Ambulatory Aids and Bath Safety

Reimbursement Requirements:

Bathroom safety items are usually not covered by insurance.

Bariatric Equipment

Reimbursement Requirements: Qualifying diagnosis requirements are generally the same for standard weight rated and bariatric equipment, with the addition of a diagnosis of morbid obesity.

Insurances define bariatric equipment in two categories; 351lbs to 600lbs, and over 600lbs.

Hospital Bed/Patient Room Products

Reimbursement Requirements: Hospital beds - Patient requires immediate repositioning to alleviate pain, smothering, aspiration, edema, to assist in wound care, to aid in transfer to wheelchair. None of this feasible in an ordinary bed. COPD, CHF, Chronic Pulmonary Heart Disease, Aspiration, G/J Feeding Tube, Osteoarthritis, Rheumatoid Arthritis, Paraplegia, Quadraplegia, CVA, MS, MD, Parkinsons, ALS, Malignant Neoplasms, Renal Failure, etc.

Manual Wheelchairs

Reimbursement Requirements: Patient can no longer safely ambulate with a cane, walker, etc. The patient cannot functionally propel a standard weight wheelchair (50 lbs), but they can propel a lightweight wheelchair (30 lbs). COPD, Emphysema, CHF, CAD, Cardiomyopathy, ASCVD, Cor Pulmonale, Osteoarthritis, Rheumatoid Arthritis, CVA, Paraplegia, CP, MS, MD, Peripheral Vascular Disease, Peripheral Neuropathy, etc.

Power Mobility Services

Reimbursement Requirements: The patient can no longer functionally ambulate or propel a manual wheelchair to care for themselves independently in their home. A thorough evaluation of the patient and their home environment must be done to ensure they receive the appropriate chair. In general, the same diagnosis apply that qualify a patient for a manual wheelchair. The evaluation (completed by an OT, PT, or physician) must show the patients has a neurological disorder, and/or has multiple debilitating diagnosis, and/or lacks the strength to propel a manual wheelchair and/or is compromised by chronic pain, and/or falls often, and/or doesn't have the pulmonary or cardiac function to independently perform activities of daily living, etc.

Respiratory Services: Oxygen Therapy

Reimbursement Requirements: To qualify for stationary and portable oxygen, a patient must have a waking room air ABG = PO2 of < 55 OR a room air pulse oximetry = SAO2 of < 88%. To qualify for a stationary oxygen for nocturnal use only, a pulse oximetry while sleeping, with a SAO2 of < 9=88% for longer than 5 minutes total during the test. COPD, Emphysema, CHF, CAD, Pulmonary Hypertension, CA of the lung, Pleural Effusion, Interstitial Lung Disease, Respiratory Distress, respiratory Failure, Cor Pulmonale, most any diagnosis lending to Hypoxemia will qualify for Oxygen Therapy.

Respiratory Services: Sleep Therapy

Reimbursement Requirements: CPAP Patient has a sleep study, the physician sees the patient has a mixture of Obstructive Sleep Apnea (OSA) episodes (airway obstruction plus hypopneas), sufficient enough to warrant ordering a Continuous Positive Airway Pressure machine. Apneas, plus Hypopneas (a shallow breathing episode < 10 seconds in duration), divided by the number of hours of sleep in the test, equals the patients Apnea/Hypopnea Index (AHI). Insurances consider an AHI > 15 as qualifying the patient for a CPAP (AHI of 4-15 will be considered with a documented history of hypertension, CHF, and/or excessive daytime sleepiness) BiLevel Patients generally need a Bi-Level machine for one of the following reasons: 1. They have OSA, have tried a CPAP and it has failed to offer the optimum therapy, or 2. An end stage COPD patient is retaining CO2 during respiration. To qualify, the patient must have waking ABG on their normal FIO2 (room air or O2), showing their PCO2 level > 52 mmhg (proving CO2 retention), in addition, they must have a nocturnal pulse oximetry test on 21pm of ) 2 or their usual FIO2 (whichever is higher), this test must show SAO2 level is < 88% for at least one full episode of > 5 minutes. 3. Restrictive Thoracic Disorders and Neuromuscular diseases have similar ABG testing requirements to prove CO2 retention, and pulmonary function tests to prove diminished inspiratory pressure and/or forced vital capacity. 4. Central Sleep Apnea with documentation of sleep associated hypoventilation.

Specialty Matresses and Overlays

Reimbursement Requirements: Patient meets criteria for a hospital bed. Prevention Overlays - Has limited ability to reposition themselves in bed, and is susceptible to skin breakdown. Therapy Mattresses - Patient must have multiple stage II ulcers or a single stage III or IV on their trunk. Generally they have tried other prevention systems and have failed or worsened. In general, the primary diagnosis that qualifies a patient for a hospital bed, i.e. COPD, CHF, Chronic Pulmonary Hear Disease, Aspiration, G/J Feeding Tube, Osteoarthritis, Rheumatoid Arthritis, Paraplegia, Quadraplegia, CVA, MS, MD, Parkinson's, ALS, Malignant Neoplasms, Renal Failure, etc., has left the patient susceptible to/or having active decubitus ulcers.

Surgical Knee Replacement Rehabilitation Service

Reimbursement Requirements: A traditional therapy regimen is for approximately 21 days for the procedure V43.65, a total knee arthroplasty due to joint deterioration from 715.98, osteoarthritis.