PROPOSED RULES
SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Original Notice.
Preproposal statement of inquiry was filed as WSR 98-24-050.
Title of Rule: Chapter 388-552 WAC, Oxygen and respiratory therapy.
Purpose: To adopt current policies into WAC, and to repeal outdated rules, WAC 388-86-097 and 388-87-080.
Statutory Authority for Adoption: RCW 74.08.090, 74.04.050, 74.09.520, and 74.09.530.
Statute Being Implemented: RCW 74.09.530, 74.08.090, 74.04.050, and 74.09.520.
Summary: This chapter sets into WAC: Payment methodology the department uses to reimburse for oxygen and respiratory therapy services, equipment, and supplies; items and services covered by the department; and requirements for reimbursement.
Reasons Supporting Proposal: To codify payment methodology and requirements for reimbursement.
Name of Agency Personnel Responsible for Drafting: Leslie Saeger, P.O. Box 45530, Olympia, WA 98504, (360) 664-2315; Implementation and Enforcement: Julie Lake, P.O. Box 45530, Olympia, WA 98504, (360) 664-2315.
Name of Proponent: Department of Social and Health Services, Medical Assistance Administration, governmental.
Rule is not necessitated by federal law, federal or state court decision.
Explanation of Rule, its Purpose, and Anticipated Effects: This chapter puts current policy into rule. It describes covered services, methods used by the department to determine reimbursement rates, and requirements for reimbursement.
Proposal Changes the Following Existing Rules: Previous rules stated that the department would make oxygen and related equipment and supplies available through contract. These rules clarify that all providers who have a signed core agreement with the Medical Assistance Administration may now provide services according to this chapter.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The Medical Assistance Administration analyzed the proposed rules and concludes that no new costs will be imposed on small businesses affected by them.
RCW 34.05.328 applies to this rule adoption. An evaluation of probable costs and benefits is available from the program staff person listed in Name of Agency Personnel above.
Hearing Location: Lacey Government Center (behind Tokyo Bento Restaurant), 1009 College Street S.E., Room 104-B, Lacey, WA 98503, on May 11, 1999, at 10:00 a.m.
Assistance for Persons with Disabilities: Contact Paige Wall by April 30, 1999, phone (360) 902-7540, TTY (360) 902-8324, e-mail pwall@dshs.wa.gov.
Submit Written Comments to: Identify WAC numbers, Paige Wall, Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 902-8292, by May 11, 1999.
Date of Intended Adoption: May 17, 1999.
March 31, 1999
Marie Myerchin-Redifer, Manager
Rules and Policies Assistance Unit
2525.4OXYGEN AND RESPIRATORY THERAPY
(1) This chapter applies to:
(a) Medical assistance administration (MAA) clients who require medically necessary oxygen and/or respiratory therapy equipment, supplies, and services in their homes and nursing facilities; and
(b) Providers who furnish oxygen and respiratory therapy equipment, supplies and services to eligible MAA clients.
(2) Instructions for clients covered by Medicare are located in Medicare's Durable Medical Equipment Regional Carrier (DMERC) Manual.
[]
The following definitions and those in WAC 388-500-0005 apply to this chapter. If a definition in WAC 388-500-0005 differs with the definition in this section, the definition in this section applies. Defined words and phrases are bolded in the text.
"Authorized prescriber" means a health care practitioner authorized by law or rule in the state of Washington to prescribe oxygen and respiratory therapy equipment, supplies, and services.
"Base year," as used in this chapter, means the year in which the oxygen and respiratory therapy billing instructions’ current fee schedule is adopted.
"Maximum allowable" means the maximum dollar amount MAA reimburses a provider for a specific service, supply, or piece of equipment.
"Oxygen" means United States Pure (USP) medical grade liquid or gaseous oxygen.
"Oxygen and respiratory therapy billing instructions" means a booklet containing procedures for billing, which is available by writing to Medical Assistance Administration, Division of Program Support, PO Box 45562, Olympia, WA, 98504-5562.
"Oxygen system" means all equipment necessary to provide oxygen to a person.
"Portable system" means a small system which allows the client to be independent of the stationary system for several hours, thereby providing mobility outside of the residence.
"Provider" means a person or company with a signed core provider agreement with MAA to furnish oxygen and respiratory therapy equipment, supplies, and services to eligible MAA clients.
