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.......................... -7.2.5 Cough Stimulating Devices................................................ -8.2.6 High Frequency Chest Wall Compression System (HFCWCS)................ -8.2.7 Mucus Clearance Valve.................................................... -9.2.8 Nebulizers................................................................ -9.2.9 Pulse Oximeters..........................................................-12.2.10 Tracheostomy Tubes....................................................-13.2.11 Other Equipment.......................................................-13.3 Claims Information.............................................................-13.4 Reimbursement................................................................-14.5 TMHP-CSHCN Services Program Contact Center.................................-14 CPT only copyright 2013 American Medical Association. All rights reserved.
CSHCN Services Program Provider Manual May 2014.1 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 Code (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. 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 2013 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 2013 American Medical Association. All rights reserved. 3
CSHCN Services Program Provider Manual May 2014 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. An example of this form is provided in Appendix B, CSHCN Services Program Documentation of Receipt, on page B-115 or the Appendix B, CSHCN Services Program Documentation of Receipt (Spanish), on page B-116. The date of delivery on the CSHCN Services Program 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 following table is a list of respiratory equipment and supplies and their limitations. Procedure Code Maximum Limitation Procedure Code Maximum Limitation Procedure Code 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 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 A4629 31 per A7000 4 per A7002 8 per A7003 2 per A7004 1 per A7005 1 per 6 A7006 1 per A7007 2 per A7009 4 per A7010 1 per 2 A7011 1 per calendar year A7012 2 per A7013 2 per A7014 1 per 3 A7015 1 per A7016 2 per A7017 1 per 3 years A7018 4 per A7026 1 per 6 A7027 1 per 3 A7028 1 per A7029 2 per A7030 1 per 3 A7031 1 per A7032 2 per A7033 2 per A7034 4 per year A70 1 per 6 A7037 1 per A7038 2 per A7039 1 per 6 A7520 1 per A7521 1 per A7522 4 per year A9284 1 per 6 A9900 1 per E0424 4 rentals per E0431 4 rentals per E0433 1 per 4 CPT only copyright 2013 American Medical Association. All rights reserved.
Respiratory Equipment and Supplies Procedure Code E0434 E0442 E0445 E0459 4 rentals per 4 rentals per per 5 years; 1 per ; 1 E0439 4 rentals per E0464 1 per E0470 per 5 years; 1 E0472 E0483 E0562 Maximum Limitation per 3 years; 1 per ; 1 per 3 years; 1 Procedure Code E0441 4 rentals per E0443 1 per E0444 1 per E0450 1 per E0457 per 3 years; 1 E0460 1 per E0463 1 per E0480 E0500 E0565 Maximum Limitation per 3 years; 1 4 rentals per per 3 years; 1 Procedure Code E0471 E0482 E0561 E0570 Maximum Limitation 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 2 per 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. Appendix B, CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME), on page B-28. Note: Fax transmittal confirmations are not accepted as proof of timely authorization submission. CPT only copyright 2013 American Medical Association. All rights reserved. 5
CSHCN Services Program Provider Manual May 2014.2.2 Cardiorespiratory (Apnea) Monitors Prior authorization with documentation of medical necessity is required for diagnoses other than those listed below for infants 4 of age or younger. Prior authorization with documentation of medical necessity is required for infants older than 4 of age. The rental of procedure code E0619 must be used when billing for recording apnea monitors with the following diagnosis codes: Diagnosis Code Description 33700 Idiopathic peripheral autonomic neuropathy, unspecified 33709 Other idiopathic peripheral autonomic neuropathy 4260 Atrioventricular block, complete 42610 Unspecified atrioventricular block 42611 First degree atrioventricular block 42612 Mobitz (type) II atrioventricular block 42613 Other second degree atrioventricular block 4270 Paroxysmal supraventricular tachycardia 4272 Unspecified paroxysmal tachycardia 42789 Other specified cardiac dysrhythmias 53011 Reflux esophagitis 53081 Esophageal reflux 74686 Congenital heart block 7707 Chronic respiratory disease arising in the perinatal period 77081 Primary apnea of newborn 77082 Other apnea of newborn 77083 Cyanotic attacks of newborn 77084 Respiratory failure of newborn 77089 Other respiratory problems after birth 77981 Neonatal bradycardia 77982 Neonatal tachycardia 7850 Tachycardia, unspecified 78603 Apnea V198 Family history of other 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 form available in Appendix B, CSHCN Services Program Prior Authorization Request for Apnea Monitor, on page B-5. 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 2013 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..2.4 Controlled Dose Inhalation Drug Delivery System A controlled dose inhalation drug delivery system (procedure code K0730) may be reimbursed when submitted with diagnosis code 4168. CPT only copyright 2013 American Medical Association. All rights reserved. 7
