Local Coverage Article

Pressure Reducing Support Surfaces - Group 2 - Policy Article

A52490

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Article Information

General Information

Article ID
A52490
Original ICD-9 Article ID
A35422
A35357
A47114
A35350
Article Title
Pressure Reducing Support Surfaces - Group 2 - Policy Article
Article Type
Article
Original Effective Date
10/01/2015
Revision Effective Date
01/01/2020
Revision Ending Date
N/A
Retirement Date
N/A
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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.

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Article Guidance

Article Text

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES

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. Information provided in this policy article relates to determinations other than those based on Social Security Act Section 1862(a)(1)(A) provisions (i.e. “reasonable and necessary”).

Pressure-reducing support surfaces are covered under the Durable Medical Equipment benefit (Social Security Act Section 1861(s)(6)). In order for a beneficiary’s DME to be eligible for reimbursement, the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.

REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217)

Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The link will be located here once it is available.

Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.

If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD, it will be eligible for coverage.

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS

In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.

Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below.

MODIFIERS

KX, GA, AND GZ MODIFIERS

Suppliers must add a KX modifier to a code only if all of the criteria in the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD 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 Coverage Indications, Limitations 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 and the model name/number.

CODING GUIDELINES

Heavy duty and bariatric devices are included in the codes for pressure reducing support surfaces: E0193, E0277, E0371, E0372 and E0373.

Code E0277 describes a powered pressure reducing mattress (alternating pressure, low air loss, or powered flotation without low air loss) which is characterized by all of the following:

  1. An air pump or blower which provides either sequential inflation and deflation of the air cells or a low interface pressure throughout the mattress, and
  2. Inflated cell height of the air cells through which air is being circulated is 5 inches or greater, and
  3. Height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure mattresses), and air pressure provide adequate beneficiary lift, reduce pressure and prevent bottoming out, and
  4. A surface designed to reduce friction and shear, and
  5. Can be placed directly on a hospital bed frame.

Code E0193 describes a semi-electric or total electric hospital bed with a fully integrated powered pressure reducing mattress which has all the characteristics defined above.

Code E0371 describes an advanced nonpowered pressure-reducing mattress overlay which is characterized by all of the following:

  1. Height and design of individual cells which provide significantly more pressure reduction than a group 1 overlay and prevent bottoming out, and
  2. Total height of 3 inches or greater, and
  3. A surface designed to reduce friction and shear, and
  4. Documented evidence to substantiate that the product is effective for the treatment of conditions described by the coverage criteria for group 2 support surfaces.

Code E0372 describes a powered pressure reducing mattress overlay (low air loss, powered flotation without low air loss, or alternating pressure) which is characterized by all of the following:

  1. An air pump or blower which provides either sequential inflation and deflation of the air cells or a low interface pressure throughout the overlay, and
  2. Inflated cell height of the air cells through which air is being circulated is 3.5 inches or greater, and
  3. Height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure overlays), and air pressure to provide adequate beneficiary lift, reduce pressure and prevent bottoming out, and
  4. A surface designed to reduce friction and shear.

Code E0373 describes an advanced nonpowered pressure reducing mattress which is characterized by all of the following:

  1. Height and design of individual cells which provide significantly more pressure reduction than a group 1 mattress and prevent bottoming out, and
  2. Total height of 5 inches or greater, and
  3. A surface designed to reduce friction and shear, and
  4. Documented evidence to substantiate that the product is effective for the treatment of conditions described by the coverage criteria for group 2 support surfaces, and
  5. Can be placed directly on a hospital bed frame.

The only products that may be billed using codes E0371 or E0373 are those for which a written coding verification review (CVR) has been made by the Pricing, Data Analysis, and Coding (PDAC) contractor and subsequently published on the Product Classification List (PCL). Information concerning the documentation that must be submitted to the PDAC for a Coding Verification Request can be found on the PDAC web site or by contacting the PDAC. A PCL with products that have received a coding verification can be found on the PDAC web site. If a product is billed to Medicare using a HCPCS code that requires written CVR, but the product is not on the PCL for that particular HCPCS code, then the claim line will be denied as incorrect coding.

Group 2 support surfaces are coded based on the characteristics specified in the above definitions. Products which do not meet these definitional characteristics but meet the characteristics for another support surface grouping (i.e., Group 1 support surfaces) will be coded based on the characteristics specified in the Coding Guidelines section of the Group 1 Pressure Reducing Support Surfaces related Policy Article. Products which do not meet the characteristics specified in either the Group 1 or Group 2 Support Surfaces related Policy Article must be coded using code E1399.

Either alternating pressure mattresses or low air loss mattresses are coded using code E0277.

Products containing multiple components are categorized according to the clinically predominant component (usually the topmost layer of a multi-layer product). For example, a product with 3" powered air cells on top of a 3" foam base would be coded as a powered overlay (code E0181) not as a powered mattress (E0277).

Suppliers should contact the PDAC contractor for guidance on the correct coding of these items.

Coding Information

CPT/HCPCS Codes

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph

The presence of an ICD-10 code listed in this section is not sufficient by itself to assure coverage. Refer to the LCD section on “Coverage Indications, Limitations, and/or Medical Necessity” for other coverage criteria and payment information.

