New Jersey Administrative Code › Title 8 - HEALTH › Chapter 85 - LONG-TERM CARE SERVICES › Subchapter 2 - NURSING FACILITY SERVICES › Section 8:85-2.15 - Medical supplies and equipment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Medical supplies
				include incontinency pads, bandages, dressings, compresses, sponges, plasters,
				tapes, cellu-cotton or other types of pads used to save labor or linen, and other
				disposable items (for example, colostomy bags), hot water bags, thermometers,
				catheters, rubber gloves, and supplies required in the administration of medication
				including disposable syringes. Routinely used medical supplies are considered part
				of the institution's cost and cannot be billed directly to the program by the
				supplier.
(b) Equipment for
				administration of oxygen for residents in a NF is a required service. Oxygen itself
				must conform to United States Pharmacopoeia Standards in order to be used as a
				medicinal gas. (United States Pharmacopoeia Convention, 12601 Twinbrook Parkway,
				Rockville, MD 20852.)
(c) Routinely used
				durable medical equipment ordered for Medicaid beneficiaries in a participating NF
				(for example, walkers, wheelchairs, bed-rails, crutches, traction apparatus,
				intermittent positive-pressure breathing (IPPB) machine, electric nebulizers,
				electric aspirators, low-end pressure relief systems such as mattress overlays and
				mattress replacements, powered mattress systems and powered flotation beds) and
				other therapeutic equipment and supplies essential to furnish the services offered
				by the facility for the care and treatment of its residents shall be considered part
				of the NF's cost, and shall not be billed directly to the program by the
				supplier.
(d) When unusual circumstances
				require special medical equipment not usually found in a NF, such special equipment
				may be reimbursable, with prior authorization from the Medical Assistance Customer
				Center (MACC) serving the county where the facility is located.
1. When special medical equipment is authorized
				and purchased on behalf of a Medicaid beneficiary, ownership of such equipment shall
				vest in the Division of Medical Assistance and Health Services (DMAHS). The
				beneficiary shall be granted a possessory interest for as long as the beneficiary
				requires use of the equipment. When the beneficiary no longer needs such equipment,
				possession and control shall revert to DMAHS. The beneficiary shall agree to this
				when he or she signs the "patient's certification" section on the claim form. The NF
				shall notify the MACC in writing when such equipment is no longer in use.
2. Prior authorization requests for special
				medical equipment shall be accompanied by documentation from the attending
				physician, the registered professional nurse who has primary responsibility for the
				beneficiary, and appropriate rehabilitative therapy personnel, which relates the
				medical necessity for the equipment and describes the extraordinary requirements of
				the beneficiary.
3. Pressure relief
				systems shall be reimbursed in a NF under the following conditions:
i. Air Fluidized and Low Air Loss therapy beds, as
				defined in 8:85-1.2, shall be considered special
				medical equipment and shall be prior authorized for reimbursement in a NF only when
				all of the following criteria, indicating medical necessity, are documented by the
				physician.
(1) The beneficiary has two stage III
				(full-thickness tissue loss) pressure sores or a stage IV (deep tissue destruction)
				pressure sore which involves two of the following sites: hips, buttocks,
				sacrum.
(2) The beneficiary with
				coexisting risk factors (such as vascular irregularities, nutritional depletion,
				diabetes or immune suppression) presents post-operatively with a posterior or
				lateral flap or graft site requiring short-term therapy until the operative site is
				viable.
(3) The beneficiary is bedridden
				or chair-bound as a result of severely limited mobility.
(4) The beneficiary is receiving maximal
				medical/nursing care, prior instituted conservative treatment has been unsuccessful
				and all other alternative equipment has been considered and ruled out.
(5) The bed is ordered, in writing, by the
				attending physician based on his or her comprehensive assessment (which includes a
				physical examination) and evaluation of the beneficiary.
(6) Prior authorization in conditions other than
				those defined above shall be considered on an individual basis by the MDO.
ii. Air fluidized and low air loss
				therapy beds shall not be covered for reimbursement in a NF under any of the
				following circumstances:
(1) As a preventative
				measure;
(2) After healing to stage II
				has occurred or wound stability (no significant change or evidence of healing) has
				been achieved;
(3) If the facility
				structure cannot support the weight of the bed or the facility electrical system is
				insufficient for the anticipated increase in energy consumption, air fluidized
				therapy shall be considered inappropriate. Reimbursement for an air fluidized bed
				shall be limited to the equipment itself. Payment shall not be made for
				architectural adjustments such as electrical or structural improvement.
iii. Prior authorization of air
				fluidized or low air loss therapy beds, if approved, shall be granted for 30 days
				only. Continued use beyond the initial approval period shall require prior
				authorization on a monthly basis. The following information shall be submitted to
				the MACC to obtain prior authorization:
(1) A
				completed FD-354 prior authorization form;
(2) The physicians' written
				prescription;
(3) A medical history
				relating to the wound which includes previous therapy and pressure relief systems
				utilized and found unsuccessful;
(4)
				Physician progress notes indicating medical necessity, plan of treatment and
				evaluation of response to treatment specific to the care of the wound;
(5) The wound care flow sheet documenting weekly
				the site, size, depth and stage of the wound, noting also the presence and
				description of drainage or odor;
(6)
				Laboratory values including a complete blood count and blood chemistries initially
				and on request thereafter;
(7) A
				nutritional assessment by a registered dietitian initially on request thereafter;
				and
(8) Photographs of the site upon
				permission of the beneficiary/family, after full due consideration is afforded to
				the beneficiary's right to privacy, dignity and confidentiality.
iv. After treatment with an air
				fluidized or low air loss therapy bed is initiated, the beneficiary shall:
(1) Be examined by the physician on a monthly
				basis;
(2) Remain on the therapy unit
				and be confined to bed, unless medically necessary. While confined to bed, due
				consideration shall be given to the beneficiary's need for social and sensory
				stimulation and recreational diversion by providing in-room visitation and
				social/recreational activities appropriate to the beneficiary's condition;
				and
(3) Be repositioned on a turning
				schedule of not less than every two hours.
v. Professional staff from the MACC may, at their
				discretion, perform an onsite visit to evaluate the beneficiary prior to or after
				therapy has been instituted. Continued approval shall be contingent upon the
				facility's compliance with the criteria and conditions defined in (d)3i, ii, iii and
				iv above and cooperation of the beneficiary to the therapeutic modality.