L11564-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Pressure Reducing Support Surfaces - Group 2

(L11564)

Contractor Information

Contractor Name CGS Administrators, LLC

Contractor Number 18003

Contractor Type DME MAC

Jurisdiction J - G

LCD Information

Document Information

LCD ID Number L11564

LCD Title Pressure Reducing Support Surfaces - Group 2

Contractor's Determination Number PRSS2

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2012 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Primary Geographic Jurisdiction

Alabama Arkansas Colorado Florida Georgia Louisiana Mississippi North Carolina New Mexico Oklahoma Puerto Rico South Carolina Tennessee Texas Virginia Virgin Islands West Virginia

Oversight Region Region IV

DME Region LCD Covers Jurisdiction C

Original Determination Effective Date

For services performed on or after 10/01/1993

Original Determination Ending Date

Revision Effective Date

For services performed on or after 08/05/2011

Revision Ending Date

CMS National Coverage Policy

CMS Pub. 100-3, (Medicare National Coverage Determinations Manual), Chapter 1, Section 280.1 Indications and Limitations of Coverage and/or Medical Necessity

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. 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.

A group 2 support surface is covered if the patient meets:

a. Criterion 1 and 2 and 3, or

b. Criterion 4, or

c. Criterion 5 and 6.

1. The patient has multiple stage II pressure ulcers located on the trunk or pelvis (ICD-9 707.02 - 707.05), and

2. Patient has been on a comprehensive ulcer treatment program for at least the past month which has included the use of an appropriate group 1 support surface, and

3. The ulcers have worsened or remained the same over the past month, or

4. The patient has large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis (ICD-9 707.02 -707.05), or

5. The patient had a recent myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis (surgery within the past 60 days) (ICD-9 707.02 -707.05), and

6. The patient has been on a group 2 or 3 support surface immediately prior to a recent discharge from a hospital or nursing facility (discharge within the past 30 days).

The comprehensive ulcer treatment described in #2 above should generally include:

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

ii. Regular assessment by a nurse, physician, or other licensed healthcare practitioner (usually at least weekly for a patient with a stage III or IV ulcer).

iii. Appropriate turning and positioning.

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

v. Appropriate management of moisture/incontinence.

vi. Nutritional assessment and intervention consistent with the overall plan of care.

If the patient is on a group 2 surface, there should be a care plan established by the physician or home care nurse which includes the above elements. The support surface provided for the patient should be one in which the patient does not "bottom out" (see Appendices section).

When a group 2 surface is covered following a myocutaneous flap or skin graft, coverage generally is limited to 60 days from the date of surgery.

When the stated coverage criteria for a group 2 mattress or bed are not met, a claim will be denied as not reasonable and necessary. A group 2 support surface billed without a KX modifier (see Documentation section) will be denied as not reasonable and necessary.

A support surface which does not meet the characteristics specified in the Coding Guidelines section of the Pressure Reducing Support Surfaces – Group 2 Policy Article will be denied as not reasonable and necessary. (See Coding Guidelines and Documentation sections concerning billing of E1399.)

Continued use of a group 2 support surface is covered until the ulcer is healed, or if healing does not continue, there is documentation in the medical record to show that: (1) other aspects of the care plan are being modified to promote healing, or (2) the use of the group 2 support surface is reasonable and necessary for wound management.

Appropriate use of the KX modifier (see Documentation section) is the responsibility of the supplier. The supplier should maintain adequate communication on an ongoing basis with the clinician providing the wound care in order to accurately determine that use of the KX modifier still reflects the clinical conditions which meet the criteria for coverage of a group 2 support surface, and that adequate documentation exists in the medical record reflecting these conditions. Such documentation should not be submitted with a

claim but should be available upon request.

In cases where a group 2 product is inappropriate, a group 1 or 3 support surface could be covered if coverage criteria for that group are met.

Coding Information

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 MODIFIER:

EY – No physician or other 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

E0193 POWERED AIR FLOTATION BED (LOW AIR LOSS THERAPY)

E0277 POWERED PRESSURE-REDUCING AIR MATTRESS

E0371 NONPOWERED ADVANCED PRESSURE REDUCING OVERLAY FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

E0372 POWERED AIR OVERLAY FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH E0373 NONPOWERED ADVANCED PRESSURE REDUCING MATTRESS

E1399 DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS

ICD-9 Codes that Support Medical Necessity

The presence of an ICD-9-CM code listed in this section is not sufficient by itself to assure coverage. Refer to the section on Indications and Limitations of Coverage and/or Medical Necessity for other coverage criteria and payment information.

707.02 - 707.05 PRESSURE ULCER, UPPER BACK - PRESSURE ULCER, BUTTOCK

Diagnoses that Support Medical Necessity Refer to the previous section.

ICD-9 Codes that DO NOT Support Medical Necessity

All ICD-9 codes that are not specified in the previous section.

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

All diagnoses that are not specified in the previous section.

