NEW COVERAGE CRITERIA FOR SUPPORT SURFACES FROM MEDICARE
Code E0277 describes a powered pressure reducing mattress ( alternating or 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 mattress ), and air pressure provide adequate patient 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.
The staging of pressure ulcers used in this policy is as follows:
Stage I - nonblanchable erythema of intact skin.
Stage II - Partial thickness skin loss involving epidermis and/or dermis.
Stage III - full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
Stage IV - full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures.
Bottoming out is the finding that an outstretched hand, placed palm up between the undersurface of the mattress and the patient's bony prominence ( coccyx or lateral trochanter), can readily palpate 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 sidelying position.
Group 2 - Pressure Reducing Support Surfaces
- Powered air flotation bed (low air loss therapy) - Alternating pressure mattress - Durable medical equipment, miscellaneous
COVERAGE CRITERIA
A group 2 mattress overlay is covered if the patient meets:
a) Criterion 1 and 2, and 3, or
b) Criterion 4, or
c) Criteria 5 and 6
1) Multiple stage II pressure ulcers located on the trunk or pelvis.
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.
3) The ulcers have worsened or remained the same over the past month.
4) Large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis.
5) Recent mycutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis (surgery within the past 60 days). 6) The patient has been on a group 2 or 3 support surface prior to discharge from a hospital or nursing facility.
The comprehensive ulcer treatment described in #2 above should generally include:
1) Education of the patient and caregiver on the prevention and/or management of pressure ulcers.
2) 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).
3) Appropriate turning and positioning.
4) Appropriate wound care (for stage II, III or IV ulcer).
5) Appropriate management of moisture/incontinence.
6) 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 ".
When a group 2 surface is covered following a mycutaneous flap or skin graft, coverage generally is limited to 60 days from the date of surgery.
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 medically necessary for wound management. 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.
A support surface which does not meet the characteristics specified in the Definition section of the support surface policies will usually be denied as not medically necessary.
Products containing multiple components are categorized according to the clinically predominant component ( usually the topmost layer of a multilayer product). For example, a product with 3" powered air cells on top of a 3" foam base would be coded as a powered overlay not as a powered mattress.
DOCUMENTATION
An order for the mattress or bed which is signed and dated by the ordering physician must be kept on file by the supplier. The written order must be obtained prior to the delivery of the item.
The supplier must obtain information concerning which, if any, of criteria 1 - 6 listed in the coverage and payment rules section of this policy the patient meets in a signed and dated statement from the physician. 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.
EFFECTIVE DATE
Claims received by the DMERC on or after January 1, 1996
