Occupational therapy programs tables of content
Medicaid Reimbursement for Wheelchair and Positioning Devices
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- Bu səhifədəki naviqasiya:
- Other Third-Party Insurers/Managed Care
- RESOURCES TO HELP FACILITATE RESOLUTION OF REIMBURSEMENT ISSUES
- DOCUMENTATION SUPPORT: SUPPLEMENTAL INFORMATION ( Please check with the insurer to be certain of specific requirements )
- WHEELCHAIR JUSTIFICATION, SAMPLE FORMAT 1
- You might wish to include pictures of your client sitting - showing why a new wheelchair or positioning device is needed. “One picture if worth a thousand words”.
- HOW DO I DEVELOP A POSITIONING PROGRAM IN MY FACILITY
Medicaid Reimbursement for Wheelchair and Positioning Devices. - Medicaid is a state administered program that is similar to Medicare in many respects, with the major exception that the guidelines vary significantly from state to state. Medicaid reimbursement is generally not as comprehensive as Medicare. Specific procedures need to be ascertained State by State. Contact the Claims/Medical Review Department of your state’s Medicaid agency and/or your facility bookkeeper to learn the specifics of coverage. A general guideline for information to find out the information to find out follows: Determine: General Medicaid guidelines to receive DME funding. Eligibility. E-codes and Medicaid allowables.
Determine what Medicaid covers for motorized/non-motorized wheelchairs, wheelchair components/parts, seating/positioning devices. Determine what is needed in order to submit a Medicaid claim to receive DME equipment. Support documentation generally includes: Copy of current Medicaid card. Motorized/non-motorized wheelchair medical clearance form. Note: A physician pad prescription may be or may not be required. Support documentation/medical necessity letter. (Find out who is responsible for writing). Medicaid Prior Authorization (PA). General process for submitting a PA. Speak with other clinicians to understand the “Key” pieces of information the reviewers in your area tend to look for. Determine who is involved in completing forms and define their roles. Physician involvement and role. Therapist involvement and role. Vendor involvement and role. Support staff involvement and role (i.e., family patient, facility, etc.) Determine what happens when Medicaid approves a claim for equipment. Vendor role and involvement. Therapist role and involvement Include process to provide billable services (i.e., order clarification, treatment plan, documentation protocol). Support System role involvement (i.e., patient/family/facility, etc.) Other Third-Party Insurers/Managed Care Many third-party health insurers, such as Health Maintenance Organizations, Blue Cross/Blue Shield, and others structure their reimbursement guidelines in a fashion similar to Medicare. Coverage for specific pieces of equipment, however, may vary significantly from provider to provider. Contact the appropriate facility staff member (i.e., bookkeeper) or insurance company directly to ascertain coverage and procedures required to obtain reimbursement for wheelchair positioning devices. Common forms include letter of medical necessity, price estimate (from vendor), predetermined request. The Claims/Medical Review Department of the insurance company may be particularly helpful. Try to get a copy of their medical review guidelines for DME when possible. Other sources of payment must be utilized prior to Medicaid or Medicare. More and more of our patients are opting for HMO/Managed Care instead of Medicare. It is important to inform the patient of any limitations in rehabilitative care that are imposed because of that choice. It is usually possible for the patient to covert back to traditional Medicare coverage to receive better benefits for rehab. Facilitate communication between the facility’s social services department and the patient to discuss this option and determine how to proceed.
