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Part II Policies and Procedures Manual for Durable Medical Equipment Services

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Part II Policies and Procedures Manual for Durable Medical Equipment Services PART II POLICIES AND PROCEDURES for DURABLE MEDICAL EQUIPMENT SERVICES GEORGIA DEPARTMENT OF COMMUNITY HEALTH DIVISION OF MEDICAL ASSISTANCE PLANS Revised: July 1, 2021 Policy Revisions Record for 2021 Part II Policies and Procedures Manual for Durable Medical Equipment Services REVISION CITATION TYPE REVISION (Revision SECTION REVISION DESCRIPTION A=Added DATE required by D=Deleted Regulation, M=Modified Legislation, etc.) 01/01/2021 601.3 Added Language for HCPCS Requirements M 01/01/2021 803.3 Added Language for HCPCS Requirements M 01/01/2021 Appendix D Added Language for HCPCS Requirements M 01/01/2021 1104.3 Disposable Insulin Management Systems A 04/01/2021 1112.11 Pulse Oximeter Guidelines M Physical or Occupational Therapist 04/01/2021 1102 (PT/OT) Requirements for Evaluations M 04/01/2021 1112.3 In Home or Mobility Facility Sleep Studies M 07/01/2021 Appendix H Georgia Families M 07/01/2021 1112.11 Pulse Oximeter/Portable Oxygen M July 2021 Durable Medical Equipment Services 1 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 www.mmis.georgia.gov, which shall constitute formal Notices to providers. The amended provisions will be effective on the date of the Notices 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. July 2021 Durable Medical Equipment Services 2 TABLE OF CONTENTS PREFACE Introduction QUARTERLY UPDATES Policy Revision Records CHAPTER 600 CONDITIONS OF PARTICIPATION CHAPTER 700 SPECIAL ELIGIBILITY CONDITIONS CHAPTER 800 PRIOR APPROVAL GUIDELINES Section 801 General Section 802 Services That Require Prior Approval Section 803 Procedures for Obtaining Prior Approval Section 804 Provider’s Review of an Approved Request Section 805 Billing for Prior Authorized Services Section 806 Equipment Rentals CHAPTER 900 SCOPE OF SERVICES Section 901 General Section 902 Coverage Guidelines for Durable Medical Equipment Section 903 Face-to-Face (F2F) Encounter Requirements Section 904 Coverage for Medical Supplies Section 905 Non-Covered Services Section 906 Durable Medical Equipment Purchase (NU) Guidelines Section 907 Durable Medical Equipment Rental (RR) Guidelines Section 908 Maintenance, Repairs, and Replacements Section 909 Table of Repairs with Allowed Units of Service Section 910 Reasonable Useful Lifetime (RUL) for Durable Medical Equipment Section 911 Temporary Out-of-State Provider Limitations Section 912 Enrolled Out-of-State Provider Limitations Section 913 General Claims Submission Policy for Ordering, Prescribing, or Referring (OPR) Providers Section 914 Commonly Used Acronyms CHAPTER 1000 BASIS FOR REIMBURSEMENT Section 1001 Durable Medical Equipment Services (Reimbursement Methodology and Copay Information) July 2021 Durable Medical Equipment Services 3 CHAPTER 1100 MEDICAL POLICIES AND SPECIAL COVERAGE CONSIDERATIONS Augmentative and Alternative Communication Devices Policy 1101 General Provisions for Speech Generating Devices Definitions Non-Covered Items Prior Authorization Required Data Third Party Liability Trial Period Notice for Decision 1101.1 Mobile Devices with Qualifying Software Covered as a Speech Generating Device (SGD) for Alternative Augmentative Communication (AAC) Therapy 1101.2 Speech Aid Policy 1102 Complex/Custom Rehabilitative Equipment Supplier Requirements for Complex Custom Rehab Equipment Physical or Occupational Therapist (PT/OT) Requirements 1102.1 Complex Custom Wheeled Mobility Devices -Power Mobility Devices 1102.2 Other Assistive Custom/Complex Rehabilitative Equipment 1102.2a Specialty Walkers 1102.2b Shower/Bath Chairs and Other Rehab Toilet Aids 1102.2c Standing Frames/ Sit-to-Stand Systems 1102.2d Gait Trainers 1102.2e Patient Lifts Policy 1103 Manual