Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook Page: Dm-114

                                
TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2

Section B: Diagnosis and Medical Information
Section B is a prescription for DME/supplies and must be filled out by the prescribing physician.
The prescribing physician must indicate the corresponding item number requested from Section A, an ICD-9 code with a brief
description, and complete justification for determination of medical necessity for the requested item(s). If applicable, include
height/weight, wound stage/dimensions and functional/mobility.
The physician is not required to repeat the procedure code or description of the requested DME or supplies in this section.
Note: The date last seen must be within the past 12 months.
The prescribing physician'must indicate the duration of need for the prescribed supplies/DME. The estimated duration of need
should specify the amount of time the supplies/DME will be needed, such as six weeks, three months, lifetime, etc. The
prescribing physician's TPI (if a Texas Medicaid provider), NPI, and license number must be indicated.
Note: Signatures from nurse practitioners, physician assistants, and chiropractors will not be accepted. Signature stamps and date
stamps are not acceptable.

Diagnosis and Medical Need Information
Item No. 2    ICD-9       Brief Diagnosis Description
(From
Section A)
1,2        438      Appropriate diagnosis description
2         27801     Appropriate diagnosis description

Complete justification for determination of medical necessity
for requested item(s). Refer to Section A: Requested Durable
Medical Equipment and Supplies.1,2
Unable to get in and out of the tub or shower.
Need swing-away arms and legs for transfer secondary to
hemiparesis and need oversize chair for clients weighing 400
lbs.

1. Refer to Footnote I of the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form.
2. Refer to Footnote 2 of the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form.
Examples of Supplies
Item No. 2    ICD-9       Brief Diagnosis Description  Complete justification for determination of medical necessity
(From                                               for requested item(s). Refer to Section A: Requested Durable
Section A)                                            Medical Equipment and Supplies.1,2
1,2,3      25001     Appropriate diagnosis description  Client has frequent variation of blood glucose levels and needs
monitoring several times a day.
1. Refer to Footnote 1 of the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form.
2. Refer to Footnote 2 of the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form.
Effective Date_1021208/Revised Date_10212008

DM-114
CPT ONLY - COPYRIGHT 2009 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.