Often, residents or their families may have resources available to pay out of pocket for wheelchair positioning devices. Many vendors will accept credit cards or personal checks for payment. Reconditioned/used equipment should be considered where appropriate. Many community organizations are beginning to establish equipment loaning libraries, and this option should be explored. (See next page) RESOURCES TO HELP FACILITATE RESOLUTION OF REIMBURSEMENT ISSUES Dealing With Denials/Appeals Your division Denials/Appeals Consultant will have good information regarding these processes. In general, for each third-party reimbursement source you should know: Process for submission of a new claim. Process/time frame to review claim, and who receives notice. Non-reimbursable equipment. Guidelines regarding rental vs. purchase of equipment; rental periods; coverage for maintenance of equipment. Denials/Appeals process and time frames The following quote comes from a successful overturn of a denial for adaptive seating and may be helpful as a guide for writing the supporting letter: “For an individual who is chair bound, the chair becomes an extension of that individual and as such is an integral part of his/her daily life, environment and personality. The psychological and physiological state of the individual is largely determined by the human body in relation to its environment. An improperly tilted seating system is as potentially harmful and hazardous as the self-prescribed drug. It can cause trauma, secondary deformities and disabilities and other complications that may be irreversible.” Facility Administrator Consult with your facility administrator to ascertain the budget set aside for durable medical equipment and positioning devices. When possible, submit a request for needed positioning devices during the facility’s normal budget planning cycle. Be sure to provide a therapeutic rationale for obtaining the equipment. Make sure the facility administrator, physician, and other key facility staff understand the benefits of good positioning. Conduct inservice education programs and invite administrators as well as caregivers. Make sure the resident and his/her family or significant others understands the benefits of good positioning. Often, family members can serve as advocates for securing the equipment the resident needs. Make sure the facility administrator and key facility staff understand how proper positioning can increase compliance with OBRA regarding restraint reduction. DME Vendor Your local DME sales representative can be an invaluable resource in determining requirements, regulation, and procedures for getting reimbursement for DME. It is strongly recommended that each therapist cultivate a relationship with a DME provider in their local area. Community Organizations Often, community-based support groups, foundations, corporations, and societies will contribute to the cost of purchasing wheelchairs and positioning supplies for needy residents. Some suggestions include: Local corporations for aging/elderly. Alzheimer’s Societies/Groups for residents with Alzheimer’s or other Dementias Veteran’s of Foreign War (VFW) for residents who are veterans. Variety Club Multiple Sclerosis Society Local Chapter of Arthritis Foundation Religious Organizations/Churches United Way Civic Groups (Jay Cees, Kiwanis, Elks, Rotary Club, etc.) DOCUMENTATION SUPPORT: SUPPLEMENTAL INFORMATION (Please check with the insurer to be certain of specific requirements) Physician’s Orders A physician’s order specifying the type of wheelchair positioning device or adaptive equipment should appear in the resident’s medical record. The order may be written by the physician, or taken as a verbal order as long as documentation of the order appears in the medical record. A “pad” script may or may not be required. Initial order should read “OT/PT evaluation and treatment indicated.” Clarification order should be obtained following evaluation to specify: Treatment procedures to be used to obtain goals. Specific frequency and duration for OT/PT intervention. Descriptions of positioning devices, if required. Physician’s Clarification Order for wheelchair devices: Orders should include minimum of 1) Patient’s diagnosis, 2) specific type of DME needed, and 3) Length of time DME is required. EXAMPLE: “OT/PT treatment of patient with right hemiplegia to improve functional mobility and skin integrity to include caregiver/resident training, wheelchair adaptations of solid drop seat insert with 2" gel/foam cushion; half-lap tray with hemi-arm support, right brake extension lever, and quick- release seat belt. Required minimum of 1 year.” Certificates of Medical Necessity Medicare and other third party insurers may require the completion of a certificate of medical necessity (CMN) for positioning/wheelchair devices. The CMN is completed by the therapist and physician, and provides evidence of the medical necessity of the device. The facility bookkeeper should be contacted to establish if a CMN is required and to get information about the appropriate procedures to follow. Pre-Authorization/Prior Approval Some third party insurers may require pre-authorization for wheelchair and positioning devices. Pre-authorization processes will vary dependent upon the insurer. The facility bookkeeper should be contacted to establish if pre-authorization is required to get information about the appropriate procedures to follow. Following is the paperwork that is generally required to obtain prior authorization from insurance companies and other funding sources: A copy of the physician’s prescription A copy of his clinic note A statement of the physical and/or mental condition of the patient that dictates the medical necessity of the prescribed service, as well as the benefits that the patient will derive from the prescribes services. A prognostic statement that clearly defines functional limitations in relation to mobility. Use terminology that is acceptable and understood by the insurance community: “communications prosthesis or custom orthotic seat and back module...” Explain how services are vital to the client’s health and well being, and that the client can use the prescribed services to become more functionally independent, to improve ability to communicate with others, improve mobility, improve education and vocational opportunities, etc. Itemized statement of charges A concise but specific statement of the diagnosis. Descriptive brochures explaining services/equipment with pictures.
