Ohio Admin. Code 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 must
include 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 must include 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. (In the appendix to
rule
5160-10-01
of the Administrative Code, the useful life of a SGD is expressed as a limit or
frequency.)
(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)
Requirements,
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 the following
items:
(a)
A
second SGD used concurrently by an individual; and
(b)
Additional
software, applications, accessories, components, peripheral devices, or pieces
of hardware that are not related to the main purpose of the SGD.
(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.
Replaces: 5160-10-24
Notes
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 09/10/1993, 12/10/1993, 12/29/1995 (Emer), 03/21/1996, 10/01/2004, 05/01/2012
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