"Respiratory care practitioner" means a person certified by the department of health according to chapter 18.89 RCW and chapter 246-928 RCW.
"Stationary system" means equipment designed to be used in one location, generally for the purpose of continuous use or frequent intermittent use.
[]
CLIENT ELIGIBILITY(1) All MAA fee-for-service clients are eligible for oxygen and respiratory therapy equipment, supplies, and services when medically necessary, with the following limitations:
(a) Clients on the medically indigent program are not eligible under this chapter; and
(b) Clients on the categorically needy/qualified Medicare beneficiaries and medically needy/qualified Medicare beneficiaries programs are covered by Medicare and Medicaid as follows:
(i) If Medicare covers the service, MAA will pay the lesser of:
(A) The full co-insurance and deductible amounts due, based upon Medicaid's allowed amount; or
(B) MAA's maximum allowable for that service minus the amount paid by Medicare.
(ii) If Medicare does not cover or denies equipment, supplies, or services that MAA covers according to this chapter, MAA reimburses at MAA's maximum allowable; except, MAA does not reimburse for clients on the qualified Medicare beneficiaries (QMB) only program.
(2) Services for clients enrolled in a healthy options managed care plan receive all oxygen and respiratory therapy equipment, supplies, and services through their designated plan, subject to the plan's coverages and limitations.
[]
PROVIDERS(1) The provider must verify that the client's original prescription is signed and dated by the authorized prescriber no more than ninety days prior to the initial date of service. The prescription must include, at a minimum:
(a) The client's medical diagnosis, prognosis, and documentation of the medical necessity for oxygen and/or respiratory therapy equipment, supplies, and/or services, and any modifications;
(b) If oxygen is prescribed:
(i) Flow rate of oxygen;
(ii) Estimated duration of need;
(iii) Frequency and duration of oxygen use; and
(iv) Lab values or oxygen saturation measurements upon the client's discharge from the hospital.
(2) The provider must provide instructions to the client and/or caregiver on the safe and proper use of equipment provided.
[]
(1) A provider must maintain legible, accurate, and complete charts and records for each client. These records must support and justify claims that the provider submits to MAA for reimbursement. Records must include, at a minimum the:
(a) Date(s) of service;
(b) Client's name and date of birth;
(c) Name and title of person performing the service, when it is someone other than the billing practitioner;
(d) Chief complaint or reason for each visit;
(e) Pertinent medical history;
(f) Pertinent findings on examination;
(g) Oxygen, equipment, supplies, and/or services prescribed or provided;
(h) The original and subsequent prescriptions according to the requirements in WAC 388-552-200 and 388-552-220;
(i) Description of treatment (when applicable);
(j) Recommendations for additional treatments, procedures, or consultations;
(k) X-rays, tests, and results;
(l) Plan of treatment/care/outcome;
(m) Logs of oxygen saturations and lab values taken to substantiate the medical necessity of continuous oxygen, as required by WAC 388-552-220;
(n) Logs of oximetry readings if required by WAC 388-552-380 for a client seventeen years of age or younger; and
(o) Recommendations and evaluations if required by WAC 388-552-230 for the infant apnea monitor program.
(2) The provider must make required charts and records available to DSHS or its contractor(s) upon request.
(3) MAA may require additional information in order to process a submitted claim.
[]
Oxygen providers must:
(1) Obtain a renewed prescription every six months if the client's condition warrants continued service;
(2) Verify, at least every six months, that oxygen saturations or lab values substantiate the need for continued oxygen use for each client. The provider may perform the oxygen saturation measurements. MAA does not accept lifetime certificates of medical need (CMNs).
[]
(1) MAA does not reimburse for apnea monitors unless the provider has a respiratory care practitioner or registered nurse with expertise in pediatric respiratory care who is responsible for their apnea monitor program.
(2) MAA does not require a confirming second opinion for the initial rental period for diagnoses of apnea of prematurity, primary apnea, obstructed airway, or congenital conditions associated with apnea. For other diagnoses, a neonatologist's confirming assessment and recommendation must be maintained as a second opinion in the client's file. The initial rental period must not exceed six months.
(3) Regardless of diagnosis, the provider must maintain in the client's file, a neonatologist's clinical evaluation justifying each subsequent rental period.
[]
(1) A respiratory care practitioner must comply with chapter 18.89 RCW and chapter 246-928 WAC to qualify for reimbursement.
