OAR 410-122-0580: Bath Supplies

(1) Indications and limitations of coverage and medical appropriateness: The Division may cover bath supplies when the client meets the conditions of coverage in OAR 410-122-0080 and when the following guidelines are met: (a) A rehab shower/commode chair may be covered when all of the following criteria are met: (A) Client is unable to use a standard shower chair/bench due to a neurological or musculoskeletal condition; (B) Client has positioning, trunk stability or neck support needs that a standard shower chair/bench cannot provide; (C) The home (shower) can accommodate a rehab shower/commode chair; (D) Less costly alternatives have been considered or tried and ruled out; (E) The rehab shower/commode chair meets the following specifications and standard features as a minimum: (i) Constructed specifically for use as a rehab shower/commode chair (corrosive resistant); (ii) Swing-away or detachable arms; (iii) Removable commode pan holder and pan; (iv) Adjustable removable footrests; (v) Wheel lock system; (F) The rehab shower/commode chair must be supplied by a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) provider that employs a Rehabilitation Engineering and Assistive Technology Society of North America (RESNA)-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the rehab shower/commode chair selection for the client; (G) Verification of the healthcare common procedure coding system (HCPCS) code assignment by the Medicare Pricing, Data Analysis and Coding (PDAC) contractor is not required for a rehab shower/commode chair; (H) Use E1399 for a rehab shower/commode chair and accessories that are not included in the base for the rehab shower/commode chair. PDAC coding verification is not required for these items as they are statutorily excluded from coverage by Medicare and have no assigned HCPCS codes. (b) Custom/Specialized Pediatric Bath Chair: (A) Custom/Specialized pediatric bath chair requires fitting and/or adjustment to treat a specific medical need; (B) Custom/Specialized pediatric bath chairs require prior authorization (PA). Documentation must include the following: (i) The treating practitioner’s records supporting the medical appropriateness of the item ordered and explaining why a standard bath chair will not meet the individual’s medical needs; and (ii) Documentation shall identify less costly alternatives and explain why a less costly alternative will fail to meet the individual’s medical needs. (C) A custom/specialized pediatric bath chair shall be billed using the appropriate HCPCS code (E0240, E0245, or E0247) and modifier 22; (i) DMEPOS providers shall refer to the product classification list on the PDAC contractor website for coding verification; (ii) A pediatric custom/specialized bath chair billed using HCPCS code E0240, E0245, or E0247 and modifier 22 shall be reimbursed following the payment methodology outlined in OAR 410-122-0186 for manually priced items. (2) Documentation requirements: (a) The practitioner’s order and medical justification for the equipment must be kept on file by the DMEPOS provider. The client’s medical records must contain information which supports the medical appropriateness of the item and accessories ordered; (b) For services requiring prior authorization, submit documentation which supports conditions of coverage in this rule are met. (3) Table 122-0580 Bath Supplies. [ED. NOTE: To view attachments referenced in rule text, click here to view rule.]