Durable medical equipment vendors must be enrolled as durable medical equipment providers. Refer to the Medical Supplier Enrollment Criteria and Forms section of the Minnesota Health Care Programs (MHCP) Provider Manual. Providers must be able to provide support services such as:

· Delivery and setup

· Repairs

· Warranty service (a copy of the warranty must be given to the member and a copy kept in the provider’s records)

· Education and ongoing assistance with the use of the stander

Providers must have skilled and knowledgeable service personnel to provide timely service and repairs.

TPL and Medicare

Providers must meet any provider criteria, including accreditation, for Medicare or other insurance, to assist members for whom MHCP is not the primary payer. Refer to the Medicare and Other Insurance section of the MHCP Provider Manual for more information.

Eligible Members

Standers are covered for eligible medical assistance and MinnesotaCare members who:

· Have little or no potential for walking

· Cannot stand unassisted long enough to successfully complete activities of daily living

· Meet coverage criteria listed under Covered Services in this manual section

Covered Services

Codes: A9999, E0637, E0638, E0641, E0642
Standing frame systems (E0637, E0638, E0641, E0642) are covered for members when the following criteria are met:

· Member must have a diagnosis of an underlying medical condition that involves inability to walk or loss of walking ability

· The stander must be an integral part of a therapy program in the home with specific, measurable outcomes unique to the member in at least two of the following areas:

· Improvement of respiratory function where the member has impaired respiratory function due to the medical condition that impairs walking ability

· Prevention of contractures and improvement of range of motion in the lower extremities

· Reduction of pain associated with hypertonia

· Maintenance of skin integrity or prevention of pressure ulcers

· Decrease in the frequency of urinary tract infections

· Decrease in the frequency of digestive disorders

· Improvement of bowel function

· Maintenance of bone density in adults when requested no later than 18 months from the onset of the condition that caused the loss of ability to walk or in children under age 21

· The therapy program must require:

· Adult members to stand at least 30 minutes per day at least five times per week

· Children must stand at least 7 to 10 hours per week

· A child with a standing program at school must stand a total of at least 10 hours per week when adding the standing time of their school program and home program together

· The therapy program must be established by a therapist with experience working with standers

Accessories Purchase Criteria for Rented Standers

· Member must have a diagnosis of an underlying medical condition that involves inability to walk

· Rental of the stander for two to three months must be necessary for continuation of a school-based therapy program or for temporary use when there is a decline in functional mobility, for example, following orthopedic surgery

Noncovered Services

MHCP does not cover the following:

· A stander for any of the following contraindications:

· Inadequate bone density to safely allow standing

· History of fainting

· History of sudden changes in blood pressure

· Uncontrolled dependent edema

· Adverse reactions while standing during the trial period

· A stander for a member who regularly uses a stander in a school or day program, although two to three-month rental may be appropriate when school is not in session. “Regularly” means a child who uses a stander 10 hours per week or an adult who uses a stander five times per week for 30 minutes or more each time.

Refer to information under the Noncovered Services heading in the Billing the Member (Recipient) section of the MHCP Provider Manual to review the conditions required to bill the member.

Authorization

Submit authorization requests and required documentation to the Medical Review Agent. Fax the MN–ITS response with the required documentation, physician’s order and the Authorization Request for Standers and Accessories (DHS-4075) (PDF). Document the MN–ITS Authorization Request number assigned on every page of each document.

The Authorization Request for Standers and Accessories must be completed and signed by the supplier’s staff person, the physical therapist and the physician. Both forms must be completed.

Attach the manufacturer’s invoice, a price list or a quote from the manufacturer dated within three months of the authorization request. Clearly indicate each item being requested with the stander on the pricing documentation. Do not modify, alter or change the pricing documentation.

Standers are reviewed as a complete package. The approved rate for purchase of a stander will include all approved accessories. The approved rate for purchase of accessories for a rented stander will include all approved accessories.

Authorization Request

· Authorization is required for all purchases and for rentals after three months.

· Authorization is required for purchase of accessories for previously purchased standers if the submitted charge for an accessory is $400 or more.

· If the member is currently in a nursing facility, authorization will be considered if requested as part of a discharge plan or if documentation establishes that there is sufficient space in the member’s room for the equipment, and that use of the stander will be part of the member’s care plan. All other criteria must be met.

· A stander in combination with a gait trainer is typically not covered. If both a stander and a gait trainer are requested, prior authorization is required and must include specific documentation of medical necessity which notes why one device alone will not meet the member's needs.

· Submit a log of the trial period with the authorization request. The Home Trial Log for Stander (DHS-5538) (PDF) is recommended.

