Florida Medicaid

Florida Medicaid DURABLE MEDICAL EQUIPMENT AND MEDICAL SUPPLY SERVICES COVERAGE AND LIMITATIONS HANDBOOK Agency for Health Care Administration JULY 2010 JULY 2010 Handbook UPDATE LOG DURABLE MEDICAL EQUIPMENT AND MEDICAL SUPPLY SERVICES COVERAGE AND LIMITATIONS HANDBOOK How to Use the Update Log Introduction The current Medicaid provider handbooks are posted on the Medicaid fiscal agent’s Web site at www.mymedicaid-florida.com. Select Public Information for Providers, then Provider Support, and then Provider Handbooks. Changes to a handbook are issued as handbook updates. An update can be a change, addition, or correction to policy. An update may be issued as either replacement pages in an existing handbook or a completely revised handbook. It is very important that the provider read the updated material and if he maintains a paper copy, file it in the handbook. It is the provider’s responsibility to follow correct policy to obtain Medicaid reimbursement. Explanation of the Update Log Providers can use the update log to determine if they have received all the updates to the handbook. Update describes the change that was made. Effective Date is the date that the update is effective. Instructions When a handbook is updated, the provider will be notified by a notice. The notification instructs the provider to obtain the updated handbook from the Medicaid fiscal agent’s Web site at www.mymedicaid-florida.com. Select Public Information for Providers, then Provider Support, and then Provider Handbooks. Providers who are unable to obtain an updated handbook from the Web site may request a paper copy from the Medicaid fiscal agent’s Provider Support Contact Center at 800-289-7799. UPDATE EFFECTIVE DATE Replacement Pages October 1999 Replacement Pages January 2000 Errata—Pen-and-Ink Correction January 2000 Replacement Pages April 2001 Errata April 2001 Replacement Pages January 2002 Replacement Pages March 2003 Revised Handbook July 2008 Revised Handbook July 2010 JULY 2010 JULY 2010 DURABLE MEDICAL EQUIPMENT AND MEDICAL SUPPLY SERVICES COVERAGE AND LIMITATIONS HANDBOOK Table of Contents Chapter/Topic Page Introduction Handbook Use and Format ....................................................................................... ii Characteristics of the Handbook ............................................................................... iii Handbook Updates .................................................................................................... iii Chapter 1 – Provider Qualifications and Enrollment Purpose and Definitions ............................................................................................ 1-1 Provider and Enrollment Qualifications ..................................................................... 1-3 Provider Requirements .............................................................................................. 1-17 Chapter 2 - Covered Services, Limitations and Exclusions General Service Requirements ................................................................................ 2-3 Medical Necessity Definition and Documentation Requirements ............................ 2-9 Service Delivery, Pick-Up, and Training Documentation Requirements ................. 2-13 Prior and Post Authorization and Exceptions to the Service Limits ......................... 2-16 Equipment Purchase, Trade, or Rental .................................................................... 2-22 Equipment Maintenance, Repair, and Renovation .................................................. 2-28 Ambulatory Aids ....................................................................................................... 2-32 Apnea Monitors ........................................................................................................ 2-32 Augmentative and Alternative Communication Systems ......................................... 2-36 Bathroom and Toileting Aids .................................................................................... 2-46 Compressors ............................................................................................................ 2-47 Custom Cranial Remolding Orthosis ........................................................................ 2-48 Disposable Incontinence Brief, Diaper, Protective Underwear, Pull-On, Liner, Shield, Guard, Pad, Undergarment………………………………………………......…2-48 Glucose Monitors, Diabetic Testing Strips, Insulin Syringes, and Blood Lancets .. 2-50 Heat Lamps and Pads.............................................................................................. 2-50 Hospital Beds, Mattresses, and Rails ...................................................................... 2-51 Intermittent Catheter with Insertion Supplies ........................................................... 2-53 Lymphedema Pump ................................................................................................. 2-54 Nebulizer .................................................................................................................. 2-55 Orthopedic Footwear ................................................................................................ 2-56 Orthotic Devices ....................................................................................................... 2-58 Osteogenesis Stimulator .......................................................................................... 2-60 Oxygen and Oxygen-Related Equipment ................................................................ 2-61 Parenteral and Drug Infusion Pumps ....................................................................... 2-72 Passive Motion Device ............................................................................................. 2-72 Patient Lifts .............................................................................................................. 2-73 Peak Flow Meter ...................................................................................................... 2-74 Pediatric Dynamic Splinting Device ......................................................................... 2-75 Phototherapy (Bilirubin) Light with Photometer ....................................................... 2-76 Chapter 2 - Covered Services, Limitations and Exclusions, continued Pressure Ulcer Care ................................................................................................. 2-77 Prosthetic Devices ................................................................................................... 2-77 Prosthetic Eyes ........................................................................................................ 2-79 Pulse Oximeter ......................................................................................................... 2-80 Resuscitator Bag ...................................................................................................... 2-81 Suction Machines ..................................................................................................... 2-82 Traction Equipment .................................................................................................. 2-83 Trapeze Equipment .................................................................................................. 2-83 Ventilator and Respiratory Equipment ..................................................................... 2-83 Wheelchairs ............................................................................................................. 2-91 Non-Covered Services and Exclusions.................................................................... 2-97 Non-Covered Services and Exclusions Exception Process ..………………………..2-98 Chapter 3 - Procedure Codes and Fees Reimbursement Information ..................................................................................... 3-1 How to Read the Fee Schedule ............................................................................... 3-4 Non-Classified Procedure Codes ............................................................................. 3-7 By Report Claims ..................................................................................................... 3-8 Procedure Code Modifiers ....................................................................................... 3-8 Appendices Appendix A: Custom Wheelchair Evaluation, AHCA Med Serv Form 015 ............. A-1 Appendix B: Quality Standards for Disposable Incontinence Brief, Diaper, Protective Underwear, Pull-On, Liner, Shield, Guard, Pad,Undergarment……...….B-1 INTRODUCTION TO THE HANDBOOK Overview This chapter introduces the format used for the Florida Medicaid handbooks Introduction and tells the reader how to use the handbooks. There are three types of Florida Medicaid handbooks: Background • Provider General Handbook describes the Florida Medicaid Program. • Coverage and Limitations Handbooks explain covered services, their limits, who is eligible to receive them, and the fee schedules. • Reimbursement Handbooks describe how to complete and file claims for reimbursement from Medicaid. Exception: For Prescribed Drugs, the coverage and limitations handbook and the reimbursement handbook are combined into one. The following federal and state laws govern Florida Medicaid: Legal Authority • Title XIX of the Social Security Act; • Title 42 of the Code of Federal Regulations; • Chapter 409, Florida Statutes; • Chapter 59G, Florida Administrative Code. This chapter contains: In This Chapter TOPIC PAGE Handbook Use and Format

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