Rule 5160-10-24 | DMEPOS: speech-generating devices.
(A) Coverage.
(1) Separate payment may be made for a speech-generating device (SGD) furnished to a resident of a long-term care facility (LTCF).
(2) The default certificate of medical necessity (CMN) form is the ODM 02924, "Certificate of Medical Necessity: Speech-Generating Devices" (rev. 7/2018). The CMN includes the following elements:
(a) A formal, written report of a face-to-face evaluation of the individual's communication abilities performed by a speech-language pathologist (SLP);
(b) Exact specifications for a SGD and the rationale for selection;
(c) Clinical documentation that the individual's cognitive and physical abilities will enable effective use of the specified SGD;
(d) Full disclosure of any SGD equipment currently in the individual's possession and an explanation of why that equipment does not meet the individual's needs;
(e) Documentation of the medical necessity of any accessory or add-on equipment, supplies, or SGD features being requested; and
(f) An explanation of the necessity or functional benefit of any requested upgrade, modification, or replacement.
(3) The formal, written evaluation report includes all of the following components:
(a) A description of the individual's current communication impairment, including the type, severity, and prognosis;
(b) An assessment of the individual's speech skills and capacity for receptive and expressive language;
(c) An explanation, as applicable, of how the individual's cognition, emotions, physical abilities, and behaviors affect the communication of basic needs;
(d) Identification of the persons with whom the individual communicates most frequently and any associated limitations and needs;
(e) Identification of the environments in which the individual communicates most frequently (including vocational and educational settings);
(f) A description of the types of messages the individual generally needs to convey and the range of vocabulary used;
(g) An assessment of the extent to which the individual's daily communication needs could be met by a SGD incorporating less complex technology or by a means of communication other than a SGD;
(h) A description of the functional communication goals expected to be achieved with a SGD;
(i) Recommendations for the following SGD features and functions:
(i) Representational systems (symbols);
(ii) Vocabulary encoding (e.g., icon, level-plus-location, traditional orthography);
(iii) Vocabulary expandability and message generation (e.g., programmed or programmable words or parts of sentences, additional memory);
(iv) Rate-enhancement techniques (e.g., simple symbol selection, symbol sequencing, key linking, dynamic display, abbreviation-expansion, word lists, word prediction, icon prediction, macros);
(v) Access techniques and strategies;
(vi) Keyboard organization (e.g., key size and spacing, overlay size and number, key guard);
(vii) Device output modes (e.g., speech synthesis, printed output, character display, auditory and visual prompting, auditory and visual feedback); and
(viii) Portability;
(j) A description of a comprehensive treatment plan that includes a training schedule for the selected SGD; and
(k) The signature and license number of the SLP and any other member of the evaluation team.
(4) Payment will not be made for a SGD until the individual has used the device for a period of at least four weeks, during which the prescriber determines that the device satisfactorily meets the individual's needs. If the device does not meet the individual's needs, then the provider may choose to submit a request for payment of one month's rental.
(5) The department will consider coverage of SGDs in any of several forms, including but not limited to the following examples:
(a) A standalone unit running dedicated, proprietary software;
(b) Commercially available software and, if necessary, hardware to run it (e.g., a portable or tablet computer);
(c) A software application that may be loaded onto devices already owned by an individual; or
(d) A combination of components that provides functionality for the user.
(6) Separate payment may be made for the following items and services:
(a) A face-to-face evaluation performed by a SLP;
(b) Brackets and mounting hardware; and
(c) An adaptive interface or other accessory if the evaluating SLP provides documentation that the item is necessary for the independent use of a SGD by a particular individual.
(7) Payment for the upgrade, modification, or replacement of a fully functional SGD during its useful life may be made only if the SGD no longer meets the individual's basic communication needs.
(a) Replacement during the useful life of a SGD will be considered only when it is more cost-effective than modification.
(b) Repair does not extend the useful life of a SGD.
(B) Constraints and limitations.
(1) Payment may be made only for the type of SGD prescribed. Substitution (e.g., provision of a tablet instead of a standalone unit running proprietary software) requires the approval of the prescriber.
(2) Payment for a SGD includes the following items and services:
(a) Supplies, equipment (e.g., interface, printer, cables, adapters, connectors), and any standard component or requested accessory that is dispensed with a SGD; and
(b) All professional, technical, and administrative services performed by the provider in relation to a SGD.
(3) No separate payment will be made for any of the following items:
(a) A second SGD used concurrently by an individual;
(b) Additional software, applications, accessories, components, peripheral devices, or pieces of hardware that are not related to the main purpose of the SGD;
(c) Purchase, rental, lease, subscription, or maintenance associated with a cellular phone, even if the cellular phone has the capability to perform SGD functions; or
(d) Features that may be added on to some models of SGD but have been integrated into the particular SGD under consideration.
(C) Claim payment.
(1) The payment amount for a portable/tablet computer with software, for portable/tablet computer software, or for an accessory (e.g., mounting bracket, adaptive interface) is determined through the prior authorization (PA) process.
(2) Payment for a face-to-face evaluation is the lesser of the submitted charge or the amount listed in appendix DD to rule 5160-1-60 of the Administrative Code.
Last updated January 2, 2024 at 8:59 AM
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