5101:3-10-27 Continuous passive motion (CPM) devices.

(A) Definition

The continuous passive motion (CPM) device is a treatment modality in which knee joint motion is provided by a machine without causing active contraction of muscle groups. The CPM device allows passive movements to be performed to a knee joint for hours at a time. The knee joint area is secured in the CPM machine, and the machine is programmed to passively flex and extend the knee joint through a pre-selected range of motion and rate of repetition. Movement is slow and controlled, and the patient does not actively exert muscle force to move the knee joint.

(B) Coverage determination

The CPM device, when initiated during the immediate post-operative period (beginning within forty-eight hours after surgery), will be considered for coverage if the CPM device is to be utilized following total knee replacement or revision of a total knee replacement and is being sought for use in the consumer’s personal residence.

(1) CPM therapy is not covered for joints other than the knee.

(2) A CPM device is not separately reimbursable for consumers who are hospitalized or in a long term care facility (LTCF) and must be billed to the facility and included in the cost report.

(3) CPM is not covered as a substitute to conventional provider delivered physical therapy.

(4) CPM therapy is not appropriate for consumers unable to independently turn the device on and off, or who are not willing to participate in a course of rehabilitation in relation to the medical event prompting the request for CPM therapy.

(D) Authorization

(1) The use of a CPM device does not require a prior authorization when utilized for a single knee surgery. However, the provider of the CPM device is required to maintain on file a legible written prescription issued by a licensed prescriber that is signed and dated no more than thirty days prior to the first date of service that defines the specific “from” and “to” dates that reflect the actual days the CPM device is to be utilized.

(2) The maximum days allowable for the utilization of a CPM device is twenty-one per medical event, per knee.

(3) If the consumer has the surgery mentioned in paragraph (B) of this rule on both knees concurrently, the following documentation must be submitted for prior authorization (PA) before reimbursement for services rendered will be authorized:

(a) A fully completed, most current version of PA form (JFS 03142, rev. 02/2003); and

(b) A legible written prescription issued by a licensed prescriber that is signed and dated no more than thirty days prior to the first date of service that defines the specific “from” and “to” dates that reflect the actual days the CPM device is to be utilized.

Documentation for the prior authorization of a CPM device must be submitted with the appropriate healthcare common procedure coding system (HCPCS) codes as defined in rule 5101:3-1-19.3 of the Administrative Code for the actual unit and any necessary soft goods supporting the unit present on the same request.

(E) Dispensing

(1) CPMs are expected to be dispensed with one complete set of supporting soft goods per CPM unit dispensed unless the consumer currently owns the supporting soft goods resulting from a previous medical event.

(2) The following components are considered “inclusive” with any CPM payment made by ODJFS on behalf of a consumer and cannot be submitted to ODJFS for separate payment:

(a) Any supporting wires, cables, or attachment kits;

(b) CPM education, training, monitoring, or counseling in support of the consumers ordered therapy;

(d) Delivery, set up, or pick up charges.

(3) The provider of a CPM device must assure that the consumer utilizing the device is properly instructed how to use the device in support of his or her ordered therapy and is aware of and understands any emergency procedures regarding the use of the CPM device. The provider must maintain written documentation regarding the consumer’s instruction on the use of the CPM device in the consumer’s medical record.

(4) The prescriber of a CPM device must assure and document in the consumer’s medical record that the continued use of the CPM device is resulting in the clinical improvement of the consumer utilizing the device. The use of the CPM device must be discontinued immediately and an alternative therapy method considered if the consumer demonstrates no progressive clinical improvement during the CPM rental period.

(5) Upon the dispensing of a CPM device the consumer must be supplied by the supplier with a twenty-four hour, seven day a week telephone number to be utilized in case of an emergency situation during the entire rental period of the CPM device. This telephone number must meet all federal Americans with Disabilities Act (ADA) of 1990 requirements.

(F) Reimbursement

CPM devices and associated soft goods are reimbursed according to the ODJFS fee schedule contained in appendix DD of rule 5101:3-1-60 of the Administrative Code, or the providers usual and customary charge, whichever is less.

Effective: 04/01/2006

R.C. 119.032 review dates: 04/01/2011

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02