Wheelchairs and Other Considerations Policy 1104 Diabetes Management 1104.1 Continuous Glucose Monitor 1104.2 Blood Glucose Monitor and Supplies Policy 1105 Home Phototherapy Policy 1106 Hospital Beds and Accessories July 2021 Durable Medical Equipment Services 4 1106.1 Enclosed Pediatric Beds or Canopy Policy 1107 Inexpensive/ Routinely Purchased Equipment 1107.1 Commode Chairs/ Raised Toilet Seat 1107.2 Canes/Crutches 1107.3 Walkers Policy 1108 Infusion Therapy 1108.1 External Infusion Pumps 1108.2 Insulin Infusion Pumps 1108.3 Parenteral Infusion Pumps 1108.4 iPort (Subcutaneous injection port) Policy 1109 Nutritional Therapy or Supplementation Services 1109.1 Enteral Nutrition 1109.2 Oral Medical Foods 1109.3 Electric Breast Pumps Policy 1110 Osteogenesis Stimulator Policy 1111 Pressure Reducing Support Surfaces (PRSS) 1111.1 GROUP 1 Pressure Reducing Support Surfaces 1111.2 GROUP 2 Pressure Reducing Support Surfaces Policy 1112 Respiratory Services Complex Respiratory Supplier Provisions Non-Complex Respiratory Supplier Provisions 1112.1 Apnea Monitors (Infant) 1112.2 Automatic External Defibrillators 1112.3 Continuous Positive Pressure Airway Devices (CPAP/BIPAP) and Accessories 1112.4 Nebulizers and Accessories 1112.5 Altera Nebulizer (Replacement Only) 1112.6 High Frequency Chest Wall Oscillation Devices 1112.7 Intrapulmonary Percussive Ventilation (IPV) System 1112.8 Mechanical In-Exsufflation Devices (Cough Stimulating Device) 1112.9 Oxygen and Oxygen Related Equipment 1112.10 Ventilators 1112.11 Pulse Oximeters July 2021 Durable Medical Equipment Services 5 Policy 1113 Suction Pumps and Supplies / Wound Care 1113.1 Negative Pressure Wound Therapy Devices 1113.2 Respiratory Suction Pumps Policy 1114 Supplies 1114.1 Ostomy Supplies 1114.2 Surgical Dressings 1114.3 Tracheostomy Supplies 1114.4 Wound Care Supplies Policy 1115 Transcutaneous Electrical Nerve Stimulators (TENS) Policy 1116 Urological Supplies July 2021 Durable Medical Equipment Services 6 APPENDIX DESCRIPTION A SAMPLE MEDICAID ID CARD B STATEMENT OF PARTICIPATION C INSTRUCTIONS FOR COMPLETING THE PRIOR AUTHORIZATION REQUEST FORM AND CMS 1500 (version 02/12) CLAIM FORM (FORMS ATTACHED) D DURABLE MEDICAL EQUIPMENT CODES THAT REQUIRE MANUAL PRICING (MANUFACTURER’S QUOTE INVOICE REQUIRED) E LIST OF COVERED WHEELCHAIR COMPONENTS OR ACCESSORIES NOT OTHERWISE SPECIFIED (K0108) THAT REQUIRE MANUAL PRICING (MANUFACTURER’S QUOTE INVOICE REQUIRED) F 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 (*Must be under 21 years of age*) ❖ Oxygen Equipment ❖ Patient Lift ❖ Respiratory Suction Pump ❖ Full Volume Ventilator ❖ Custom Durable Medical Equipment (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) ❖ External Infusion Pump and Supplies F.1 FACE-TO-FACE EVALAUATION ❖ Face-To-Face Encounter Certification G DOCUMENTATION REQUIREMENTS FOR DURABLE MEDICAL EQUIPMENT H GEORGIA FAMILIES July 2021 Durable Medical Equipment Services 7 I GEORGIA 360 J GENERAL CLAIMS SUBMISSION POLICY FOR ORDERING, PRESCRIBING, REFERRING (OPR) PROVIDERS K GEORGIA HEALTH PARTNERSHIP (GHP) L (PAGE INTENTIONALLY LEFT BLANK) M COMMONLY ASKED QUESTIONS (Q&A) N (PAGE INTENTIONALLY LEFT BLANK) O COMMON MODIFIERS July 2021 Durable Medical Equipment Services 8 CHAPTER 600 DME SUPPLIER STANDARDS FOR PARTICIPATION IN THE GEORGIA MEDICAID PROGRAM 601. In addition to all conditions of participation in the Medical Assistance Program as outlined in the Part 1 Policies and Procedures for Medicaid and PeachCare for Kids, Section 106, providers of Durable Medical Equipment must also be compliant with all standards outlined in Chapter 600 of the Part II Policies and Procedures for Durable Medical Equipment Services. 601.1 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. 601.2 A supplier must provide the Department with a valid business license. A business license is considered valid if it is in accordance
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