A picture of the client Letters from satisfied clients Extra supporting medical data, i.e., letters from referring physicians, therapists, teachers, etc. Other financial aid available (such as insurance secondary pay). Joint funding by several sources is possible and often aids in getting other funds from Medicaid, United Cerebral Palsy, Easter Seals, etc. Patient Agreement Wheelchair positioning devices are considered to be durable medical equipment and are subject to a 20% co-insurance payment by residents who are covered by Medicare Part B. Other third party insurers may have a similar requirement. Patient agreement to pay the co-insurance is generally required prior to billing the insurance company for the positioning device regardless of who (the facility or NovaCare) is the original purchaser of the device. Consult with the appropriate facility staff member (bookkeeper, administrator, rehab coordination, etc.) regarding the preferred procedures for obtaining patient agreements. In some facilities, the therapist may be required to obtain the agreement, in others this responsibility is delegated to other personnel. Motorized/Non-Motorized Medical Clearance Form or Other Forms May Also Be Required.
NAME:
MEDICAL RECORDS NUMBER: MEDICAL ASSISTANCE NUMBER (if any): MEDICARE NUMBER (if any): PRIVATE INSURANCE NUMBERS (if any): LEVEL OF CARE: DIAGNOSIS: RANGE OF MOTION: RANGE OF MOTION - LIMITATIONS: AMBULATION SKILLS: TRANSFER ABILITIES: ABILITY TO PROPEL WHEELCHAIR: GROWTH POTENTIAL OF CLIENT: CURRENT WHEELCHAIR: TRAIL IN DIFFERENT WHEELCHAIRS: POSSIBLE LIFE SPAN OF REQUESTED WHEELCHAIR: SAFETY ISSUES: COMMUNITY INTEGRATION ISSUES Intermediate or Skilled Explain if necessary, if deteriorating physical condition, etc. Actual measurements, if limited Expound in narrative form. Explain how it impacts on function. State NONE if non-ambulatory Address mechanical lift if appropriate With hands or feet or why not able i.e., “She/he is an adult and her/his weight is closely monitored by medical staff, she/he is not expected to grow further” Age, condition, and how not appropriate. Duration of trial and results. Must always address this section. If no trials – state why, i.e., want same chair as currently using. I.e., “ Life span of E&J (or other brand name) approximately 10-15 years. It is a sturdy system and expected to wear well. If any, i.e., “old warped frame that cannot be re-welded or repaired. i.e., “ With the increased community integration required for our clients, (Name) needs his/her own personal wheelchair to meet these state & federal guidelines/goals.” Note: mention if new wheelchair will enable client to attend work, school, therapy, to be more independent, etc.
