Respiratory Equipment and Supplies Chapter.1 Enrollment..................................................................... -2.2 Benefits, Limitations, and Authorization Requirements........................... -2.2.1 General Authorization Requirements...................................... -5.2.2 Cardiorespiratory (Apnea) Monitors........................................ -6.2.3 Continuous Positive Airway Pressure (CPAP) and Bi-level Positive Airway Pressure (BiPAP) Systems........................................................ -7.2.4 Controlled Dose Inhalation Drug Delivery System.......................... -8.2.5 Cough Stimulating Devices................................................ -8.2.6 High Frequency Chest Wall Compression System (HFCWCS)................ -8.2.7 Mucus Clearance Valve.................................................... -9.2.8 Nebulizers................................................................ -9.2.8.1 Small Volume Nebulizer With Related Compressor..................-10.2.8.2 Large Volume Nebulizer With Compressor..........................-13.2.8.3 Filtered Nebulizer or Related Compressor...........................-13.2.9 Pulse Oximeters..........................................................-14.2.10 Tracheostomy Tubes....................................................-14.2.11 Other Equipment.......................................................-14.3 Claims Information.............................................................-14.4 Reimbursement................................................................-15.5 TMHP-CSHCN Services Program Contact Center.................................-15 CPT only copyright 2015 American Medical Association. All rights reserved.
CSHCN Services Program Provider Manual February 2016.1 Enrollment Durable medical equipment (DME) providers must be actively enrolled in Texas Medicaid, have a valid Provider Agreement with the CSHCN Services Program, have completed the CSHCN Services Program enrollment process, and comply with all applicable state laws and requirements. Out-ofstate respiratory equipment providers must meet all of these conditions and be located in the United States, within 50 miles of the Texas state border, and approved by the Department of State Health Services (DSHS). Important: CSHCN Services Program providers are responsible for knowing, understanding, and complying with the laws, administrative rules, and policies of the CSHCN Services Program and Texas Medicaid. By enrolling in the CSHCN Services Program, providers are charged not only with knowledge of the adopted CSHCN Services Program agency rules published in Title 25 Texas Administrative (TAC), but also with knowledge of the adopted Medicaid agency rules published in 1 TAC, Part 15, and specifically including the fraud and abuse provisions contained in Chapter 371. CSHCN Services Program providers also are required to comply with all applicable laws, administrative rules, and policies that apply to their professions or to their facilities. Specifically, it is a violation of program rules when a provider fails to provide health-care services or items to recipients in accordance with accepted medical community standards and standards that govern occupations, as explained in 1 TAC 371.1659 for Medicaid providers, which also applies to CSHCN Services Program providers as set forth in 25 TAC 38.6(b)(1). Accordingly, CSHCN Services Program providers can be subject to sanctions for failure to deliver, at all times, health-care items and services to recipients in full accordance with all applicable licensure and certification requirements. These include, without limitation, requirements related to documentation and record maintenance, such that a CSHCN Services Program provider can be subject to sanctions for failure to create and maintain all records required by his or her profession, as well as those required by the CSHCN Services Program and Texas Medicaid. Refer to: Section 2.1, Provider Enrollment, on page 2-2 for more detailed information about CSHCN Services Program provider enrollment procedures..2 Benefits, Limitations, and Authorization Requirements The CSHCN Services Program may reimburse the rental or purchase of medically necessary and appropriate respiratory equipment. The item must be prescribed by a licensed physician and be a benefit of the CSHCN Services Program. Equipment may be rented or purchased depending on the cost-effectiveness of the action requested. In general, equipment is purchased if it is needed for more than 6 s. The CSHCN Services Program purchases only new, unused equipment. The reimbursement of rented equipment includes all supplies, accessories, adjustments, repairs, and replacement parts needed during the iod. Exception: Ventilators, oxygen concentrators, and cough stimulating devices are rented, not purchased, because of high maintenance costs and the frequency of required repairs. Repairs are considered if the item was purchased by the CSHCN Services Program or is an item on the CSHCN Services Program-approved list that was obtained from another source. The repair must be more cost-effective than the cost of replacement. Repairs may be reimbursed at the list price of parts plus labor time. Providers must use procedure code E1340 when requesting authorization and submitting claims for repairs. The CSHCN Services Program considers requests for coverage of the following types of respiratory equipment: Rental or purchase of: Suction equipment Electric percussors for chest physiotherapy High frequency chest wall compression systems (HFCWCS) Medical grade or heavy duty air compressors 2 CPT only copyright 2015 American Medical Association. All rights reserved.