Group 1 Codes
CodeDescription
L89.100 Pressure ulcer of unspecified part of back, unstageable
L89.102 Pressure ulcer of unspecified part of back, stage 2
L89.103 Pressure ulcer of unspecified part of back, stage 3
L89.104 Pressure ulcer of unspecified part of back, stage 4
L89.110 Pressure ulcer of right upper back, unstageable
L89.112 Pressure ulcer of right upper back, stage 2
L89.113 Pressure ulcer of right upper back, stage 3
L89.114 Pressure ulcer of right upper back, stage 4
L89.120 Pressure ulcer of left upper back, unstageable
L89.122 Pressure ulcer of left upper back, stage 2
L89.123 Pressure ulcer of left upper back, stage 3
L89.124 Pressure ulcer of left upper back, stage 4
L89.130 Pressure ulcer of right lower back, unstageable
L89.132 Pressure ulcer of right lower back, stage 2
L89.133 Pressure ulcer of right lower back, stage 3
L89.134 Pressure ulcer of right lower back, stage 4
L89.140 Pressure ulcer of left lower back, unstageable
L89.142 Pressure ulcer of left lower back, stage 2
L89.143 Pressure ulcer of left lower back, stage 3
L89.144 Pressure ulcer of left lower back, stage 4
L89.150 Pressure ulcer of sacral region, unstageable
L89.152 Pressure ulcer of sacral region, stage 2
L89.153 Pressure ulcer of sacral region, stage 3
L89.154 Pressure ulcer of sacral region, stage 4
L89.200 Pressure ulcer of unspecified hip, unstageable
L89.202 Pressure ulcer of unspecified hip, stage 2
L89.203 Pressure ulcer of unspecified hip, stage 3
L89.204 Pressure ulcer of unspecified hip, stage 4
L89.210 Pressure ulcer of right hip, unstageable
L89.212 Pressure ulcer of right hip, stage 2
L89.213 Pressure ulcer of right hip, stage 3
L89.214 Pressure ulcer of right hip, stage 4
L89.220 Pressure ulcer of left hip, unstageable
L89.222 Pressure ulcer of left hip, stage 2
L89.223 Pressure ulcer of left hip, stage 3
L89.224 Pressure ulcer of left hip, stage 4
L89.300 Pressure ulcer of unspecified buttock, unstageable
L89.302 Pressure ulcer of unspecified buttock, stage 2
L89.303 Pressure ulcer of unspecified buttock, stage 3
L89.304 Pressure ulcer of unspecified buttock, stage 4
L89.310 Pressure ulcer of right buttock, unstageable
L89.312 Pressure ulcer of right buttock, stage 2
L89.313 Pressure ulcer of right buttock, stage 3
L89.314 Pressure ulcer of right buttock, stage 4
L89.320 Pressure ulcer of left buttock, unstageable
L89.322 Pressure ulcer of left buttock, stage 2
L89.323 Pressure ulcer of left buttock, stage 3
L89.324 Pressure ulcer of left buttock, stage 4
L89.42 Pressure ulcer of contiguous site of back, buttock and hip, stage 2
L89.43 Pressure ulcer of contiguous site of back, buttock and hip, stage 3
L89.44 Pressure ulcer of contiguous site of back, buttock and hip, stage 4
L89.45 Pressure ulcer of contiguous site of back, buttock and hip, unstageable

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

All ICD-10 codes that are not specified in the previous section.

Group 1 Codes

N/A

Additional ICD-10 Information

N/A

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

N/A

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 article, 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 article should be assumed to apply equally to all Revenue Codes.

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
01/01/2020 R7

Revision Effective Date: 01/01/2020
CODING GUIDELINES:
Added: “(CVR)” after reference to coding verification review
Added: “(PCL)” after reference to “Product Classification List”
Revised: Coding verification review information, to include incorrect coding denial language for products billed using HCPCS that require written coding verification review


03/18/2021: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2020 R6

Revision Effective Date: 01/01/2020
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217):
Added: Section and related information based on Final Rule 1713
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Covered” updated to “ICD-10 Codes that Support Medical Necessity”
ICD-10 CODES THAT DO NOT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Not Covered” updated to “ICD-10 Codes that DO NOT Support Medical Necessity”

02/27/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2019 R5

Revision History Effective Date: 01/01/2019
ICD-10 CODES THAT ARE COVERED:
Added: All diagnosis codes formerly listed in the LCD
ICD-10 CODES THAT ARE NOT COVERED:
Added: Notation excluding all unlisted diagnosis codes from coverage

02/28/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

05/25/2017 R4 Revision Effective Date: 05/25/2017
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: Modifier requirements
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements Language Article

07/01/2016 R3 Revision Effective Date: 07/01/2016
Removed: WOPD, this is in the document requirement section
07/01/2016 R2 Effective July 1, 2016 oversight for DME MAC Articles is the responsibility of CGS Administrators, LLC 18003 and 17013 and Noridian Healthcare Solutions, LLC 19003 and 16013. No other changes have been made to the Articles.
10/01/2015 R1 Revision Effective Date: 10/01/2014
CODING GUIDELINES:
Revised: E1399 Code Guidelines

Associated Documents

Related National Coverage Documents
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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03/12/2021 01/01/2020 - N/A Currently in Effect You are here
02/21/2020 01/01/2020 - N/A Superseded View
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Keywords

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