A home phototherapy device uses light exposure with white, blue, or green lights to increase bilirubin excretion in the infant with elevated bilirubin levels.
Home phototherapy services include parent/guardian education and obtaining laboratory specimens. Laboratories performing analysis of specimens can bill according to established procedures.
Clients younger than 21 years of age who do not qualify based on the Texas Medicaid Title XIX
Home Health Services benefit criteria for home phototherapy devices can be considered through the Comprehensive Care Program (CCP).
Procedure code L-E0202 can be submitted for reimbursement consideration of a home phototherapy device.
Authorization Requirements
Home phototherapy devices require prior authorization and are provided only for the days that are medically necessary.
A completed Home Health (Title XIX) DME/Medical Supplies Physician Order Form prescribing the durable medical equipment (DME) and/or medical supplies must be signed and dated by the prescribing physician familiar with the client prior to requesting authorization. All signatures must be current, unaltered, original, and handwritten. Computerized or stamped signatures will not be accepted. The completed Title XIX Prior Authorization Form must be maintained by the requesting provider and the prescribing physician. The original signature copy must be kept by the physician in the client’s medical record.
To avoid unnecessary denials, the physician must provide correct and complete information, including documentation for medical necessity of the equipment and/or supplies requested. The physician must maintain documentation of medical necessity in the client’s medical record. The requesting provider may be asked for additional information to clarify or complete a request for the home phototherapy device.
The DME Certification and Receipt Form is required and must be completed before reimbursement can be made for any DME that is delivered to a client. The certification form must include the name of the item, the date the client received the DME, and the signatures of the provider and the client or primary caregiver. This form must be maintained by the DME provider in the client’s medical record.
Consideration for the rental of a home phototherapy device includes, but is not limited, to the following primary diagnosis codes:
Diagnosis Code Description
7740 Perinatal jaundice from hereditary hemolytic anemias
7741 Perinatal jaundice from other excessive hemolysis
7742
77430
77431
77439
7744
Neonatal jaundice associated with preterm delivery
Neonatal jaundice due to delayed conjugation, cause unspecified
Neonatal jaundice due to delayed conjugation in diseases classified elsewhere
Other neonatal jaundice due to delayed conjugation from other causes.
Perinatal jaundice due to hepatocellular damage

Diagnosis Code Description
7745 Perinatal jaundice from other causes
7746
7747
Unspecified fetal and neonatal jaundice
Kernicterus of fetus or newborn not due to isoimmunization
Authorization requirements are based on the current American Academy of Pediatrics (AAP) standards and guidelines.
Lower risk infants are defined as greater than or equal to 38 weeks of gestation and well.
Indications for phototherapy in the home setting for infants 35 weeks of gestation or greater at low risk are:

0 through 24 hours of age with a bilirubin level of 6 –10 mg/dl

25 through 48 hours of age with a bilirubin level of 10 –16 mg/dl

49 through 72 hours of age with a bilirubin level of 13 –18 mg/dl

Greater than 72 hours of age with a bilirubin level of 16 –21 mg/dl
Risk factors can include, but are not limited to, isoimmune hemolytic disease, G6PD deficiency, asphyxia, significant lethargy, temperature instability, sepsis, acidosis, or a serum albumin level less than 3.0 g/dl (if measured).
Documentation of medical necessity is required if the infant does not meet the guidelines above.
Prior authorization may be given for up to a maximum of seven days at a time, with documentation of the following medical necessity criteria:

Serum bilirubin level (in mg/dl)

Gestational age

Any known risk factors (for example, breastfeeding, jaundice within the first 24 hours, and blood group incompatibility)
 Physician’s Plan of Care (POC) for intervention after seven days

Anticipated number of days the client will need the phototherapy light

Documentation of parental education regarding the importance of monitoring and follow-up
Note: Total serum bilirubin levels listed are guides for authorization only.
A new prior authorization is required for requests beyond seven days. Home phototherapy devices will not be considered for prior authorization if the client has an open authorization for skilled nursing visits (SNV) for hyperbilirubenemia.
As stated in the AAP standards and guidelines, the Texas Medicaid Program expects that there will be ongoing assessments for risk of severe hyperbilirubenemia for all infants receiving home phototherapy.
Newborn babies may not have a Medicaid number at the time that services are ordered by the physician and provided by the supplier. In these cases, authorization may be given retroactively for those services rendered between the start date and the date the client’s Medicaid number becomes available.
The provider is responsible for verifying the effective dates of client eligibility.
The provide r has 95 days from the date the client’s Medicaid number is available (add date) to obtain authorization for services already rendered.
Services provided after the client’s Medicaid number becomes available must be prior authorized within three business days.
Clients younger than 21 years of age who do not qualify based on the Title XIX Home Health
Services benefit criteria for home phototherapy devices can be considered through the
Comprehensive Care Program (CCP).

Reimbursement
Items and/or services addressed in this policy are either reimbursed at a maximum fee determined by HHSC or are manually priced. If an item is manually priced, manufacturer suggested retail pricing (MSRP) must be submitted for consideration of rental or purchase with the appropriate procedure codes. Manually priced items are reimbursed at the retail price minus a discount (18 percent) or as determined by HHSC.
Routine maintenance of rental equipment is the provider’s responsibility. Rental of a phototherapy device is reimbursed as a daily global fee. The global fee includes SNVs for client teaching, monitoring, and customary and routine laboratory work. SNVs are denied as part of the phototherapy device rental.
Providers may not bill for those days the phototherapy device is at the client’s home and is not in use.
For more information, call the TMHP Contact Center at 1-800-925-9126.