Respiratory Equipment and Supplies Continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP) machines (BiPAP machines will only be provided to clients who have documented treatment failure of CPAP) Immersion heaters Nebulizers Pulse oximeters Ventilators and supplies (ventilators may be a benefit for lease only) Controlled dose inhalation drug delivery system Cardiorespiratory (apnea) monitors (only nonrecording apnea monitors will be authorized for ventilator dependent clients) Rental of: Stationary gaseous oxygen cylinders or liquid oxygen systems Portable gaseous oxygen system Note: Stands, carts, regulators, oxygen conservers, and carrying cases are included in the rental reimbursement for stationary gaseous oxygen cylinders, liquid oxygen systems, and portable gaseous oxygen systems. Oxygen concentrators (a back up cylinder of gaseous oxygen is included in the rental reimbursement) Cough stimulating devices (Cofflator) Purchase of: Liquid or gaseous oxygen contents or refills for client-owned equipment Oxygen humidification devices (e.g., Cascade device) Ambu bag Tracheostomy tubes and supplies Incentive spirometer Mucus clearance valve Note: Rental of substitute equipment is not covered when a purchased item that is under warranty is being repaired. The CSHCN Services Program will cover only one of the following per client: A cough stimulating device An HFCWCS The CSHCN Services Program will consider the following two situations with documentation of medical necessity: Requests for the rental or purchase of duplicate items that will be used in two different locations. The CSHCN Services Program will not pay for the rental or purchase of items when the provision of the items are the legal responsibility of a school district or the Texas Department of Assistive and Rehabilitative Services (DARS). Requests to replace items purchased within the last 2 years. The CSHCN Services Program may cover items under the Family Support Services (FSS) benefit within annual coverage limits. Type of items include, but are not limited to: Room air vaporizers or humidifiers Air filtering systems Specialized vacuum cleaners Heaters Air conditioners Dehumidifiers CPT only copyright 2015 American Medical Association. All rights reserved. 3
CSHCN Services Program Provider Manual February 2016 Contact the CSHCN Services Program at 1-800-252-8023 for additional information about the FSS benefit. The following equipment is not a benefit of the CSHCN Services Program: Intrapulmonary percussive ventilation (IPV) Vaporizers Intermittent pressure breathing (IPPB) machines Disposal tracheostomy inner cannulas Providers must have the client or the client s representative complete the CSHCN Services Program Documentation of Receipt form when DME is delivered to the client. The date of delivery on the documentation of receipt form is the date of service that should appear on the claim. The provider should retain this form; do not submit it with the claim. The documentation of receipt form is available in both English and Spanish. The following table is a list of respiratory equipment and supplies and their limitations. Procedure Maximum Limitation Procedure Maximum Limitation Procedure Maximum Limitation A4481 31 per A4483 31 per A4605 10 per A4606 4 per A4611 1 per 5 years A4612 1 per 5 years A4613 1 per 5 years A4614 1 per 6 A4615 2 per s A4616 4 per year A4617 2 per A4618 4 per A4619 2 per A4620 2 per A4623 1 per A4624 90 per A4627 1 per 6 A4628 2 per s A4629 31 per A7000 4 per A7002 8 per A7003 2 per A7004 1 per A7005 1 per 6 s A7006 1 per A7007 2 per A7009 4 per A7010 1 per 2 A7012 2 per A7013 2 per s A7014 1 per 3 A7015 1 per A7016 2 per s A7017 1 per 3 years A7018 4 per A7026 1 per 6 s A7027 1 per 3 A7028 1 per A7029 2 per s A7030 1 per 3 A7031 1 per A7032 2 per s A7033 2 per A7034 4 per year A70 1 per 6 s A7037 1 per A7038 2 per A7039 1 per 6 s A7520 1 per A7521 1 per A7522 4 per year A9284 1 per 6 s E0431 4 rentals per E0439 4 rentals per A9900 1 per E0424 4 rentals per E0433 1 per E0434 4 rentals per E0441 4 rentals per E0442 4 rentals per 4 CPT only copyright 2015 American Medical Association. All rights reserved.
