addition to the clinical documentation, the provider must submit an External Insulin Pump form that indicates: The client or caregiver possesses: o The cognitive and physical abilities to use the recommended insulin pump treatment regimen. o An understanding of cause and effect. o The willingness to support the use of the external insulin pump. The prescribing provider has attested that: o A training/education plan will be completed prior to initiation of pump therapy. o The client or caregiver will be given face-to-face education and instruction and will be able to demonstrate the necessary proficiency to integrate insulin pump therapy with their current treatment regimen for ambient glucose control. External Insulin Pump Purchase An external insulin pump purchase may be considered for prior authorization after it has been rented for a three-month trial and all of the following documentation has been provided: The training/education plan has been completed. The pump is the appropriate equipment for the specific client. The client is compliant with the use of the pump.