Title: Assistive Technology, PERS,
1Assistive Technology, PERS, Environmental
Modifications
- Virginia Department of Medical Assistance
Services - Fall 2000
2DURABLE 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.
3ASSISTIVE TECHNOLOGY (AT)
-
- Definition Assistive technology equipment
includes, but is not limited to, consumer lifts,
bath chairs, wall-mounted insulin delivery
devices, - and automatic feeders.
4AT 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
5AT 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
6Under 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.
7Current 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.
8Current 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.
9Example 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)
10Example 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).
11Assistive 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.
12Equipment 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
13Equipment 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.
14AT 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.
15AT 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. -
16AT 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
17AT 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
18Provider 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.
19Provider 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.
20Provider Documentation RequirementsCont.
- Documentation of the date services are rendered
and the amount of service needed - Any other relevant information about the device
or modification
21Provider 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.
22AT 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.
23Example 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)
24Billing 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.
25Billing RequirementsCont.
- Any warranty agreement or servicing requirements.
26Environmental 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
27Definition 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.
28Definition 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
29Definition 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. -
30Environmental 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.
31Modifications 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.
33Modifications and Activities Contd
- Modifications to the primary vehicle used by the
consumer (car or van)
34Criteria 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.
35CriteriaContd
- 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.
36CriteriaContd
- 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.
37CriteriaContd
- 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.
38Service 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.
39Provider 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.
40Provider 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.
41Provider 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.
42Provider Documentation RequiredContd
- Instructions regarding any warranty, repairs,
complaints, and servicing that may be needed.
43Billing 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 -
44Billing Codes..Contd
- Z8602 Environmental Modification, Transportation
Mod. Unit is IC - Y0058 Environmental Modification, Maintenance
Costs. Unit is IC
45Example 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.
46BillingContd
- 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. -
47Billing 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.
48Personal 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
49PERS 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)
51PERS 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
52PERS 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
53PERS 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
54Criteria 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
55Criteria 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
56Criteria 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
57PERS 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
58PERS 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
59PERS 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
60PERS 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
61Additional 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)
62Additional 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
63Additional 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
64Additional 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
65Additional 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
66Additional 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
67Additional 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
68Additional 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
69Additional 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
70Additional 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
71Billing 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
72Billing 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
73Thank You For Coming!
- We look forward to partnering with you to provide
Assistive Technology, Environmental
Modifications, PERS - Any Questions? Please Ask