Respiratory Equipment and Supplies Procedure E0443 1 per E0444 1 per E0445 per 5 years; 1 E0457 per 3 years; 1 E0459 per ; 1 E0466 1 per E0470 per 5 years; 1 E0472 E0483 E0562 Maximum Limitation per 3 years; 1 per ; 1 per 3 years; 1 Procedure E0480 E0500 E0565 Maximum Limitation per 3 years; 1 4 rentals per per 3 years; 1 Procedure E0465 E0471 E0482 E0561 E0570 Maximum Limitation 1 per per 3 years; 1 1 per per 5 years; 1 1 per 3 years E0575 1 per 3 years E0580 1 per 3 years E0600 1 per 3 years E0601 per 3 years; 4 rentals per E0605 1 per 3 years E0618 1 per E0619 4 rentals per E13 1 per year E15 1 per 3 years E1372 1 per 3 years E1399 Limited by S8101 1 per 180 days policy S8185 1 per 5 years S8189 Limited by policy S8999 1 per year.2.1 General Authorization Requirements Requirements for authorization and prior authorization vary with the type of equipment requested. Refer to the types of equipment listed below for authorization and prior authorization requirements. Authorization and prior authorization request forms must be submitted in writing and must include documentation of medical necessity. Refer to: Chapter 4, Prior Authorizations and Authorizations, on page 4-1. CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME) Form. Note: Fax transmittal confirmations are not accepted as proof of timely authorization submission. CPT only copyright 2015 American Medical Association. All rights reserved. 5
CSHCN Services Program Provider Manual February 2016.2.2 Cardiorespiratory (Apnea) Monitors Prior authorization with documentation of medical necessity is required for diagnoses other than those listed below for infants 3 s of age or younger. Prior authorization with documentation of medical necessity is required for infants older than 4 s of age. The rental of procedure code E0619 must be used when billing for recording apnea monitors with the following diagnosis codes: G9009 I440 I441 I442 I4430 I4439 I471 I479 I498 K210 K219 P228 P270 P271 P278 P282 P283 P284 P285 P2889 P2911 P2912 Q246 R000 R0681 Z8489 Other idiopathic peripheral autonomic neuropathy Atrioventricular block, first degree Atrioventricular block, second degree Atrioventricular block, complete Unspecified atrioventricular block Other atrioventricular block Supraventricular tachycardia Paroxysmal tachycardia, unspecified Other specified cardiac arrhythmias Gastro-esophageal reflux disease with esophagitis Gastro-esophageal reflux disease without esophagitis Other respiratory distress of newborn Wilson-Mikity syndrome Bronchopulmonary dysplasia originating in the perinatal period Other chronic respiratory diseases originating in the perinatal period Cyanotic attacks of newborn Primary sleep apnea of newborn Other apnea of newborn Respiratory failure of newborn Other specified respiratory conditions of newborn Neonatal tachycardia Neonatal bradycardia Congenital heart block Tachycardia, unspecified Apnea, not elsewhere classified Family history of other specified conditions Prior authorization may be given for nonrecording apnea monitors (procedure code E0618) used by ventilator dependent clients. Documentation must be submitted to the claims contractor. Documentation should include information that supports medical necessity. The documentation must include interpretation of previous apnea monitor downloads, be signed and dated by the physician who interpreted the download when the infant had previous monitoring, and document that the apnea monitor to be rented is capable of recording and storing data. Providers must use the CSHCN Services Program Prior Authorization Request for Apnea Monitor Rental. Electrodes and lead wires (procedure codes A4556 and A4557) that are used with an apnea monitor owned by a client must be authorized. The CSHCN Services Program requires that a physician statement declaring that the client owns the monitor be submitted with the claim. 6 CPT only copyright 2015 American Medical Association. All rights reserved.
