Current through Reg. 49, No. 38; September 20, 2024
(a) Purpose. This section details the
requirements for receiving reimbursement for the provision of, or the
performance of a major modification to, a wheeled mobility system. This section
implements Texas Human Resources Code §
RSA
32.0425.
(b) Definitions. The following words and
terms when used in this section have the following meanings, unless the context
clearly indicates otherwise.
(1) Occupational
therapist (OT)--A person licensed by the Texas Board of Occupational Therapy
Examiners to practice occupational therapy, as defined in Texas Occupations
Code §
RSA
454.002(4) (relating to
Definitions).
(2) Physical
therapist (PT)--A person licensed by the Texas Board of Physical Therapy
Examiners to practice physical therapy, as defined in §
RSA 354.1121 of this
subchapter (relating to Definitions).
(3) Qualified rehabilitation professional
(QRP)--A person who holds one or more of the following certifications:
(A) a certification as an assistive
technology professional or a rehabilitation engineering technologist issued by,
and in good standing with, the Rehabilitation Engineering and Assistive
Technology Society of North America (RESNA);
(B) a certification as a seating and mobility
specialist issued by, and in good standing with, RESNA; or
(C) a certification as a certified
rehabilitation technology supplier issued by, and in good standing with, the
National Registry of Rehabilitation Technology Suppliers (NRRTS).
(4) Wheeled Mobility System--An
item of durable medical equipment (DME) that is a customized powered or manual
mobility device or a feature or component of the device, including:
(A) seated positioning components;
(B) powered or manual seating
options;
(C) specialty driving
controls;
(D) multiple adjustment
frame;
(E) nonstandard performance
options; and
(F) other complex or
specialized components.
(c) Roles and responsibilities. The following
persons, when referenced in this section, shall have the following roles in the
provision of, or the performance of a major modification to, a wheeled mobility
system, unless the context clearly indicates otherwise.
(1) The OT is responsible for completing the
clinical assessment of a recipient required for obtaining a wheeled mobility
system. The assessment must include detailed documentation of medical need for
specific mobility or seating equipment and all necessary accessories.
(2) The PT is responsible for completing the
clinical assessment of a recipient required for obtaining a wheeled mobility
system. The assessment must include detailed documentation of medical need for
specific mobility or seating equipment and all necessary accessories.
(3) The QRP is required to:
(A) be present for and involved in the
clinical assessment of the recipient;
(B) be present at the time of delivery of the
wheeled mobility system to direct the fitting of the wheeled mobility system to
ensure that the system is appropriate for the recipient; and
(C) verify that the wheeled mobility system
functions correctly relative to the recipient.
(4) A person that is licensed as an OT or a
PT, and is also certified as a QRP, may perform either the role of the
therapist or the QRP during the clinical assessment of the recipient, but
cannot serve in both roles at the same time.
(d) Benefit. Wheeled mobility systems are a
covered home health services benefit when the following criteria are met.
(1) All the requirements for DME, as detailed
in §354.1039 of this division (relating to Benefits and Limitations of
Home Health Services) are met.
(2)
The wheeled mobility system is provided by an enrolled DME supplier that
directly employs or contracts with a QRP.
(3) An enrolled DME supplier obtains prior
authorization for a wheeled mobility system from HHSC.
(e) Prior authorization requirements. The
following documentation must be submitted in a manner approved by HHSC to
obtain prior authorization for a wheeled mobility system.
(1) A signed and dated physician's or allowed
practitioner's prescription, or other such documentation as directed by HHSC,
that details a wheeled mobility system, including all necessary components the
recipient needs.
(2) A clinical
assessment that includes detailed documentation of medical need for specific
mobility or seating equipment and all necessary accessories, signed and dated
by an OT or PT authorized to perform the assessment.
(3) Documentation in a form or manner
directed by HHSC attesting that a QRP was present for and involved in the
clinical assessment of the recipient.
(4) Any other documentation deemed necessary
by HHSC to adequately explain the medical necessity of the requested
equipment.
(f)
Requirements for reimbursement. Reimbursement for the provision of, or the
performance of a major modification to, a wheeled mobility system will be
considered only when:
(1) the system is
delivered to a recipient by a Medicaid-enrolled DME provider that directly
employs or contracts with, a QRP, and the QRP was present and involved in the
clinical assessment of the recipient for the requested wheeled mobility system;
and
(2) at the time the wheeled
mobility system is delivered to the recipient, the QRP is present and
responsible for:
(A) directing the fitting to
ensure that the system is appropriate for the recipient; and
(B) verifying that the system functions
correctly relative to the recipient.
(g) Documentation requirements for
reimbursement. The following documentation must be submitted by the enrolled
DME supplier with the claim for consideration of reimbursement for a wheeled
mobility system in a manner approved by HHSC.
(1) A signed and dated HHSC DME Certification
and Receipt Form as required in §
RSA
354.1185 of this subchapter (relating to
Provider Compliance with Durable Medical Equipment (DME) Certification
Requirements).
(2) Documentation in
a form and manner as directed by HHSC attesting that a QRP was present at the
time of delivery and:
(A) directed the
fitting of the wheeled mobility system to ensure that the system was
appropriate for the recipient; and
(B) verified that the wheeled mobility system
functions correctly relative to the recipient.
(h) Effective dates for services provided.
The provisions of this section apply to the following services:
(1) wheeled mobility systems delivered on or
after September 1, 2011;
(2) a
major modification to a wheeled mobility system provided on or after September
1, 2011; and
(3) QRP functions,
including participating in a clinical assessment of a recipient and directing
the fitting of a wheeled mobility system, related to the provision of, or a
major modification to, a wheeled mobility system when:
(A) the wheeled mobility system is delivered
on or after September 1, 2011; and
(B) the QRP functions are performed after the
effective date of the associated rates as determined by HHSC.
