Assistive Technology, PERS,

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Assistive Technology, PERS, Environmental
Modifications

• Virginia Department of Medical Assistance
  Services
• Fall 2000

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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.

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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.

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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

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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

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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.

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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.

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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.

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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)

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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).

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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.

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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

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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.

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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.

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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.

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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

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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

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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.

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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.

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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

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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.

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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.

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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)

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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.

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Billing RequirementsCont.

• Any warranty agreement or servicing requirements.

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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

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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.

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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

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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.

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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.

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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).

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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.

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Modifications and Activities Contd

• Modifications to the primary vehicle used by the
  consumer (car or van)

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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Provider Documentation RequiredContd

• Instructions regarding any warranty, repairs,
  complaints, and servicing that may be needed.

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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

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Billing Codes..Contd

• Z8602 Environmental Modification, Transportation
  Mod. Unit is IC
• Y0058 Environmental Modification, Maintenance
  Costs. Unit is IC

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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.

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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.

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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.

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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

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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

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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)

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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)

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Thank You For Coming!

• We look forward to partnering with you to provide
  Assistive Technology, Environmental
  Modifications, PERS
• Any Questions? Please Ask