CSHCN Services Program Provider Manual May 2014.2.5 Cough Stimulating Devices Prior authorization is required for cough stimulating devices (procedure code E0482). Cough stimulating devices may be rented for 3. 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 Hospitalizations or infections that required IV antibiotics in the last 6 Work or school absences during the last 6 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 form located in Appendix B, CSHCN Services Program Prior Authorization Request for Chest Physiotherapy Devices, on page B-15..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 must be submitted with documentation of medical necessity. Prior authorization for the purchase of HFCWCS may be considered with the following diagnosis codes. Other diagnoses will be considered with documentation of medical necessity. Diagnosis Code Description 27700 Cystic fibrosis without mention of meconium ileus 27701 Cystic fibrosis with meconium ileus 27702 Cystic fibrosis with pulmonary manifestations 27703 Cystic fibrosis with gastrointestinal manifestations 27709 Cystic fibrosis with other manifestations 310 Unspecified spinal muscular atrophy 311 Kugelberg-Welander disease 319 Other spinal muscular atrophy 3430 Diplegic infantile cerebral palsy 3431 Hemiplegic infantile cerebral palsy 3432 Quadriplegic infantile cerebral palsy 3433 Monoplegic infantile cerebral palsy 3434 Infantile hemiplegia 3438 Other specified infantile cerebral palsy 3439 Unspecified infantile cerebral palsy 91 Hereditary progressive muscular dystrophy (Duchenne s only) 8 CPT only copyright 2013 American Medical Association. All rights reserved.
Respiratory Equipment and Supplies 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. Hospitalizations or infections in the last 6 that required intravenous (IV) antibiotics. Work or school absences in the last 6 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 form located in Appendix B, CSHCN Services Program Prior Authorization Request for Chest Physiotherapy Devices, on page B-15. 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. 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 Codes Small Volume Nebulizer and Supplies A7003 A7004 A7005 A7006 E0565 E0572 Large Volume Nebulizer and Supplies A7007 A7008 E0585 CPT only copyright 2013 American Medical Association. All rights reserved. 9
CSHCN Services Program Provider Manual May 2014 Procedure Codes Filtered Volume Nebulizer and Supplies A7006 E0565 E0572 Ultrasonic Volume Nebulizer and Supplies E0574 E0575 Authorization is not required for nebulizers if an approved diagnosis, listed in the table above, is submitted: Small volume nebulizer with related compressor Diagnosis Code Description 042 Human immunodeficiency virus (HIV) 1363 Pneumocystosis 27700 Cystic fibrosis without mention of meconium ileus 27701 Cystic fibrosis with meconium ileus 27702 Cystic fibrosis with pulmonary manifestations 27703 Cystic fibrosis with gastrointestinal manifestations 27709 Cystic fibrosis with other manifestations 46611 Acute bronchiolitis due to respiratory syncytial virus (RSV) 46619 Acute bronchiolitis due to other infectious organisms 4800 Pneumonia due to adenovirus 4801 Pneumonia due to respiratory syncytial virus 4802 Pneumonia due to parainfluenza virus 4803 Pneumonia due to SARS-associated coronavirus 4808 Pneumonia due to other virus not elsewhere classified 4809 Unspecified viral pneumonia 481 Pneumococcal pneumonia (streptococcis pneumoniae pneumonia) 4820 Pneumonia due to Klebsiella pneumoniae 4821 Pneumonia due to Pseudomonas 4822 Pneumonia due to Hemoplilus influenzae (H. influenzae) 48230 Pneumonia due to unspecified Streptococcus 48231 Pneumonia due to Streptococcus, group A 48232 Pneumonia due to Streptococcus, group B 48239 Pneumonia due to other Streptococcus 48240 Pneumonia due to Staphylococcus, unspecified 48241 Methicillin susceptible Staphylococcus aureus 48242 Methicillin resistant pneumonia due to Staphylococcus aureus 48249 Other Staphylococcus pneumonia 48281 Pneumonia due to anaerobes 48282 Pneumonia due to Escherichia coli (E. coli) 48283 Pneumonia due to other gram-negative bacteria 48284 Legionnaires disease 48289 Pneumonia due to other specified bacteria 4829 Unspecified bacterial pneumonia 10 CPT only copyright 2013 American Medical Association. All rights reserved.
