(A) Coverage determination
(1) The provider must document medical necessity in the consumer's medical record that clearly supports the need for a commode.
(2) Commodes must be prescribed by a prescriber actively involved in managing the consumer's medical care through a comprehensive plan of care that addresses the need for a commode. This prescription must contain the original signature of the ordering prescriber that attests to the medical necessity of the commode.
(3) A commode is covered when the consumer is physically incapable of utilizing regular toilet facilities and is physically able to use a commode, otherwise a bedpan is indicated. This limitation must be documented in the consumer's medical record and available for review upon request by the department. One or more of the following situations must be present in order for a commode to be justified for reimbursement:
(a) The consumer is confined to a single room due to a documented medical condition; or
(b) The consumer is confined to one level of the home due to a documented medical condition and there is no toilet on that level; or
(c) The consumer is confined to the home due to a documented medical condition and there are not toilet facilities in the home.
(4) An extra wide/heavy duty commode chair is covered for consumers who weigh three hundred pounds or more. If a consumer weighs less than three hundred pounds, the consumer's medical record must document the medical necessity of this type of commode chair.
(5) A commode chair with detachable arms is covered only if this feature is necessary to facilitate transferring the consumer or if the consumer has a body configuration that requires extra width. The consumer's medical record must document the medical necessity of this type of commode chair.
(B) Coverage limitations
(1) Providers are responsible, prior to dispensing a commode, to determine whether the consumer previously acquired this item from another provider.
(2) Commodes for consumers residing in long term care facilities are reimbursed through the facility's cost report.
(3) Providers cannot bill for the concurrent supply of both a commode and a bedpan.
Commodes are reimbursed at the lesser of the department's fee schedule contained in appendix DD to rule 5101:3-1-60 of the Administrative Code or the provider's usual and customary charge.