You must justify all non-standard parts on the wheelchair. Below is a partial list to help you get started: RECLINING FEATURES: Include health reasons here DETACHABLE/ADJUSTABLE HEIGHT/DESK ARMS: To aid in transfers in/out of wheelchair To get closer to work/eating surfaces To position upper extremities for function SOLID FOLDING SEAT: For better pelvic control/support Because of decreased ROM in hips and knees
For better trunk support and positioning ABDUCTOR: To keep legs apart To prevent breakdown of medial knee region
To decrease edema in legs HEAVY DUTY FRAME: If client is more than 250 lbs. SEAT BELT: Safety in transport For pelvic control
To support legs in sitting, so they don’t pull back under the wheelchair ANTI-TIPPERS: To prevent tipping of wheelchair due to rocking or bouncing the wheelchair TRUNK SUPPORTS: To provide support to trunk due to heavy leaning or due to scoliosis FUNDING: This is the last issue you need to address in the Justification. Some facilities receive a PER DIEM RATE from the insurer for each client they serve. Some forms of insurance believes this per diem rate covers Wheelchairs. An example of an institutional facility response is enclosed here to assist you in developing one for your facility. “ (Name) ‘s treatment at (Facility) Is covered through a per diem rate that is set to cover goods and services provided to (Name) at (Facility) . No funds are available for purchase of this special seating system in the per diem rate. This seating system is necessary for continuous care and exclusive use of (Name) in order to meet his/her medical needs. This need is identified and documented in (Name) ‘s care plan. We, therefore, request Medical Assistance (or other insurer) to fund this seating system for (Name) “. SIGNATURES: Occupational Therapist Physical Therapist Adaptive Equipment Specialist - If any Physician PRESCRIPTION To this justification, attach a prescription signed by the physician. Once this is written, typed, reviewed, revised and retyped it is submitted to the vendor of your choice who places the order for the wheelchair. If you do not know how to measure a client for a wheelchair, the vendor will assist you. Two helpful hints (1) Use as much verbage as you need to. You are trying to help the Reviewer “see” your client and that client’s need for a wheelchair. (2) You might wish to include pictures of your client sitting - showing why a new wheelchair or positioning device is needed. “One picture if worth a thousand words”. Taken From: AOTA Resource Packet “Seating and Wheeled Mobility” WHEELCHAIR JUSTIFICATION, SAMPLE FORMAT #2 (Your hospital letterhead) EQUIPMENT LETTER OF MEDICAL NECESSITY TO WHOM IT MAY CONCERN: Patient Name: Bill Ross Age 67 Phone #: 555-2923 Address: 1034 Hudson Blvd. Medicare #: 224-56-9453A New York NY Insurance #: AARP 224-56-3453 Diagnosis: CVA w/right hemiparesis Weight: 180# Height: 6'0" EQUIPMENT NEEDED: Jay contoured cushion (18x18) Jay adjustable solid drop seat, Jay contoured back system w/adjustable lateral trunk supports and lumbar roll, and spinal fiolite pad. CURRENT MEDICAL/PHYSICAL STATUS: Cardio-respiratory status: Coronary artery by-pass surgery in 1982. Congestive heart failure 1981. Tone/movement: Flacid Right arm-no movement. Hypotonic trunk, Right side hypertonic in flexor synergy, Right leg movement in synergy only. Orthopaedic considerations: Severe osteoarthritis both hips and knees, Right total hip replacement 1986. Cognitive level: Alert and oriented, poor memory, difficulty following directions with poor carry over of learned activities. Visual/perceptual deficits: Right visual hemianopsia. SITTING POSTURE: Balance: Poor--needs external support to maintain sitting balance. Pelvic tilt: Posterior pelvic tilt. Pelvic obliquity: increased weight bearing right hip Leg Position: windswept to right Lumbar lordosis decreased Thoracic kyphosis: increased Scoliosis: functional-flexible convex to left Shoulder/scapula position: Right shoulder depressed and subluxed Head position: rotated and tilted to the left SKIN CONDITION/INTEGRITY: Client has or is highly susceptible to decubitus ulcers: yes Sensation: Decreased right arm, leg and trunk Bowel/Bladder status: continent of bowel, inconsistent with bladder. Present/history of ulcer: Yes Where: Ischial tuberosity Right stage 1 Coccyx stage 1 Trochanter No Spinous process T 6-8 stage Confined in W/C: yes Time spent in W/C: 8 hours FUNCTIONAL STATUS: Transfers: minimal assist. W/C propulsion: Indep. With left arm/let w/a 17 ½ “ seat to floor height. Ability to perform pressure relief: minimal assist Ambulatory status: Moderate assist of 2 people with quad cane and right ankle-foot brace 20 feet maximum distance. OTHER EQUIPMENT EVALUATED BUT NOT PRESCRIBED: Flat foam, eggcrate-a flat cushion causes increaed kyphoscoliosis of the spine with redness on spine, sling seat upholstery causes pelvic obliquity and adduction and internal rotation at the legs and pt. is unable to reach the floor for propulsion. THERAPEUTIC OBJECTIVES/BENEFITS OF PRESCRIBED EQUIPMENT: 1) Firm back & laterals facilitate upright midline posture correcting scoliosis 2) Lumbar roll restores support to torsal curve eliminating low back & neck pain. 3) Flolite spinal pad eliminated reddened pressure area over T6 spinous process. 