Rule 5160-10-07 | DMEPOS: bathing seats.
(A) Definitions and explanations.
(1) "Assistance," for purposes of this rule, is help with bathing-related tasks that individuals cannot accomplish by themselves, such as getting into and out of a bathing chair, moving in and out of the bathing area, or fastening and unfastening securements and positioners. The term does not include actual bathing (soaping, shampooing, scrubbing, rinsing).
(2) "Bathing seat" is a collective term for an item or device that enables an individual to sit securely and comfortably while taking a bath or shower.
(3) The primary healthcare purpose of a bathing seat is to promote cleanliness. Certain bathing seats can also function as commodes, and many commodes can be used as bathing seats. An item that functions equally well as a bathing seat and as a commode is deemed to be a commode for medicaid payment purposes.
(4) Prior authorization (PA) may be given only if a face-to-face evaluation of need has been performed not earlier than one hundred eighty days before the submission of the PA request.
(B) Providers.
(1) Prescribing providers. Eligible medicaid providers of the following types, acting within their scope of practice, may prescribe a bathing seat and may certify the medical necessity of a bathing seat when such certification is needed:
(a) A physician;
(b) An advanced practice registered nurse with a relevant specialty;
(c) A physician assistant; or
(d) A podiatrist.
(2) Evaluators. The following professionals may evaluate an individual's particular needs for a bathing seat:
(a) A physician, including a physiatrist, orthopedic surgeon, and neurologist;
(b) An advanced practice registered nurse with a relevant specialty;
(c) A physician assistant;
(d) A podiatrist;
(e) A physical therapist; or
(f) An occupational therapist.
(3) Rendering providers. A medicaid provider enrolled as a basic durable medical equipment (DME) supplier may furnish a bathing seat, part, or accessory or may render a related service.
(4) Billing providers. A medicaid provider enrolled as a basic DME supplier may receive medicaid payment for submitting a claim for a bathing seat, part, accessory, or related service.
(C) Coverage.
(1) Principles.
(a) If documentation of medical necessity is needed, the default certificate of medical necessity (CMN) is form ODM 10274, "Certificate of Medical Necessity: Bathing Seats" (rev. 7/2024).
(b) If more than one type of bathing seat will meet an individual's needs and satisfy the criteria of medical necessity, then the maximum payment amount is the lowest of the respective costs, regardless of which bathing seat is supplied.
(c) The provision of or payment for the purchase of a medically necessary bathing seat for a resident of a long-term care facility (LTCF) is the responsibility of the LTCF. Therefore, claims submitted to the department for bathing seats furnished to LTCF residents will be denied.
(d) Bathing seats on wheels are not to be used simply as transport chairs from which an individual then transfers to a bathtub, standard shower enclosure, or stationary bathing seat. A request for a bathing seat on wheels is therefore not appropriate if the individual does not have a roll-in shower enclosure.
(e) A back support for use in a bathtub is not a bathing seat.
(2) Classification. For purposes of this rule, bathing seats are classified into three categories (basic, intermediate, complex) and eleven total subcategories. The descriptions of the categories and subcategories given here are meant to be generally illustrative and neither all-inclusive nor exclusive.
(a) Basic bathing seats.
(i) Basic bath/shower chair.
(a) Appearance: it looks like a simple chair. It does not have wheels. It may have a back, armrests, or both. It may have any number of legs (including none). It is not wall-mounted.
(b) Construction: it is a standard off-the-shelf product.
(c) Positioning: it does not recline nor have tilt-in-space capability. It does not have securement straps.
(d) Independent use: the individual is able to use it without assistance.
(e) Commode capability: it cannot be used as a commode.
(f) Assessment and documentation: no face-to-face evaluation is needed. No PA is needed. No CMN is needed in addition to the prescription.
(ii) Basic bath/shower bench.
(a) Appearance: it looks like a simple bench. It does not have wheels. It may have a back, armrests, or both. It may have any number of legs (including none). It is not wall-mounted.
(b) Construction: it is a standard off-the-shelf product.
(c) Positioning: it does not recline nor have tilt-in-space capability. It does not have securement straps.
(d) Independent use: the individual is able to use it without assistance.
(e) Commode capability: it cannot be used as a commode.
(f) Assessment and documentation: no face-to-face evaluation is needed. No PA is needed. No CMN is needed in addition to the prescription.
(iii) Basic stationary transfer bath/shower bench.
(a) Appearance: it looks like a simple transfer bench, which straddles the side of the bathtub. It has a stationary seat. It does not have wheels. It may have a back, armrests, or both. It may have any number of legs (including none). It is not wall-mounted.