Respiratory Equipment and Supplies Electrodes and lead wires for the apnea monitor may be reimbursed separately only if the client owns the monitor..2.3 Continuous Positive Airway Pressure (CPAP) and Bi-level Positive Airway Pressure (BiPAP) Systems A CPAP system is used primarily for the treatment of obstructive sleep apnea. Other conditions may be considered based on medical necessity. Providers must use procedure code E0601 for the CPAP system and procedure code E0470, E0471, or E0472 for the BiPAP system. CPAP and BiPAP systems require authorization. Providers may submit evidence of medical necessity with the first claim to the CSHCN Services Program claims contractor. The rental of BiPAP machines will only be provided to clients who have a documented failure with a CPAP device. The CPAP system may be prior authorized for rental or purchase based on the physician s predicted length of treatment. The CPAP system may be approved for an initial 3- iod based on documentation that supports the medical necessity and appropriateness of the system. CPAP may be approved for an initial 3- period for adults if one of the following conditions is met: The Sleep Study Respiratory Disturbance Index (RDI) or Apnea/Hypopnea Index (AHI) is greater than or equal to 15 per hour The Sleep Study RDI or AHI is greater than 5 per hour and at least one of the following is true: Excessive daytime sleepiness (documented by either an Epworth greater than ten or a Multiple Sleep Latency Test less than six) Documented symptoms of impaired cognition, mood disorders, or insomnia Documented hypertension (systolic blood pressure greater than 140 mm Hg and/or diastolic blood pressure greater than 90 mm Hg) Documented ischemic heart disease Documented history of stroke Greater than 20 episodes of oxygen desaturation less than 85 percent during a full night sleep study Any one episode of oxygen desaturation less than 70 percent One of the following AHI or oxygen saturation levels may be used for children: Polysomnography documentation of an AHI greater than 1 An oxygen saturation of less than 92 percent, taken upon exertion and breathing room air. Headgear, tubing, and filters used with client-owned positive airway pressure systems do not require prior authorization. Headgear, tubing, and filters are considered part of the rental and will not be reimbursed separately. Humidifiers may be prior authorized when used with a CPAP system and with documentation of medical necessity. Note: Supplies are limited to the amounts that an average client would use. If a client has an unusual need or situation, prior authorization for overages may be obtained with documentation of medical necessity. CPT only copyright 2015 American Medical Association. All rights reserved. 7
CSHCN Services Program Provider Manual February 2016.2.4 Controlled Dose Inhalation Drug Delivery System Authorization is not required for a controlled dose inhalation drug delivery system for the following diagnoses: I272 I2789 Other secondary pulmonary hypertension Other specified pulmonary heart disease.2.5 Cough Stimulating Devices Prior authorization is required for cough stimulating devices (procedure code E0482). Cough stimulating devices may be rented for 3 s. Documentation of medical necessity must include the following: Why other modes of chest physiotherapy have not been effective for the client (include information about other modes used with the client) Results of pulmonary function tests (PFTs) done in the last 6 s Hospitalizations or infections that required IV antibiotics in the last 6 s Work or school absences during the last 6 s because of problems related to a respiratory condition Whether the client has discontinued sports or other extracurricular activities because of fatigue related to the respiratory condition Rental beyond the initial 3- period will be considered with the following: PFT results from the final of rental Evidence of clinical improvement, other than PFTs, including improved work or school attendance or the ability to participate in extracurricular activities Providers must document the information on the CSHCN Services Program Prior Authorization Request for Chest