LCD/NCD Portal

L11564 PRESSURE REDUCING SUPPORT SURFACES - GROUP 2

 

Region IV

DME Region LCD Covers

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.

 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:

o Criterion 1 and 2 and 3

o Criterion 4

o Criterion 5 and 6.

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

 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

 The ulcers have worsened or remained the same over the past month

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

 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)

 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:

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 (usually at least weekly for a patient with a stage III or IV ulcer).

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.

• 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.

o 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.

o 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.

o (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:

o Other aspects of the care plan are being modified to promote healing.

o 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.

o 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.

o 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

 

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

 

 

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 made available upon request.

o 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.

o 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.

o This statement must be supported by information in the patient's medical record which would be available upon request.

o Do not submit this form unless specifically requested.

 

• KX, GA, AND GZ MODIFIERS

o 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.

o 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.

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

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

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

Appendices

• 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.

• 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.

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.

 

 

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

 

A35357 - Pressure Reducing Support Surfaces - Group 2 - Policy Article - Effective January 2011

 

Statement of Ordering Physician Group 2 Support Services

 

Local Coverage Determination (LCD) for Pressure Reducing Support Surfaces - Group 2 (L11564)