(b) Construction: it is a standard off-the-shelf product.
(c) Positioning: it does not recline nor have tilt-in-space capability. It does not have securement straps.
(d) Independent use: the individual is able to use it without assistance.
(e) Commode capability: it cannot be used as a commode.
(f) Assessment and documentation: no face-to-face evaluation is needed. No PA is needed. No CMN is needed in addition to the prescription.
(iv) Basic sliding transfer bath/shower bench.
(a) Appearance: it looks like a simple transfer bench, which straddles the side of the bathtub. It has a sliding seat, which may swivel. It does not have wheels. It may have a back, armrests, or both. It may have any number of legs (including none). It is not wall-mounted.
(b) Construction: it is a standard off-the-shelf product.
(c) Positioning: it does not recline nor have tilt-in-space capability. It does not have securement straps.
(d) Independent use: the individual is able to use it (and operate the sliding seat) without assistance.
(e) Commode capability: it cannot be used as a commode.
(f) Assessment and documentation: no face-to-face evaluation is needed. No PA is needed. No CMN is needed in addition to the prescription.
(v) Basic shower chair commode.
(a) Appearance: it looks like a standard wheelchair (two large rear wheels and two eight-inch front casters) or transport chair (four small casters or two small front casters and two slightly larger rear wheels). It generally has a back and may have footrests. It does not have a separate base.
(b) Construction: the frame may be made either of metal such as steel or aluminum or of a polymer such as polyvinyl chloride (PVC).
(c) Positioning: it may recline but does not have tilt-in-space capability. It may have securement straps.
(d) Independent use: the individual is able to use it without assistance.
(e) Commode capability: it is used as a commode.
(f) Assessment and documentation: no face-to-face evaluation is needed. No PA is needed. No CMN is needed in addition to the prescription.
(b) Intermediate bathing seats.
(i) Intermediate non-assisted shower chair.
(a) Appearance: it looks like a standard wheelchair (two large rear wheels and two eight-inch front casters) or transport chair (four small casters or two small front casters and two slightly larger rear wheels). It does not have a separate base.
(b) Construction: the frame may be made of steel or aluminum but not PVC.
(c) Positioning: it may recline but does not have tilt-in-space capability. It may have basic securement straps and positioners.
(d) Independent use: the individual is able to use it without assistance.
(e) Commode capability: it should be used as a commode if a commode is needed. (A request for a separate commode will not be granted unless a medical reason contraindicates a bathing seat with a commode function.)
(f) Assessment and documentation: a face-to-face evaluation is needed. PA is needed. A CMN is needed in addition to the prescription.
(ii) Intermediate assisted multi-position beach style bathing chair.
(a) Appearance: it looks like a typical beach chair, sitting close to the ground (or floor) on short legs. It is intended for use only in a bathtub. It may have the capability to be used with a base, but any such base is a separate item.
(b) Construction: the frame may be made of steel or aluminum but not PVC.
(c) Positioning: it may recline in multiple positions. It may have a head support. It may have basic securement straps and positioners.
(d) Independent use: the individual needs assistance in using it.
(e) Commode capability: it cannot be used as a commode.
(f) Assessment and documentation: a face-to-face evaluation is needed. PA is needed. A CMN is needed in addition to the prescription.
(iii) Intermediate assisted single-position shower chair.
(a) Appearance: it looks like a transport chair (four small casters or two small front casters and two slightly larger rear wheels). It does not have a separate base.
(b) Construction: the frame may be made of steel or aluminum but not PVC.
(c) Positioning: it does not recline nor have tilt-in-space capability. It may have basic securement straps and positioners.
(d) Independent use: the individual needs assistance in using it.
(e) Commode capability: it should be used as a commode if a commode is needed. (A request for a separate commode will not be granted unless a medical reason contraindicates a bathing seat with a commode function.)
(f) Assessment and documentation: a face-to-face evaluation is needed. PA is needed. A CMN is needed in addition to the prescription.
(iv) Intermediate assisted multi-position shower chair.
(a) Appearance: it looks like an examination or treatment chair on small wheels such as casters. It may have a separate base.
(b) Construction: the frame may be made of steel or aluminum but not PVC.
(c) Positioning: it may recline in multiple positions but does not have tilt-in-space capability. It may have basic securement straps and positioners. It may have a head support.
(d) Independent use: the individual needs assistance in using it.
(e) Commode capability: it should be used as a commode if a commode is needed. (A request for a separate commode will not be granted unless a medical reason contraindicates a bathing seat with a commode function.)
(f) Assessment and documentation: a face-to-face evaluation is needed. PA is needed. A CMN is needed in addition to the prescription.
