LCD/NCD Portal

L11563 PRESSURE REDUCING SUPPORT SURFACES - GROUP 1

 

Region IV

Jurisdiction C

 

08/05/2011

 

 

• For any item to be covered by Medicare, it must:

o be eligible for a defined Medicare benefit category

o be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member

o Meet all other applicable Medicare statutory and regulatory requirements.

o For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following indications and limitations of coverage and/or medical necessity.

• These items require a written order prior to delivery.

o Refer to the Policy Article for additional information on orders.

• A Group 1 mattress overlay or mattress (E0181-E0189, E0196-E0199, and A4640) is covered if one of the following three criteria are met:

o The patient is completely immobile - i.e., patient cannot make changes in body position without assistance

o The patient has limited mobility - i.e., patient cannot independently make changes in body position significant enough to alleviate pressure and at least one of conditions A-D below

o The patient has any stage pressure ulcer on the trunk or pelvis and at least one of conditions A-D below.

• Conditions for criteria 2 and 3 (in each case the medical record must document the severity of the condition sufficiently to demonstrate the medical necessity for a pressure reducing support surface):

o Impaired nutritional status

o Fecal or urinary incontinence

o Altered sensory perception

o Compromised circulatory status.

• When the coverage criteria for a Group 1 mattress overlay or mattress are not met, the claim will be denied as not reasonable and necessary.

• The support surface provided for the patient should be one in which the patient does not "bottom out".

o Bottoming out is the finding that an outstretched hand, placed palm up between the undersurface of the mattress overlay or mattress and the patient's bony prominence (coccyx or lateral trochanter), can readily palpate the bony prominence.

o This bottoming out criterion should be tested with the patient in the supine position with their head flat, in the supine position with their head slightly elevated (no more than 30 degrees), and in the side-lying position.

• A support surface which does not meet the characteristics specified in the Coding Guidelines section of the Policy Article will be denied as not reasonable and necessary.

 

 

Bill Type Codes:

• Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.

• Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type.

• Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

 

Revenue Codes:

• Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service.

• In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination.

• Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

 

 

CPT/HCPCS Codes

 

The appearance of a code in this section does not necessarily indicate coverage.

 

 

HCPCS MODIFIERS:

 

EY – No physician or other licensed health care provider order for this item or service

 

GA - Waiver of liability statement issued as required by payer policy, individual case

 

GZ - Item or service expected to be denied as not reasonable and necessary

 

KX - Requirements specified in the medical policy have been met

 

HCPCS CODES:

 

A4640 REPLACEMENT PAD FOR USE WITH MEDICALLY NECESSARY ALTERNATING PRESSURE PAD OWNED BY PATIENT

A9270 NON-COVERED ITEM OR SERVICE

E0181 POWERED PRESSURE REDUCING MATTRESS OVERLAY/PAD, ALTERNATING, WITH PUMP, INCLUDES HEAVY DUTY

E0182 PUMP FOR ALTERNATING PRESSURE PAD, FOR REPLACEMENT ONLY

E0184 DRY PRESSURE MATTRESS

E0185 GEL OR GEL-LIKE PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

E0186 AIR PRESSURE MATTRESS

E0187 WATER PRESSURE MATTRESS

E0188 SYNTHETIC SHEEPSKIN PAD

E0189 LAMBSWOOL SHEEPSKIN PAD, ANY SIZE

E0196 GEL PRESSURE MATTRESS

E0197 AIR PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

E0198 WATER PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

E0199 DRY PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

E1399 DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS

 

 

Documentations Requirements

• Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider".

o It is expected that the patient’s medical records will reflect the need for the care provided.

o The patient’s medical records include the physician’s office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.

• An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and be available upon request. Items delivered before a signed written order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code.

• The supplier must obtain information concerning which, if any, of the criteria listed in the "Indications and Limitations of Coverage and/or Medical Necessity" section of this policy the patient meets in a signed and dated statement from the treating physician.

o A suggested form for collecting this information is attached.

o Questions pertaining to medical necessity on any form used to collect this information may not be completed by the supplier or anyone in a financial relationship with the supplier.

o This statement must be supported by information in the patient's medical record which would be available upon request. Do not submit this form unless specifically requested.

 

• KX, GA AND GZ MODIFIERS

• Suppliers must add a KX modifier to a code only if all of the criteria in the “Indications and Limitations of Coverage and/or Medical Necessity” section of this policy have been met and evidence of such is maintained in the supplier's files.

o This information must be available upon request.

• If all of the criteria in the Indications and Limitations of Coverage and/or Medical Necessity section have not been met, the GA or GZ modifier must be added to the code.

o When there is an expectation of a denial as not reasonable and necessary, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or the GZ modifier if they have not obtained a valid ABN.

• Claim lines billed without a KX, GA, or GZ modifier will be rejected as missing information.

 

• MISCELLANOUS

• When code E1399 is billed, the claim must include a narrative description of the item, the manufacturer, the product name/number, and information justifying the medical necessity for the item.

• Refer to the Supplier Manual for more information on documentation requirements.

 

 

• Appendices

• RELATED CLINICAL INFORMATION:

 

• Patients needing pressure reducing support surfaces should have a care plan which has been established by the patient's physician or home care nurse, which is documented in the patient's medical records, and which generally should include the following:

o Education of the patient and caregiver on the prevention and/or management of pressure ulcers

o Regular assessment by a nurse, physician, or other licensed healthcare practitioner

o Appropriate turning and positioning

o Appropriate wound care (for a stage II, III, or IV ulcer)

o Appropriate management of moisture/incontinence

o Nutritional assessment and intervention consistent with the overall plan of care

• The staging of pressure ulcers used in this policy is as follows:

o Suspected Deep Tissue Injury:

 Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

 The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

o Stage I

 Intact skin with non-blanchable redness of a localized area usually over a bony prominence.

 Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.

o Stage II

 Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.

 May also present as an intact or open/ruptured serum-filled blister.

o Stage III

 Full thickness tissue loss.

 Subcutaneous fat may be visible but bone, tendon or muscle are not exposed.

 Slough may be present but does not obscure the depth of tissue loss.

 May include undermining and tunneling.

o Stage IV

 Full thickness tissue loss with exposed bone, tendon or muscle.

 Slough or eschar may be present on some parts of the wound bed.

 Often include undermining and tunneling.

o Unstageable:

 Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

 

Sources of Information and Basis for Decision

 

National Pressure Ulcer Advisory Panel (NPUAP) Revised Staging Definitions for Pressure Ulcers accessed at www.npuap.org on August 28, 2008.

 

A33747 - Pressure Reducing Support Surfaces - Group 1 - Policy Article - Effective January 2011

 

Statement of Ordering Physician Group 1 Support Services

 

Local Coverage Determination (LCD) for Pressure Reducing Support Surfaces - Group 1 (L11563)