4) Solid drop seat creates optimal seat to floor height allowing indep. w/c propulsion 5) Cusion provides optimal base of support for stability and pressure, distribution with positioning relieving pressure off coccyx and disappearance of redness over right 1T since use. OTHER SPECIAL CONSIDERATIONS: Client will be attending adult “day care” program where he will require optimal positioning for activities (i.e., envelope stuffing, stamping, etc.). LENGTH OF TIME NEEDED: Lifetime (cushion will need to be partially or wholly replaced every 2-3 yrs.) We hope that you will be able to accommodate this need in an expedient manner. Thank you very much for your cooperation and assistance in this matter. Physician’s name: Robert Henderson, M.D. Therapist’s name: Louise Bass, RPT Facility Name: Hudson Rehab. Address: 222 Phillips Lane New York, NY Phone: 555-1243 Physician’s signature:__________________________________ Date:_____________ Notes:_____________________________________________________________________________ __________________________________________________________________________________
TO WHOM IT MAY CONCERN: Patient Name:______________________________ Age______ Phone #:___________________ Address:___________________________________ Medicare #:_________________ ___________________________________ Insurance #:_________________ Diagnosis:_________________________________ Weight:__________ Height:______________ EQUIPMENT NEEDED:_________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
Cardio-respiratory status:________________________________________________________________ Tone/movement:_______________________________________________________________________ _____________________________________________________________________________________ Orthopaedic considerations:______________________________________________________________ _____________________________________________________________________________________ Cognitive level:_________________________________________________________________________ Visual/perceptual deficits:________________________________________________________________ SITTING POSTURE: Balance:______________________________________________________________________________ Pelvic tilt:_____________________________________________________________________________ Pelvic obliquity:________________________________________________________________________ Leg position:___________________________________________________________________________ Lumbar lordosis:________________________________________________________________________ Thoracic kyphosis:______________________________________________________________________ Scoliosis:______________________________________________________________________________ Shoulder/scapula position:________________________________________________________________ Head position:_________________________________________________________________________ SKIN CONDITION/INTEGRITY: Client has or is highly susceptible to decubitus ulcers:__________________________________________ Sensation:_____________________________________________________________________________ Bowel/Bladder status:____________________________________________________________________ Present/history of ulcer:__________________________________________________________________ Where: Ischial tuberosity:_____________________________ Coccyx:__________________________ Trochanter:______________________________ Spinous process:___________________ Confined in W/C:________________________________ Time spent in W/C:_________________ FUNCTIONAL STATUS: Transfers:_______________________________ W/C propulsion:__________________________ _____________________________________________________________________________________ Ability to perform pressure relief:__________________________________________________________ _____________________________________________________________________________________ Ambulatory status:______________________________________________________________________ OTHER EQUIPMENT EVALUATED BUT NOT PRESCRIBED:___________________________________ __________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________
____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ OTHER SPECIAL CONSIDERATIONS:____________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________
Address:______________________________________________________________ ______________________________________________________________ Phone:___________________________________________ Physician’s signature:____________________________________________ Date:_______________ Notes:________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(Attach photo if available.) HOW DO I DEVELOP A POSITIONING PROGRAM IN MY FACILITY? 1. POSITIONING/SEATING PROGRAM COMMITTEE. Primary rold of the committee is to: identify program goals formulate a plan - with a timeline formulate policy and procedures, as needed identify roles of team members inventory current equipment evaluate current residents’ needs develop a plan for identifying and securing the equipment needed to give resident’s a “trial” of a seating system. Basic devices include: solid seat inserts back supports lateral supports “sit-straight” or similar cushion selection of seat belts lap tray wheelchair foot support/platform |