Physiotherapy Devices Form..2.6 High Frequency Chest Wall Compression System (HFCWCS) Providers must use procedure code E0483 when billing for HFCWCS. Prior authorization is required for HFCWCS. A completed CSHCN Services Program Prior Authorization Request for Chest Physiotherapy Devices Form must be submitted with documentation of medical necessity. Prior authorization for the purchase of HFCWCS may be considered for clients with the following diagnoses: E840 E8411 E8419 E848 E849 G121 G128 G129 G710 G800 Cystic fibrosis with pulmonary manifestations Meconium ileus in cystic fibrosis Cystic fibrosis with other intestinal manifestations Cystic fibrosis with other manifestations Cystic fibrosis, unspecified Other inherited spinal muscular atrophy Other spinal muscular atrophies and related syndromes Spinal muscular atrophy, unspecified Muscular dystrophy Spastic quadriplegic cerebral palsy 8 CPT only copyright 2015 American Medical Association. All rights reserved.
Respiratory Equipment and Supplies G801 G802 G804 G808 G809 Spastic diplegic cerebral palsy Spastic hemiplegic cerebral palsy Ataxic cerebral palsy Other cerebral palsy Cerebral palsy, unspecified Other diagnoses will be considered with documentation of medical necessity. Documentation of medical necessity must include: An explanation of why other modes of chest physiotherapy have not been effective for the client. Include information about other modes used with the client. Results of PFTs done in the last 6 s. Hospitalizations or infections in the last 6 s that required intravenous (IV) antibiotics. Work or school absences in the last 6 s because of problems related to the respiratory condition. Whether the client has discontinued sports or other extracurricular activities because of fatigue related to a respiratory condition. If documentation supports the need for an HFCWCS, a 3- rental trial may be approved. If the HFCWCS is documented to be effective at the end of the initial 3- iod, purchase of the system may be authorized. If at the end of the initial 3- iod a determination of purchase cannot be made, an additional 3- rental may be given. At the end of the 3- trial, the following information should be sent with the request to purchase the generator for the client: PFT results from the final of rental Evidence of clinical improvement, other than PFTs, including improved work or school attendance or the ability to participate in extracurricular activities The frequency and compliance graphs that were generated by the compressor for the 6- period and that indicate compliance with the physician s prescription Providers must document the information on the CSHCN Services Program Prior Authorization Request for Chest Physiotherapy Devices Form. The rental fees for these systems are applied to the purchase price of the compressor; therefore, a new compressor is provided at the onset of the iod. An HFCWCS is a once-in-a- purchase because the manufacturer provides a warranty. An exception may be considered for replacement of the HFCWCS vest if documentation indicates that the client has outgrown the vest. An HFCWCS is not purchased or rented if the CSHCN Services Program is currently renting a cough stimulating device for the client..2.7 Mucus Clearance Valve Providers must use procedure code S8185 for the purchase of a mucus clearance valve. The mucus clearance valve does not require authorization..2.8 Nebulizers A nebulizer may be rented or purchased for clients when: The equipment is prescribed by a physician for an approved diagnosis. The documentation submitted with the claim, the authorization, or prior authorization request supports medical necessity and appropriateness. CPT only copyright 2015 American Medical Association. All rights reserved. 9
CSHCN Services Program Provider Manual February 2016 The purchase of nebulizers may be reimbursed with the anticipation that the equipment will last a minimum of 2 years with continuous use and up to 5 years with intermittent use. The following procedure codes may be reimbursed for nebulizers and supplies: Procedure s Small Volume Nebulizer and Supplies A7003 A7004 A7005 A7006 E0565 E0572 Large Volume Nebulizer and Supplies A7007 A7008 E0585 Filtered Volume Nebulizer and Supplies A7006 E0565 E0572 Ultrasonic Volume Nebulizer and Supplies E0574 E0575.2.8.1 Small Volume Nebulizer With Related Compressor Authorization is not required for small volume nebulizer with related compressor for the diagnoses listed in the table below: A3701 A3711 A3781 A3791 A481 B20 B250 B440 B59 E840 E8411 E8419 E848 E849 J09X1 J09X2 J120 J121 J122 J123 J1281 J1289 J129 J13 Whooping cough due to Bordetella pertussis with pneumonia Whooping cough due to Bordetella parapertussis with pneumonia Whooping cough due to other Bordetella species with pneumonia Whooping cough, unspecified species with pneumonia Legionnaires' disease Human immunodeficiency virus [HIV] disease Cytomegaloviral pneumonitis Invasive pulmonary aspergillosis Pneumocystosis Cystic fibrosis with pulmonary manifestations Meconium ileus in cystic fibrosis Cystic fibrosis with other intestinal manifestations Cystic fibrosis with other manifestations Cystic fibrosis, unspecified Influenza due to identified novel influenza A virus with pneumonia Influenza due to identified novel influenza A virus with other respiratory manifestations Adenoviral pneumonia Respiratory syncytial virus pneumonia Pneumonia due to parainfluenza virus Human metapneumovirus pneumonia Pneumonia due to SARS-associated coronavirus Other viral pneumonia Viral pneumonia, unspecified Pneumonia due to Streptococcus pneumoniae 10 CPT only copyright 2015 American Medical Association. All rights reserved.
Respiratory Equipment and Supplies J14 J150 J151 J1520 J15211 J15212 J1529 J153 J154 J155 J156 J157 J158 J159 J160 J168 J17 J180 J181 J188 J189 J210 J211 J218 J219 J440 J441 J449 J4520 J4521 J4522 J4530 J4531 J4532 J4540 J4541 J4542 J4550 J4551 J4552 J45901 Pneumonia due to Hemophilus influenzae Pneumonia due to Klebsiella pneumoniae Pneumonia due to Pseudomonas Pneumonia due to staphylococcus, unspecified Pneumonia due to Methicillin susceptible Staphylococcus aureus Pneumonia due to Methicillin resistant Staphylococcus aureus Pneumonia due to other staphylococcus Pneumonia due to streptococcus, group B Pneumonia due to other streptococci Pneumonia due to Escherichia coli Pneumonia due to other aerobic Gram-negative bacteria Pneumonia due to Mycoplasma pneumoniae Pneumonia due to other specified bacteria Unspecified bacterial pneumonia Chlamydial pneumonia Pneumonia due to other specified infectious organisms Pneumonia in dideases classified elsewhere Bronchopneumonia, unspecified organism Lobar pneumonia, unspecified organism Other pneumonia, unspecified organism Pneumonia, unspecified organism Acute bronchiolitis due to respiratory syncytial virus Acute bronchiolitis due to human metapneumovirus Acute bronchiolitis due to other specified organisms Acute bronchiolitis, unspecified Chronic obstructive pulmonary disease with acute lower respiratory infection Chronic obstructive pulmonary disease with (acute) exacerbation Chronic obstructive pulmonary disease, unspecified Mild intermittent asthma, uncomplicated Mild intermittent asthma with (acute) exacerbation Mild intermittent asthma with status asthmaticus Mild persistent asthma, uncomplicated Mild persistent asthma with (acute) exacerbation Mild persistent asthma with status asthmaticus Moderate persistent asthma, uncomplicated Moderate persistent asthma with (acute) exacerbation Moderate persistent asthma with status asthmaticus Severe persistent asthma, uncomplicated Severe persistent asthma with (acute) exacerbation Severe persistent asthma with status asthmaticus Unspecified asthma with (acute) exacerbation CPT only copyright 2015 American Medical Association. All rights reserved. 11
CSHCN Services Program Provider Manual February 2016 J45902 J45909 J45990 J45991 J45998 J690 J691 Q334 T8601 T8602 T8603 T8609 T8611 T8612 T8613 T8619 T8621 T8622 T8623 T86290 T86298 T8641 T8642 T8643 T8649 T86810 T86811 T86812 T86818 T86830 T86831 T86832 T86838 T86850 T86851 T86852 T86858 T86890 T86891 T86892 T86898 Unspecified asthma with status asthmaticus Unspecified asthma, uncomplicated Exercise induced bronchospasm Cough variant asthma Other asthma Pneumonitis due to inhalation of food and vomit Pneumonitis due to inhalation of oils and essences Congenital bronchiectasis Bone marrow transplant rejection Bone marrow transplant failure Bone marrow transplant infection Other complications of bone marrow transplant Kidney transplant rejection Kidney transplant failure Kidney transplant infection Other complication of kidney transplant Heart transplant rejection Heart transplant failure Heart transplant infection Cardiac allograft vasculopathy Other complications of heart transplant Liver transplant rejection Liver transplant failure Liver transplant infection Other complications of liver transplant Lung transplant rejection Lung transplant failure Lung transplant infection Other complications of lung transplant Bone graft rejection Bone graft failure Bone graft infection Other complications of bone graft Intestine transplant rejection Intestine transplant failure Intestine transplant infection Other complications of intestine transplant Other transplanted tissue rejection Other transplanted tissue failure Other transplanted tissue infection Other complications of other transplanted tissue 12 CPT only copyright 2015 American Medical Association. All rights reserved.
Respiratory Equipment and Supplies T8690 T8691 T8692 T8693 T8699 Unspecified complication of unspecified transplanted organ and tissue Unspecified transplanted organ and tissue rejection Unspecified transplanted organ and tissue failure Unspecified transplanted organ and tissue infection Other complications of unspecified transplanted organ and tissue.2.8.2 Large Volume Nebulizer With Compressor Authorization is not required for a large volume nebulizer with compressor for the following diagnoses: E840 E8411 E8419 E848 E849 J398 J471 J479 J9809 Z430 Z930 Cystic fibrosis with pulmonary manifestations Meconium ileus in cystic fibrosis Cystic fibrosis with other intestinal manifestations Cystic fibrosis with other manifestations Cystic fibrosis, unspecified Other specified diseases of upper respiratory tract Bronchiectasis with (acute) exacerbation Bronchiectasis, uncomplicated Other diseases of bronchus, not elsewhere classified Encounter for attention to tracheostomy Tracheostomy status.2.8.3 Filtered Nebulizer or Related Compressor Authorization is not required for a filtered nebulizer or related compressor for the following diagnoses: B20 T8690 T8691 T8692 T8693 T8699 Human immunodeficiency virus [HIV] disease Unspecified complication of unspecified transplanted organ and tissue Unspecified transplanted organ and tissue rejection Unspecified transplanted organ and tissue failure Unspecified transplanted organ and tissue infection Other complications of unspecified transplanted organ and tissue Prior authorization requests must be submitted in writing to the CSHCN Services Program and must document the medical necessity of a nebulizer for any diagnosis not listed above or to justify the purchase of more than one nebulizer. The purchase of ultrasonic nebulizers (procedure codes E0574 and E0575) may be considered for prior authorization with documentation of the failure of standard therapy. CPT only copyright 2015 American Medical Association. All rights reserved. 13
CSHCN Services Program Provider Manual February 2016.2.9 Pulse Oximeters Pulse oximeters require prior authorization. A completed CSHCN Services Program Prior Authorization Request for Pulse Oximeter Devices form, must be submitted with documentation of medical necessity. The rental of pulse oximeters includes the probes. Oximeters may be reimbursed for a iod of up to 6 s. Extensions will be considered with documentation of medical necessity. Purchase may be considered with documentation of medical necessity. Pulse oximeters should be billed using procedure code E0445. Pulse oximeters may be prior authorized for clients who meet one of the following criteria: Client is oxygen or ventilator dependent, or Client is clinically stable and is weaning off the oxygen or ventilator, or Client has another condition that requires monitoring of oxygen saturation. Client needs continuous monitoring or monitoring during sleep, or Client needs continuous monitoring to maintain optimal oxygen saturation