(2) A respiratory care practitioner must complete at least the following in each client visit:
(a) Check equipment and ensure equipment settings continue to meet the client's needs; and
(b) Communicate with the client's physician if there are any concerns or recommendations.
[]
COVERAGE(1) Due to legislative appropriations, MAA may reduce or eliminate coverage for oxygen and respiratory therapy equipment, supplies, and services which are not part of home health or hospice programs.
(2) MAA does not reimburse for a service or product if any of the following apply:
(a) The service or product is not covered by MAA;
(b) The service or product is not medically necessary;
(c) The client has third party coverage and the third party pays as much as, or more than, MAA allows for the service or product; or
(d) The client and provider do not meet the requirements in this chapter.
[]
(1) MAA reimburses for oxygen provided to:
(a) Clients eighteen years of age or older with:
(i) PO2<= fifty-five mm on room air; or
(ii) SaO2<= eighty-eighty percent on room air; or
(iii) PaO2<= fifty-five mm on room air.
(b) Clients seventeen years of age or younger to maintain SaO2 at:
(i) Ninety-two percent; or
(ii) Ninety-four percent in a child with cor pulmonale or pulmonary hypertension.
(2) MAA may cover spare tanks of oxygen and other equipment if the provider and attending physician document that travel distance or potential weather conditions could reasonably be expected to interfere with routine delivery of such equipment and supplies.
[]
(1) MAA covers the rental and/or purchase of medically necessary CPAP equipment and related accessories when all of the following apply:
(a) The results of a prior sleep study indicate the client has sleep apnea;
(b) The client's attending physician determines that the client's sleep apnea is chronic;
(c) CPAP is the least costly, most effective treatment modality;
(d) The item is to be used exclusively by the client for whom it is requested;
(e) The item is FDA-approved; and
(f) The item requested is not included in any other reimbursement methodology such as, but not limited to, diagnosis-related group (DRG).
(2) MAA covers the rental of CPAP equipment for a maximum of two months. Thereafter, if the client’s primary physician determines the equipment is tolerated and beneficial to the client, MAA reimburses for its purchase.
(3) Refer to oxygen and respiratory therapy billing instructions to determine which CPAP accessories are covered.
[]
(1) MAA covers medically necessary ventilator equipment rental and related disposable supplies when all of the following apply:
(a) The ventilator is to be used exclusively by the client for whom it is requested;
(b) The ventilator is FDA-approved; and
(c) The item requested is not included in any other reimbursement methodology such as, but not limited to, diagnosis-related group (DRG).
(2) MAA's monthly rental payment includes medically necessary accessories, including, but not limited to: humidifiers, nebulizers, alarms, temperature probes, adapters, connectors, fittings, and tubing.
(3) MAA covers a secondary (back-up) ventilator at fifty percent of the monthly rental if medically necessary.
(4) MAA covers the purchase of durable accessories for client-owned ventilator systems according to the fee schedule in the current oxygen and respiratory therapy billing instructions.
[]
(1) A provider must comply with WAC 388-552-230 to qualify for reimbursement for the infant apnea monitor program.
(2) MAA covers infant apnea monitors on a rental basis.
(3) MAA includes all home visits, follow-up calls, and training in the rental allowance.
[]
(1) MAA covers prescribed medically necessary respiratory and ventilator therapy services in the home.
(2) Therapy services must be provided by a certified respiratory care practitioner;
(3) MAA does not reimburse separately for respiratory and ventilator therapy services provided to clients residing in nursing facilities. This service is included in the nursing facility's per diem.
[]
(1) MAA covers suction pumps and supplies when medically necessary for deep oral or tracheostomy suctioning.
(2) MAA may cover one stationary and one portable suction pump for the same client if warranted by the client's condition. The provider and attending physician must document that either:
(a) Travel distance or potential weather conditions could reasonably be expected to interfere with the delivery of medically necessary replacement equipment; or
(b) The client requires suctioning while away from the client's place of residence.
[]
Inhalation drugs and solutions are included in the prescription drug program. Refer to chapter 388-530 WAC.
[]
(1) MAA covers oximeters for clients seventeen years of age or younger when the client has one of the following conditions:
(a) Chronic lung disease, is on supplemental oxygen, and is at risk for desaturation with sleep, stress, or feeding;
(b) A compromised or artificial airway, and is at risk for major obstructive events or aspiration events; or
(c) Chronic lung disease, requires ventilator or BIPAP support, and may be at risk for atelectasis or pneumonia as well as hypoventilation.
