LCD/NCD Portal

L11565 PRESSURE REDUCING SUPPORT SURFACES - GROUP 3

 

Region IV

DME

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.

• An air-fluidized bed is covered only if all of the following criteria are met:

o The patient has a stage III (full thickness tissue loss) or stage IV (deep tissue destruction) pressure ulcer (ICD-9 codes 707.23 - 707.24).

o The patient is bedridden or chair bound as a result of severely limited mobility.

o In the absence of an air-fluidized bed, the patient would require institutionalization.

o The air-fluidized bed is ordered in writing by the patient’s attending physician based upon a comprehensive assessment and evaluation of the patient after completion of a course of conservative treatment designed to optimize conditions that promote wound healing.

 The evaluation generally must be performed within one month prior to initiation of therapy with the air-fluidized bed.

o The course of conservative treatment must have been at least one month in duration without progression toward wound healing.

 This month of prerequisite conservative treatment may include some period in an institution as long as there is documentation available to verify that the necessary conservative treatment was rendered.

 Conservative treatment must include:

• Frequent repositioning of the patient with particular attention to relief of pressure over bony prominences (usually every 2 hours); and

• Use of a Group 2 support surface to reduce pressure and shear forces on healing ulcers and to prevent new ulcer formation; and

• Necessary treatment to resolve any wound infection; and

• Optimization of nutrition status to promote wound healing; and

• Debridement by any means, including wet-to-dry gauze dressings, to remove devitalized tissue from the wound bed; and

• Maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings protected by an occlusive covering, while the wound heals.

 In addition, conservative treatment should generally include:

• Education of the patient and caregiver on the prevention and management of pressure ulcers; and

• Assessment by a physician, nurse, or other licensed healthcare practitioner at least weekly, and

• Appropriate management of moisture/incontinence.

• Wet-to-dry dressings when used for debridement do not require an occlusive dressing.

o Use of wet-to-dry dressings for wound debridement, begun during the period of conservative treatment and which continue beyond 30 days will not preclude coverage of an air-fluidized bed.

o Should additional debridement again become necessary while a patient is using an air-fluidized bed (after the first 30-day course of conservative treatment) that will not cause the air-fluidized bed to be denied.

• A trained adult caregiver is available to assist the patient with activities of daily living, fluid balance, dry skin care, repositioning, recognition and management of altered mental status, dietary needs, prescribed treatments, and management and support of the air-fluidized bed system and its problems such as leakage.

• A physician directs the home treatment regimen, and reevaluates and recertifies the need for the air-fluidized bed on a monthly basis.

• All other alternative equipment has been considered and ruled out.

• An air-fluidized bed will be denied as not reasonable and necessary under any of the following circumstances:

o The patient has coexisting pulmonary disease (the lack of firm back support makes coughing ineffective and dry air inhalation thickens pulmonary secretions)

o The patient requires treatment with wet soaks or moist wound dressings that are not protected with an impervious covering such as plastic wrap or other occlusive material

o The caregiver is unwilling or unable to provide the type of care required by the patient on an air-fluidized bed

o Structural support is inadequate to support the weight of the air-fluidized bed system (it generally weighs 1600 pounds or more)

o Electrical system is insufficient for the anticipated increase in energy consumption; or

o Other known contraindications exist.

• Payment is not included for the caregiver or for architectural adjustments such as electrical or structural improvement.

• The continued coverage of an air-fluidized bed as reasonable and necessary must be documented by the treating physician every month.

o Continued use of an air fluidized bed is covered until the ulcer is healed or, if healing does not continue, there is documentation to show that:

 other aspects of the care plan are being modified to promote healing, or

 The use of the bed is reasonable and necessary for wound management.

• If the stated coverage criteria for an air-fluidized bed are not met, the claim 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 MODIFIER:

 

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:

 

E0194 AIR FLUIDIZED BED

 

ICD-9 Codes that Support Medical Necessity

 

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

 

707.23 - 707.24

PRESSURE ULCER, STAGE III - PRESSURE ULCER, STAGE IV

 

 

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.

o 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.

• On a monthly basis, the treating physician must document the need for the equipment with a written statement specifying:

o The size of the ulcer

o If the ulcer is not healing, what other aspects of the care plan are being modified to promote healing

o Continued use of the bed is reasonable and necessary for wound management.

• This monthly physician statement must be kept on file by the supplier and be available for inspection upon request.

 

• KX, GA, and GZ MODIFIERS:

o Suppliers must add a KX modifier to E0194 on the initial claim 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 retained in the supplier’s files and available to the DME MAC upon request.

o For each subsequent month’s claim use a KX modifier only if the physician’s monthly certification indicates that continued use is necessary.

 Discontinue use of the KX modifier if the coverage criteria are not met or use is discontinued.

o In all of the situations above describing use of the KX modifier, if all of the specific coverage criteria 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 Claims lines billed with codes without a KX, GA or GZ modifier will be rejected as missing information.

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.

 

 

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

 

A37055 - Pressure Reducing Support Surfaces - Group 3- Policy Article - Effective January 2011

 

Local Coverage Determination (LCD) for Pressure Reducing Support Surfaces - Group 3 (L11565)