General Information

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". It is expected that the patient’s medical records will reflect the need for the care provided. 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 made 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 criteria 1-6 listed in the Indications and Limitations of Coverage section of this policy the patient meets in a signed and dated statement from the treating physician. A suggested form for collecting this information is attached. Questions pertaining to medical necessity on any form used to obtain this information may not be completed by the supplier or anyone in a financial relationship with the supplier. 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. 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. 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.

When code E1399 is billed, the claim must include the manufacturer name and the model name/number.

Refer to the Supplier Manual for more information on documentation requirements. Appendices The staging of pressure ulcers used in this policy is as follows:

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.

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.

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.

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.

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.

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.

Bottoming out is the finding that an outstretched hand can readily palpate the bony prominence (coccyx or lateral trochanter) when it is placed palm up beneath the undersurface of the mattress or overlay and in an area under the bony prominence. 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.

Utilization Guidelines Refer to Indications and Limitations of Coverage and/or Medical Necessity.

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 Advisory Committee Meeting Notes

Start Date of Comment Period 04/30/1993

End Date of Comment Period 06/14/1993

Start Date of Notice Period 08/01/1993

Revision History Number 011

Revision History Explanation Revision Effective Date: 01/01/2011 HCPCS CODES AND MODIFIERS:

Revised: GA modifier

Revision Effective Date: 04/01/2010 HCPCS CODES AND MODIFIERS:

Added: GA and GZ modifiers Revised: KX modifiers Documentation Requirements:

Added: Instructions for the use of GA and GZ modifiers

Revision Effective Date: 01/01/2009 APPENDICES:

Revised: Definitions of pressure ulcer stages

SOURCES OF INFORMATION AND BASIS FOR DECISION:

Added: Reference to NPUAP guidelines for pressure ulcer staging

08/10/2008 - This policy was updated by the ICD-9 2008-2009 Annual Update.

03/01/2008 - In accordance with Section 911 of the Medicare Modernization Act, this policy was transitioned to DME MAC CIGNA Government Services (18003) LCD L11517 from DME PSC TrustSolutions (77012) LCD L11517.

Revision Effective Date: 07/01/2007 INDICATIONS AND LIMITATIONS OF COVERAGE:

Removed: DMERC references DOCUMENTATIONS GUIDELINES:

Removed: DMERC references

06/01/2007 - In accordance with Section 911 of the Medicare Modernization Act of 2003, Virginia and West Virginia were transitioned from DME PSC TriCenturion (77011) to DME PSC TrustSolutions (77012).

03/01/2006 - In accordance with Section 911 of the Medicare Modernization Act of 2003, this policy was transitioned to DME PSC TrustSolutions (77012) from DMERC Palmetto GBA (00885).

Revision Effective Date: 10/01/2005 LMRP converted to LCD and Policy Article

INDICATIONS AND LIMITATIONS OF COVERAGE:

Added: ICD-9 codes 707.02-707.05

ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY:

Added: ICD-9 codes 707.02-707.05

Revision Effective Date: 04/01/2003 HCPCS CODES AND MODIFIERS:

Added: EY modifier

INDICATIONS AND LIMITATIONS OF COVERAGE:

Adds standard language concerning coverage of items without a written order prior to delivery DOCUMENTATION REQUIREMENTS:

Adds standard language concerning use of EY modifier for items without a written order prior to delivery

The revision dates listed below are the dates the revisions were published and not necessarily the effective dates for the revisions.

07/01/2002 - Staging of pressure ulcers revised under Definition section. Changed ZX modifier to KX, including all references in policy.

03/01/1998 – HCPCS codes K0413, K0414, and K0454 crosswalked to E0371, E0372 and E0373.

06/01/1997 - In the Pressure Reducing Support Surfaces - Group 2 policy, the narrative for code K0413 has been revised and a new code has been added.

K0413 - Non-powered, advanced pressure- reducing overlay for mattress, standard mattress length and width

K0454 - Non-powered, advanced pressure- reducing mattress

The revision and addition are valid for dates of service on or after 9/1/97. Both codes are in the capped rental payment category.

The ZX modifier should be used for billing these codes only when the criteria for its use (as specified in the Documentation section of the Group 2 Support Surfaces policy) are met.

04/01/1996 – Two new codes have been established for Group 2 support surfaces: K0413 – Non-powered adjustable zone pressure-reducing air mattress overlay K0414 – Powered air overlay for mattress

Both codes are valid for dates of service on or after April 1, 1996. Both codes are in the capped rental category.

10/01/1995 - Alternating Pressure Pads and Mattresses policy was separated into three policies – Pressure Reducing Support Surfaces, Group 1, Group 2, and Group 3. Added HCPCS codes for Group 2 – E0193 and E1399. Revised entire policy for information specific to Group 2 support surfaces and added Statement of Ordering Physician-Group 2 Support Surfaces form.

12/01/1993 – Clerical corrections as follows: CMN for Group 2 corrected to 01 from 01.00; and HAO corrected to HA0 in Documentation section.

08/05/2011 - The Jurisdiction C contractor adopted a new business name. This LCD revision only includes the change from CIGNA Government Services to CGS Administrators, LLC. No coverage information was included in this revision and no provider action is needed regarding this revision.

Reason for Change Maintenance (annual review with new changes, formatting, etc.)