· A trial, which must include a minimum of three days and occur partially in the member’s home, of the requested stander is required:

· If the requested stander is replacing an existing stander of the same type (prone, supine, sit-to-stand), the trial need only establish:

· The new stander fits in the member’s home

· Is configured to meet the member’s standing needs (This can usually be accomplished within a few hours)

· If the member participated in a standing program at school, a day program or previous residence and has lost access to the stander, the trial needs to establish the new stander:

· Fits in the member’s home

· Is configured to meet the member’s standing needs

· Is willingly used by the member in the new environment

· Caregivers are willing and able to assist with the standing program (This can usually be accomplished within a few days)

· If the member does not have a history of a standing program within the previous 12 months, the trial needs to establish the stander:

· Fits in the member’s home

· Is configured to meet the member’s standing needs

· Is willingly used by the member

· Caregivers are willing and able to assist with the standing program

· The standing program has resulted in progress toward the stated goals or the member has significantly increased standing time (This can usually be accomplished within two weeks)

· A log completed by the member or caregiver must be included with the authorization request

· If the requested stander is replacing an existing stander but is of a different type (prone, supine, sit-to-stand), the trial needs to establish the stander:

· Fits in the member’s home

· Is configured to meet the member’s standing needs

· Is willingly used by the member

· Caregivers are willing and able to assist with the standing program

· The standing program has resulted in progress toward the stated goals or the member significantly increased standing time (This can usually be accomplished within two weeks)

· A log completed by the member or caregiver must be included with the authorization request

· All authorization requests must include an assessment by a physical therapist. The assessment must include:

· The current program and functional goals

· Baseline for each goal

· The effect of the trial period or previous standing on the goals

· A description of the member’s history of standing

· Functional mobility status, including the amount of assistance required for sitting, standing, ambulation and transfers

· All authorization requests must include descriptions of what less costly alternatives were considered or tried, and why they were rejected. This should address other standing devices considered, as well as other approaches for meeting the member’s goals.

· Authorization requests for members under age 21 must describe how the requested device will accommodate expected growth.

· Authorization requests for members with progressive diseases or conditions must include:

· An assessment of the effects of the disease’s progress on the member’s ability to use the requested device

· An estimate of how long the requested device is expected to meet the member’s needs

· Submit the HCPCS code and appropriate modifiers for the requested stander. Include a list of all accessories with documentation of medical necessity, for each item added to the stander with the authorization request.

· Use A9999 for accessories for previously purchased standers. Authorization is required for accessories when the submitted charge is over $400. Include documentation of medical necessity. If authorization is not required, maintain documentation of medical necessity in the provider’s files.

Authorization is required for purchase of accessories for use with a rented stander when the submitted charge for the accessories is over $400. Documentation must include:

· The name and model of the stander

· Justification for the requested accessories

· The individualized therapy program for which the stander is required

· A minimum three-day trial in the member’s home is required. The trial must partially occur in the member’s home, and the remainder may occur in the clinic, school, or member’s other living arrangement. The trial needs to establish the new stander:

· Fits in the member’s home

· Is configured to meet the member’s standing needs

· Is willingly used by the member in the new environment

· Caregivers are willing and able to assist with the standing program (This can usually be accomplished within a few days)

· Submit the HCPCS code for the stander for which the accessories are requested. Use modifier 52 to indicate this is a reduced service and does not represent a request to purchase a stander. Include a list of all accessories are being requested with documentation of medical necessity for each item.

Billing

Providers are responsible to coordinate services. Refer to the Billing Policy Overview section of Provider Basics for general billing information.

Bill Standers using MN–ITS 837P. Refer to the MHCP MN–ITS Billing for Durable Medical Equipment, Medical Supplies, Prosthetics and Orthotics, and Augmentative Devices for claim instructions.

Approved Purchase

Submit a claim for the stander. Make sure the HCPCS code, modifiers and the description on the claim match the same information on the prior authorization.

Enter the authorization number in the authorization field on the claim information tab of MN–ITS.

Rental with Purchased Accessories

Submit a claim for the stander using the appropriate HCPCS code and RR modifier. For codes requiring manual pricing, attach the manufacturer’s invoice, a price list, or a quote from the manufacturer dated within three months.

If billing for accessories under $400, bill on the same claim, using the same HCPCS code and modifier 52. Attach the manufacturer’s invoice, a price list, or a quote from the manufacturer dated within three months of the authorization request. Clearly indicate each item being requested on the pricing documentation. Do not modify, alter or change the pricing documentation.

If billing for accessories over $400, bill on a separate claim. Make sure the HCPCS code, modifiers and description on the claim match the same information on the authorization. Enter the authorization number in the authorization field on the claim information tab of MN–ITS.

If authorization for purchase of the same type of stander is submitted and approved within three months of the last rental date of service, the rental price will be subtracted from the approved amount.

Accessories for Previously Purchased Standers

If billing for accessories under $400, bill using the A9999 and NU modifier. Attach the manufacturer’s invoice, a price list or a quote from the manufacturer dated within three months. Clearly indicate each item that is being requested on the pricing documentation. Do not modify, alter or change the pricing documentation.

Rental when Purchase Authorization is Denied

When authorization for purchase has been denied, the medical supplier may bill one-month rent to cover expenses incurred in evaluation, fitting and stander trial period. Bill the appropriate HCPCS code modifiers RR and 52. For codes requiring manual pricing, attach the manufacturer’s invoice, a price list or a quote from the manufacturer dated within three months.

If authorization for purchase of the same type of stander is resubmitted and approved within three months of the rental date of service, the rental price will be subtracted from the approved amount.

Report this page

Issue:
Email:
Comments: