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Assistive Technology, PERS,

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Title: Assistive Technology, PERS,


1
Assistive Technology, PERS, Environmental
Modifications
  • Virginia Department of Medical Assistance
    Services
  • Fall 2000

2
DURABLE MEDICAL EQUIPMENT (DME)
  • Recipients in any Waiver may receive any
    medically necessary DME available to the general
    Medicaid population.
  • Specific documentation requirements and coverage
    criteria are in the DME Manual, Chapter IV.

3
ASSISTIVE TECHNOLOGY (AT)
  • Definition Assistive technology equipment
    includes, but is not limited to, consumer lifts,
    bath chairs, wall-mounted insulin delivery
    devices,
  • and automatic feeders.

4
AT Criteria under DME
  • Under the current DME criteria, all
    assistive-technology equipment must be medically
    necessary and essential for the treatment of an
    illness or injury

5
AT Criteria Under DME Contd
  • . Excluded from covered services are
  • --home modifications
  • --furniture and appliances not defined
  • as medical equipment
  • --items that are not for the diagnosis and
    treatment of illness or injury or
  • to improve functioning
  • --equipment that is primarily for
  • vocational or educational use

6
Under current DME criteria, the following must be
met
  • 1.) Recipient-Based Outcomes (one of the
    following must be met)
  • an identified, realistic goal exists that
    makes necessary the use of the assisted-technology
    equipment for the treatment of the medical
    condition or
  • anticipated stabilization of a medical
    condition or progress toward a goal is related to
    the equipment.

7
Current DME Criteria for AT (Contd)
  • 2.) Supportive Activities to Accomplish
    Outcomes (all of the following must be met)
  • Goals must be part of an active, rehabilitative,
    therapeutic plan of care.
  • The recipient or caregiver demonstrates the
    ability to cognitively, motivationally, and
    physically use the equipment.

8
Current DME Criteria for AT (Contd)
  • Alternatives to the equipment have been explored
    and rejected as not appropriate.
  • The recipient does not have a condition that
    precludes his/her ability to use the equipment.
  • The equipment will reduce the need for other
    reimbursed health care, such as personal care,
    private duty nursing, etc.

9
Example of AT Under DME
  • Patient Lift HCPCS E0630
  • 1.) Recipient-based outcome anticipated to
    stabilize the recipients medical condition by
    getting recipient up twice a day.
  • 2.) Supportive Activities to Accomplish Outcome
    (must document all of the following)
  • Part of care plan (up twice a day)

10
Example of AT Under DME Contd
  • Recipient/caregiver knows how to use the lift.
  • Alternatives did not work (caregiver is unable to
    lift recipient out of bed twice a day).
  • Recipient has no health condition that prohibits
    the use of the lift.
  • Equipment reduces the need for other services
    (nurses aide).

11
Assistive Technology Under the DD Waiver
Definition
  • Specialized medical equipment and supplies,
    including those devices, controls, or appliances
    specified in the CSP but not available under
    regular DME criteria which enable consumers to
    increase their abilities to perform activities of
    daily living or to perceive, control, or
    communicate with the environment in which they
    live or which are necessary to their proper
    functioning.

12
Equipment and Activities Under AT in the DD Waiver
  • The equipment and activities are
  • Specialized medical equipment and ancillary
    equipment, necessary for life support not
    available under the State Plan for Medical
    Assistance
  • Durable or non-durable medical equipment and
    supplies (DME) not available under the State Plan
    for Medical Assistance

13
Equipment and Activities Under AT in the DD
Waiver Contd
  • Adaptive devices, appliances, or controls, or
    all, not available under the State Plan for
    Medical Assistance which enable a consumer to be
    more independent in areas of personal care and
    activities of daily living
  • Equipment/devices not available under the State
    Plan which enable a consumer to communicate more
    effectively.

14
AT Criteria
  • Service is available to consumers who are
    receiving at least one other DD Waiver service.
  • Equipment or supplies already covered under
    regular DME criteria may not be purchased under
    the DD Waiver Assistive Technology.
  • Equipment/supplies must be purchased from a DME
    provider, if available.

15
AT Criteria Contd.
  • A Rehabilitation Engineer may be utilized if, for
    example
  • The assistive-technology will be initiated in
    combination with environmental modifications
    involving systems which are not designed to go
    together or
  • An existing device must be modified or a
    specialized device must be designed and
    fabricated.

16
AT Service Units and Service Limitations
  • Service must be prior authorized by DMAS
  • Service unit is hourly for Rehabilitation
    Engineering (or consultation) or is the total
    cost of the item or supplies or both

17
AT Service Units and Service Limitations Contd
  • Maximum expenditure is 5000.00 per calendar year
  • Costs for AT shall not be carried over from year
    to year

18
Provider Documentation Requirements
  • Supporting documentation that outlines the need
    for the service (CSP), the process to obtain this
    service (contracts with potential
    vendors/contractors of service, etc.) and the
    time frame during which the service is to be
    provided
  • Separate notation of evaluation/design, labor,
    and supplies/materials.

19
Provider Documentation RequirementsCont.
  • Documentation of the need for a Rehabilitative
    Engineer if one is needed (if disability
    expertise is required that a general contractor
    will not have)
  • Documentation that the item is not covered by the
    State Plan for Medical Assistance under DME or is
    not available from a DME provider.

20
Provider Documentation RequirementsCont.
  • Documentation of the date services are rendered
    and the amount of service needed
  • Any other relevant information about the device
    or modification

21
Provider Documentation Requirements Cont.
  • Documentation in the Support Coordination record
    of notification by the consumer or consumers
    parent or legal guardian of satisfactory
    completion of the service.
  • Instructions regarding any warranty, repairs,
    complaints, or servicing that may be needed.

22
AT Billing Codes
  • Z8603 Assistive Technology, Rehab. Engineer.
    Unit is IC.
  • Z8604 Assistive Technology, Off Shelf Item.
    Unit is IC.
  • Z8605 Assistive Technology, Supply Cost Only.
    Unit is IC.

23
Example of AT Purchase
  • A hand-held shower device is not covered under
    the State Plan for Medical Assistance (regular
    DME criteria). However, it could be needed to
    assist the consumer in performing activities of
    daily living.
  • Documentation required to obtain the device
  • Need for the device must be documented in the
    Consumer Service Plan (CSP)

24
Billing RequirementsCont.
  • Documentation of the cost of the device and
    installation cost, if needed.
  • Documentation in the record that this is an
    non-covered device under the State Plan.
  • Date the device is provided to the consumer and
    the cost of the device.
  • Documentation of the consumers satisfaction with
    the device.

25
Billing RequirementsCont.
  • Any warranty agreement or servicing requirements.

26
Environmental Modifications
  • Under the State Plan for Medical Assistance,
    home and environmental modifications are
    non-covered services
  • Under the State Plan for Medical Assistance,
    items solely for safety and/or convenience of the
    consumer are non-covered services

27
Definition of Environmental Modifications
  • Environmental modifications are physical
    adaptations to a house, place of residence,
    vehicle, or work site, when the modification
    exceeds reasonable accommodation requirements of
    the Americans with Disabilities Act, necessary to
    ensure consumers health and safety or to enable
    functioning with greater independence.

28
Definition of Environmental Modifications..Cont.
  • The adaptation is not to be used to bring
    substandard housing up to standard
  • The adaptation is to be of direct medical or
    remedial benefit to the consumer
  • Environmental modifications are available to
    consumers receiving at least one other waiver
    service

29
Definition of Environmental Modifications Cont.
  • The need for the adaptation must be documented in
    the Consumer Service Plan (CSP)
  • The adaptation must be necessary to ensure the
    health, welfare, and safety of the consumer or
    enable the consumer to function with greater
    independence in the home, and without which, the
    consumer would require institutionalization.

30
Environmental ModificationExclusions
  • Adaptations or improvements to the home that are
    of general utility and not of direct medical or
    remedial benefit, such as carpeting, roof repair,
    central air conditioning, etc.

31
Modifications and Activities
  • All adaptations must be provided in accordance
    with applicable state or local building codes.
  • Modifications and activities are
  • Physical adaptations to a house or place of
    residence necessary to ensure a consumers health
    or safety (installation of specialized electric
    and plumbing systems to accommodate medical
    equipment).

32
Modifications and Activities Contd
  • Physical adaptations to a house or place of
    residence that enable a consumer to live in a
    non-institutional setting and to function with
    greater independence (ramps, grab bars, widening
    of doorways, modifications to bathroom
    facilities, etc)
  • Environmental adaptations to the work site.

33
Modifications and Activities Contd
  • Modifications to the primary vehicle used by the
    consumer (car or van)

34
Criteria to Receive Environmental Modifications
  • Demonstrated a need for the modification of a
    medical or remedial benefit in the consumers
    home, vehicle, community activity setting, or day
    program.
  • The modification cannot be covered under the
    State Plan for Medical Assistance, or another
    program, such as DRS, or the Consumer Service
    Fund.

35
CriteriaContd
  • A Rehabilitation Engineer may be used to evaluate
    the consumers needs and act as project manager.
  • A Rehabilitative Engineer may design and complete
    the modification.
  • A Physical Therapist or Occupational Therapist
    may evaluate for modifications. These services
    may be under the State Plan or DD Waiver
    Therapeutic Consultation.

36
CriteriaContd
  • A building contractor may design and complete the
    structural modifications
  • A vendor who supplies the necessary materials may
    be separately reimbursed or supplies may be
    included in the bill or the contractor or
    Rehabilitation Engineer.

37
CriteriaContd
  • A Rehabilitation Engineer may be required if (for
    example)
  • The environmental modification involves
    combinations of systems which are not designed to
    go together or
  • The structural modification requires a project
    manager to assure that design and functionality
    meet ADA accessibility guidelines.

38
Service Units and Service Limitations
  • Service unit is hourly for Rehabilitative
    Engineering, is individually contracted for
    building contractors, and may include supplies,
    or is the total cost of supplies if the supplies
    are billed separately, or both.
  • Must be prior authorized by DMAS the maximum
    expenditure is 5000.00 per calendar year.

39
Provider Documentation Requirements Contd
  • Supporting documentation that outlines the need
    for the service (CSP), the process to obtain this
    service (contracts with potential
    vendors/contractors of service, etc.) and the
    time frame during which the service is to be
    provided.
  • Separate notation of evaluation/design, labor,
    and supplies/materials.

40
Provider Documentation Required..Contd
  • Documentation in the CSP of the reason a
    Rehabilitation Engineer is needed, if one is
    involved.
  • Documentation in the consumers file that a
    licensed professional (i.e., Occupational
    Therapist) determined what environmental
    modifications are needed and for what purpose.

41
Provider Documentation RequiredContd
  • Documentation of the dates of service and amount
    of service.
  • Documentation of any other relevant information.
  • Documentation of notification by the consumer or
    consumers parent or legal guardian of
    satisfactory completion of the service.


42
Provider Documentation RequiredContd
  • Instructions regarding any warranty, repairs,
    complaints, and servicing that may be needed.

43
Billing Codes for Environmental Modifications
  • Z8599 Environmental Modification, Rehab.
    Engineer. Unit is IC
  • Z8600 Environmental Modification, Structural
    Mod. Unit is IC
  • Z8601 Environmental Modification, Supply Only.
    Unit is IC

44
Billing Codes..Contd
  • Z8602 Environmental Modification, Transportation
    Mod. Unit is IC
  • Y0058 Environmental Modification, Maintenance
    Costs. Unit is IC

45
Example of Environmental Modification
  • Wheelchair ramp
  • Non-covered service under the State Plan for
    Medical Assistance (DME criteria).
  • Covered service under the DD Waiver
  • Documentation requirements
  • Included in CSP as needed service
  • If Rehabilitation Engineer is needed, document
    need in CSP.

46
BillingContd
  • Documentation that the ramp is not covered by the
    State Plan under DME criteria.
  • Documentation that a licensed professional, (PT,
    OT, or Rehab. Engineer) determined the need and
    purpose of the modification.
  • Documentation of date of service and cost of the
    ramp.

47
Billing Contd
  • Documentation of notification by the consumer or
    consumers parent or legal guardian of
    satisfactory completion of the service.
  • Instructions regarding any warranty, repairs,
    complaints, and servicing that may be needed.

48
Personal Emergency Response Systems (PERS) -
Definition
  • PERS an electronic device that enables
    consumers at high risk of institutionalization to
    secure help in an emergency
  • PERS- electronically monitors consumer safety in
    home provides access to emergency crisis
    intervention through use of two-way voice
    communication system

49
PERS Definition Contd
  • In the event of emergency, the communication
    system dials a 24-hour response or monitoring
    center upon activation
  • When appropriate, PERS may also include
    medication monitoring

50
Who can be a PERS Provider?
  • Providers must have a current participation
    agreement with DMAS to provide PERS and bill DMAS
  • PERS providers enroll as durable medical
    equipment providers with DMAS (providers must
    have a Virginia business license)

51
PERS Provider Requirements Contd
  • Must have an emergency response center staff with
    fully trained operators
  • Center must be capable of receiving signals for
    help from a consumers PERS equipment 24 hours a
    day, 365 days per year
  • Capable of determining if emergency exists and
    notifying EMS that the consumer needs emergency
    help

52
PERS Provider Requirements Contd
  • Provider must comply with
  • all applicable Virginia statutes
  • all applicable regulations of DMAS and
  • all governmental agencies having jurisdiction
    over the services performed
  • All PERS equipment must be approved by Federal
    Communications Commission and meet UL safety
    standards

53
PERS Provider Requirements Contd
  • PERS device must be able to automatically reset
    by the response center after each activation to
    ensure subsequent signals can be transmitted
    without requiring manual resent by the consumer

54
Criteria for Consumers to Receive PERS
  • PERS is limited to consumers who live alone or
    who for consumers who
  • Are alone for significant parts of the day
  • Have no regular caregiver for extended periods of
    time and
  • Who would otherwise require extensive routine
    supervision

55
Criteria for Consumers to Receive PERS Contd
  • PERS can be authorized when no one else is in the
    home who is competent and continuously available
    to call for help in an emergency
  • If consumers caregiver has a business in the
    home, PERS will only be approved if the consumer
    is independent in behavior orientation pattern

56
Criteria for Consumers to Receive PERS Contd
  • PERS Medication Monitoring units
  • must be physician ordered
  • are not considered a stand-alone service
  • consumers must receive PERS and the Medication
    Monitoring unit simultaneously

57
PERS Service Units and Service Limitations
  • One unit of service shall include administrative
    costs, time, labor, and supplies associated with
    the installation, maintenance, and monitoring of
    the PERS
  • One unit of service is a one-month rental price
    established by DMAS

58
PERS Service Units and Service Limitations Contd
  • One-time installation of the unit shall include
    installation, account activation, consumer and
    caregiver instructions, and removal of equipment
  • PERS services shall be capable of being activated
    by a remote wireless device be connected to the
    consumers phone line

59
PERS Service Units and Service Limitations Contd
  • PERS console unit must provide hands-free
    voice-to-voice communication with the response
    center
  • The activating device shall
  • Be waterproof
  • Automatically transmit, to the response center,
    an activator low battery signal prior to the
    battery losing power and
  • Be able to be worn by the consumer

60
PERS Service Units and Service Limitations Contd
  • In cases where the medication monitoring units
    must be filled by the provider, the person
    filling the medication units must be a Registered
    Nurse or a Licensed Practical Nurse
  • Units can be refilled every 14 days

61
Additional PERS Provider Requirements
  • The PERS provider must properly install all PERS
    equipment into a PERS consumers functioning
    telephone line and furnish all supplies to ensure
    the system is working properly
  • The installation shall include local seize line
    circuitry (guarantees the unit has priority over
    the phone line)

62
Additional PERS Provider Requirements
  • The PERS provider must maintain all installed
    PERS equipment in proper working order
  • PERS provider must maintain a data record for
    each PERS consumer at no additional cost to DMAS

63
Additional PERS Provider Requirements Contd
  • The record shall contain
  • Delivery date and installation of PERS
  • Enrollee/caregiver signature verifying receipt of
    PERS device
  • PERS device is operational as verified by a
    monthly test
  • Updated and current consumer and contact
    information and
  • Case log documenting consumer system utilization
    and/or consumer communication

64
Additional PERS Provider Requirements Contd
  • PERS provider must have back-up monitoring
    capacity in case the primary system cannot handle
    incoming emergency signals
  • PERS provider shall furnish education, date and
    ongoing assistance to DMAS to familiarize staff
    with the service, allow for ongoing evaluation
    and refinement of the program

65
Additional PERS Provider Requirements Contd
  • PERS provider shall instruct the consumer,
    caregiver, and responders in the use of the PERS
    service
  • Emergency activator must be able to be activated
    by breath, by touch, or by some other means, and
    must be usable by persons with visual or hearing
    impairments and individuals with physical
    disabilities

66
Additional PERS Provider Requirements Contd
  • The emergency response communicator must be
    capable of operating without external power
    during a power failure at the consumers home for
    a minimum 24-hour period
  • Communicator must also be able to self-disconnect
    and redial without the consumer resetting the
    system if it cannot get its signal accepted at
    the response center

67
Additional PERS Provider Requirements Contd
  • Providers monitoring agency must be capable of
    continuously monitoring and responding to
    emergencies under all conditions
  • Equipment must include
  • Primary receiver and back-up receiver, which must
    be independent and interchangeable
  • A back-up information retrieval system
  • A clock printer

68
Additional PERS Provider Requirements Contd
  • Equipment contd
  • A back-up power supply
  • A separate telephone service
  • A toll-free number to be used by the PERS
    equipment in order to contact the primary or
    back-up response center and
  • A telephone line monitor, which must give visual
    and audible signals when the incoming line is
    disconnected for more than 10 seconds

69
Additional PERS Provider Requirements Contd
  • Providers monitoring agency must maintain
    detailed technical and operations manuals that
    describe the PERS elements, including
  • the installation, functioning, and testing of
    PERS equipment
  • emergency response protocols and
  • record keeping and reporting procedures

70
Additional PERS Provider Requirements Contd
  • The PERS provider shall document and furnish a
    written report to the support coordinator each
    emergency signal, which resulted in action being
    taken on behalf of the consumer
  • Shall include test signals or activations made in
    error

71
Billing Codes for PERS
  • Y0071 PERS Installation Unit is 50.00 Rest of
    State, 59.00 NOVA
  • Y0072 PERS Medication Monitoring Installation
    Unit is 75.00 Rest of State, 88.50 NOVA
  • YOO73 PERS Monthly - Unit is 30.00 Rest of
    State, 35.40 NOVA

72
Billing Codes for PERS Contd
  • Y0074 PERS and Medication Monitoring Monthly -
    50.00 Rest of State, 59.00 NOVA
  • Y0075 PERS Nursing, RN - 15.00 Rest of State,
    12.25 NOVA
  • Y0076 PERS Nursing, LPN - 13.00 Rest of State,
    10.25 NOVA

73
Thank You For Coming!
  • We look forward to partnering with you to provide
    Assistive Technology, Environmental
    Modifications, PERS
  • Any Questions? Please Ask
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