levels, and Client is clinically unstable or just returned home from a hospital stay. There must be a caregiver identified and present who has been trained in use of the oximeter and how to respond to readings in a medically safe way..2.10 Tracheostomy Tubes Standard tracheostomy tubes do not require prior authorization. Tracheostomy tubes billed with modifiers TF or TG must be prior authorized. Documentation of medical necessity and the manufacturer s suggested retail price (MSRP) must accompany the prior authorization request form. One standard tracheostomy tube and/or one inner cannula is a benefit per. If a client has a custom tracheostomy tube, no inner cannulas will be authorized. Disposable tracheostomy inner cannulas are not a benefit. Providers must use procedure code A7520, A7521, or A7522 when billing tracheostomy tubes. Providers must add modifier TF when billing a tracheostomy with specialized functions and modifier TG when billing a custom-made tracheostomy..2.11 Other Equipment All other respiratory equipment must be authorized. Documentation of medical necessity for the item must accompany the claim..3 Claims Information DME services must be submitted to TMHP in an approved electronic format or on the CMS-1500 paper claim form. Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms. When completing a CMS-1500 paper claim form, all required information must be included on the claim, as information is not keyed from attachments. Superbills, or itemized statements, are not accepted as claim supplements. Modifier RR must be used for DME rental equipment, and modifier NU must be used for the purchase of new DME equipment. Home health DME providers must use benefit code DM3 on all claims and authorization requests. All other providers must use benefit code CSN on all claims and authorization requests. The Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes included in policy are subject to National Correct Coding Initiative (NCCI) relationships. Exceptions to NCCI code relationships that may be noted in CSHCN Services Program medical policy are no longer valid. Providers should refer to the CMS NCCI web page for correct 14 CPT only copyright 2015 American Medical Association. All rights reserved.
Respiratory Equipment and Supplies coding guidelines and specific applicable code combinations. In instances when CSHCN Services Program medical policy quantity limitations are more restrictive than NCCI Medically Unlikely Edits (MUE) guidance, medical policy prevails. Refer to: Chapter 40, TMHP Electronic Data Interchange (EDI), on page 40-1 for information about electronic claims submissions. Chapter 5, Claims Filing, Third-Party Resources, and Reimbursement, on page 5-1 for general information about claims filing. Section 5.7.2.4, CMS-1500 Paper Claim Form Instructions, on page 5-25 for instructions on completing paper claims. Blocks that are not referenced are not required for processing and may be left blank..4 Reimbursement Respiratory equipment may be reimbursed the lower of either the billed amount or the amount allowed by Texas Medicaid. Reimbursement of rented equipment includes all of the supplies, accessories, adjustments, repairs, and replacement parts needed during the iod. For fee information, providers can refer to the Online Fee Lookup (OFL) on the TMHP website at www.tmhp.com. The CSHCN Services Program implemented rate reductions for certain services. The OFL includes a column titled Adjusted Fee to display the individual fees with all percentage reductions applied. Additional information about rate changes is available on the TMHP website at www.tmhp.com/pages/topics/rates.aspx. Note: Certain rate reductions including, but not limited to, reductions by place of service, client type program, or provider specialty may not be reflected in the Adjusted Fee column..5 TMHP-CSHCN Services Program Contact Center The TMHP-CSHCN Services Program Contact Center at 1-800-568-2413 is available Monday through Friday from 7 a.m. to 7 p.m., Central Time, and is the main point of contact for the CSHCN Services Program provider community. CPT only copyright 2015 American Medical Association. All rights reserved. 15