Respiratory Equipment and Supplies Diagnosis Code Description 4830 Pneumonia due to Mycoplasma pneumoniae 4831 Pneumonia due to Chlamydia 4838 Pneumonia due to other specified organism 4841 Pneumonia in cytomegalic inclusion disease 4843 Pneumonia in whooping cough 4845 Pneumonia in anthrax 4846 Pneumonia in aspergillosis 4847 Pneumonia in other systemic mycoses 4848 Pneumonia in other infectious diseases classified elsewhere 485 Bronchopneumonia, organism unspecified 486 Pneumonia, organism unspecified 48801 Influenza due to identified Avian influenza virus with pneumonia 48802 Influenza due to identified Avian influenza virus with other respiratory manifestations 48811 Influenza due to identified 2009 H1N1 influenza virus with pneumonia 48812 Influenza due to identified 2009 H1N1 influenza virus with other respiratory manifestations 48881 Influenza due to identified novel influenza A virus with pneumonia 48882 Influenza due to identified novel influenza A virus with other respiratory manifestations 49300 Extrinsic asthma, unspecified 49301 Extrinsic asthma with status asthmaticus 49302 Extrinsic asthma with (acute) exacerbation 49310 Intrinsic asthma, unspecified 49311 Intrinsic asthma with status asthmaticus 49312 Intrinsic asthma with (acute) exacerbation 49320 Chronic obstructive asthma, unspecified 49321 Chronic obstructive asthma with status asthmaticus 49322 Chronic obstructive asthma with (acute) exacerbation 49381 Exercise induced bronchospasm 49382 Cough variant asthma 49390 Asthma, unspecified 49391 Asthma, unspecified, with status asthmaticus 49392 Asthma, unspecified with (acute) exacerbation 5070 Pneumonitis due to inhalation of food or vomitus 5071 Pneumonitis due to inhalation of oils and essences 74861 Congenital bronchiectasis 99680 Complications of transplanted organ, unspecified site 99681 Complications of transplanted kidney 99682 Complications of transplanted liver 99683 Complications of transplanted heart 99684 Complications of transplanted lung CPT only copyright 2013 American Medical Association. All rights reserved. 11
CSHCN Services Program Provider Manual May 2014 Diagnosis Code Description 99685 Complications of transplanted bone marrow 99686 Complications of transplanted pancreas 99687 Complications of transplanted organ, intestine 99689 Complications of other transplanted organ Large Volume Nebulizer with Compressor Diagnosis Code Description 27700 Cystic fibrosis without mention of meconium ileus 27701 Cystic fibrosis with meconium ileus 27702 Cystic fibrosis with pulmonary manifestations 27703 Cystic fibrosis with gastrointestinal manifestations 27709 Cystic fibrosis with other manifestations 4940 Bronchiectasis without acute exacerbation 4941 Bronchiectasis with acute exacerbation 51919 Other diseases of trachea and bronchus V440 Tracheostomy status V550 Attention to tracheostomy Filtered Nebulizer or Related Compressor Diagnosis Code Description 042 Human immunodeficiency virus (HIV) 99680 Complications of organ transplants, unspecified site 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..2.9 Pulse Oximeters Pulse oximeters require prior authorization. A completed CSHCN Services Program Prior Authorization Request for Pulse Oximeter Devices form, which can be found on page B-75 must be submitted with documentation of medical necessity. Simple nonrecording oximeters may be billed using procedure code E0445. Recording pulse oximeters may be billed using procedure code E0445 with modifier TF. The rental of pulse oximeters includes the probes. Oximeters may be reimbursed for a iod of up to 6. Extensions will be considered with documentation of medical necessity. Purchase may be considered with documentation of medical necessity. Pulse oximeters may be prior authorized for clients who meet the following criteria: Procedure Code E0445 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 does not usually require continuous or long-term monitoring. Client usually requires only spot checks for oxygen saturation. Procedure Code E0445 with Modifier TF 12 CPT only copyright 2013 American Medical Association. All rights reserved.
Respiratory Equipment and Supplies Client is oxygen- or ventilator-dependent, and Client needs continuous monitoring or monitoring during sleep, or Client needs continuous monitoring to maintain optimal oxygen saturation levels, and There is a caregiver who has been identified, and is present, and has been trained in the use of the oximeter and how to respond to readings in a medically safe way. Client is clinically unstable or just returned home from a hospital stay..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 Centers for Medicare & Medicaid Services (CMS) NCCI web page at www.medicaid.gov/medicaid-chip-program-information/by- Topics/Data-and-Systems/National-Correct-Coding-Initiative.html for correct 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 5-27 for instructions on completing paper claims. Blocks that are not referenced are not required for processing and may be left blank. CPT only copyright 2013 American Medical Association. All rights reserved. 13
CSHCN Services Program Provider Manual May 2014.4 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. 14 CPT only copyright 2013 American Medical Association. All rights reserved.