(c) Complex bathing seats.
(i) Complex positioning shower chair.
(a) Appearance: it looks like a complex wheelchair. It has small wheels such as casters. It has no separate base.
(b) Construction: the frame may be made of steel or aluminum but not PVC.
(c) Positioning: it may recline in multiple positions. It generally has basic securement straps and positioners. It may have multiple support devices for the head, torso, arms, and legs.
(d) Independent use: the individual needs assistance in using it.
(e) Commode capability: it should be used as a commode if a commode is needed. (A request for a separate commode will not be granted unless a medical reason contraindicates a bathing seat with a commode function.)
(f) Assessment and documentation: a face-to-face evaluation is needed. PA is needed. A CMN is needed in addition to the prescription.
(ii) Complex transfer bath/shower chair.
(a) Appearance: it consists of a rolling base with a chair seat and small wheels such as casters, a stationary base in the bathing area, and a connecting track or rail that permits the chair seat to slide from the rolling base to the stationary base (and thereby transfer the individual to the inside of the bathtub or shower enclosure).
(b) Construction: the frame may be made of steel or aluminum but not PVC.
(c) Positioning: it may recline in multiple positions and may have tilt-in-space capability. It generally has basic securement straps and positioners. It may have multiple support devices for the head, torso, arms, and legs.
(d) Independent use: the individual may need assistance in using it.
(e) Commode capability: it should be used as a commode if a commode is needed. (A request for a separate commode will not be granted unless a medical reason contraindicates a bathing seat with a commode function.)
(f) Assessment and documentation: a face-to-face evaluation is needed. PA is needed. A CMN is needed in addition to the prescription. This type of bathing seat may be requested only when there is no other appropriate form of transfer in and out of the bathing space. Because the rolling base with chair seat functions as a transport chair, a request for a separate transport chair for travel to and from the bathing area will be denied.
(3) Purchase.
(a) Payment for intermediate and complex bathing seats is subject to prior authorization (PA), which may be given only if a face-to-face evaluation of need has been performed not earlier than one hundred eighty days before the submission of the PA request.
(b) The purchase of a bathing seat includes the bathing seat, delivery, setup, instruction and training in use, adjustments or minor modifications, and other parts or accessories (either substituted or added on). No separate payment is made for these items.
(c) Authorization will not be given for the purchase of more than one bathing seat for concurrent use by an individual.
(4) Repair, including replacement of existing parts or accessories.
(a) The repair of an individual component is subject to need verification. No verification is needed for the repair of a wear item.
(b) For a bathing seat not purchased by the department, submission of documentation of the medical necessity of the bathing seat itself is needed for the initial repair but not for subsequent repairs. The determination that a bathing seat not purchased by the department is medically necessary does not indicate that the bathing seat itself would be authorized for purchase.
(c) Payment is not permitted for temporary replacement equipment (a "loaner bathing seat") provided while an individual's bathing seat is being repaired.
(d) No payment is made for routine maintenance.
(5) Evaluation and management.
(a) An evaluator may receive payment for determining an individual's needs for a bathing seat. Not more than one payment will be made per bathing seat per individual.
(b) Payment includes all services rendered by the evaluator, including evaluation, product selection, confirmation at delivery, and follow-up.
(6) Additional provisions and specifications.
(a) After delivery, the supplier needs to maintain documentary evidence that the following statements are true concerning a bathing seat and any related accessories:
(i) They were delivered to the individual for whom they were prescribed;
(ii) They are consistent with the items described in the CMN, if applicable; and
(iii) They correspond exactly to the items listed on the submitted claim.
(b) Claim payments for which there is insufficient documentation are subject to recovery.
(c) A PA request needs to specify all relevant information, such as procedure code, manufacturer, and model. A fully detailed PA request for repair (either of the entire bathing seat or of multiple components) includes the serial number of the equipment and a complete itemization of parts and estimated labor needed.
(d) When an authorization specifies a manufacturer, model, part number, or other information identifying a particular item, then a supplier may provide and subsequently submit claims only for the specified item.
(e) Payment will not be authorized for a bathing seat to be used by an individual younger than one year. For a child one year of age or older whose needs are not met by an adult-sized bathing seat, consideration for authorization will be given only to bathing seats that accommodate growth, unless there is a more appropriate, cost-effective, medically necessary alternative available. Payment may be made for additional parts needed to "grow" a bathing seat if the combined cost of the parts and related labor is less than the cost of a new bathing seat.
(f) A bathing seat purchased by medicaid is the property of the individual for whom it was prescribed.
Last updated July 2, 2024 at 10:44 AM
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