(2) The provider must review oximetry needs and fluctuations in oxygen levels monthly, and log results in the client's records.
[]
(1) MAA reimburses according to this chapter for the chronic use of medically necessary oxygen, and oxygen and respiratory equipment and supplies to eligible clients who reside in nursing facilities.
(2) Nursing facilities are reimbursed in their per diem rate for:
(a) Oxygen and oxygen equipment and supplies used in emergency situations; and
(b) Respiratory and ventilator therapy services.
(3) Nursing facilities with a "piped" oxygen system may submit a written request to MAA for permission to bill MAA for oxygen. See oxygen and respiratory therapy billing instructions.
[]
REIMBURSEMENT(1) A provider must bill MAA according to the procedures and codes in the current oxygen and respiratory therapy billing instructions.
(2) MAA does not reimburse separately for telephone calls, mileage, or travel time. These services are included in the reimbursement for other equipment and/or services.
[]
MAA bases the decision to rent or purchase medical equipment for a client, or pay for repairs to client-owned equipment, on the least costly and/or equally effective alternative.
(1) Rental.
(a) Types of rental equipment:
(i) Equipment that normally requires frequent maintenance (such as ventilators and concentrators) is reimbursed on a rental basis for as long as medically necessary; and
(ii) Equipment with lower maintenance requirements (such as suction pumps and humidifiers) is reimbursed on a rental basis for a specified rental period, after which the equipment is considered purchased and owned by the client. Refer to the oxygen and respiratory therapy billing instructions for detailed information.
(b) The monthly rental rate includes, but is not limited to:
(i) A full service warranty covering the rental period;
(ii) Any adjustments, modifications, repairs or replacements required to keep the equipment in good working condition on a continuous basis throughout the total rental period;
(iii) All medically necessary accessories and disposable supplies, unless separately billable according to current oxygen and respiratory therapy billing instructions;
(iv) Instructions to the client and/or caregiver for safe and proper use of the equipment; and
(v) Cost of pick-up and delivery to the client's residence or nursing facility and, when appropriate, to the room in which the equipment will be used.
(2) Purchase.
(a) Purchased equipment becomes the property of the client;
(b) MAA reimburses for:
(i) Equipment that is new at the time of purchase, unless otherwise specified in current oxygen and respiratory therapy billing instructions; and
(ii) One maintenance and service visit every six months for purchased equipment.
(c) MAA does not reimburse for:
(i) Defective equipment;
(ii) The cost of materials covered under the manufacturer's warranty; or
(iii) Repair or replacement of equipment if evidence indicates malicious damage, culpable neglect, or wrongful disposition.(d) The reimbursement rate for purchased equipment includes, but is not limited to:
(i) A manufacturer's warranty for a minimum warranty period of one year for medical equipment, not including disposable/ non-reusable supplies;
(ii) Instructions to the client and/or caregiver for safe and proper use of the equipment; and
(iii) The cost of delivery to the client's residence or nursing facility and, when appropriate, to the room in which the equipment will be used.
(e) The provider must make warranty information, including date of purchase and warranty period, available to MAA upon request.
[]
MAA, at its discretion, uses the following methods to determine the maximum allowable amount for each purchased and rented item and service:
(1) Monthly rental reimbursement methodology.
(a) Medicare's fee as of October 31 of the year prior to the base year; or
(b) A maximum allowable equal to:
(i) One-tenth of the purchase maximum allowable for that product; or
(ii) If MAA does not reimburse for the purchase of that product, one-tenth of the amount calculated using the methodology in subsection (1) of this section.
(2) Purchase reimbursement methodology.
(a) Medicare's fee as of October 31 of the year prior to the base year; or
(b) A maximum allowable equal to the seventieth percentile price of an array of input prices.
(i) The number of input prices included in each array may be limited by MAA based on consideration of product quality, cost, available alternatives, and client needs.
(ii) An input price used in the maximum allowable calculation is the lesser of:
(A) Eighty percent of the manufacturer's list or suggested retail price as of October 31 of the base year; or
(B) One hundred thirty-five percent of the wholesale acquisition cost as of October 31 of the base year.
[]
The following sections of the Washington Administrative Code are repealed:
| WAC 388-86-097 | Respiratory therapy services. |
| WAC 388-87-080 | Payment--Oxygen. |