Group 1 Support Surfaces
A therapeutic support surface, according to the National Pressure Ulcer Advisory Panel, is a specialized device for pressure redistribution designed for management of tissue loads, microclimate, and/or other therapeutic functions. Pressure reducing support surfaces are specially designed to reduce or relieve pressure in order to prevent or heal pressure ulcers. A support surface is not a replacement for turning and positioning, but an adjunct to therapy.
There are several different categories of support surfaces.
1. Overlay: An additional support surface designed to be placed directly on top of an existing surface (mattress). The therapeutic component of the overlay could be foam, air or gel.
2. Mattress: A support surface designed to be placed directly on the existing bed frame to replace the standard mattress. Mattresses may be in the form of static air, alternating air, low air loss, or immersion. They could also be powered or non- powered. The bed frame must be a hospital bed in order to be reimbursed from Medicare.
3. Non-Powered: A support surface not requiring or using external sources of energy for operation
4. Powered: Any support surface requiring or using external sources of energy for operation.
Categories based upon reimbursement
There are 2 categories of support surfaces based upon reimbursement:
1. Prevention (Pressure Reduction):
· Products that reduce interface pressure to prevent pressure ulcers and treat partial thickness ulcers through Stage II. May also be used for comfort and pain management.
2. Therapeutic (Pressure Relief):
· Products that reduce interface pressure to treat full thickness pressure ulcers through Stage IV and myocutaneous flaps and grafts. May additionally be used for moisture and heat dissipation, comfort and pain management.
Note: According to Medicare, a Group 1 support surface is categorized as a prevention technology.
HCPCS codes for Group 1 support surfaces:
Below is a list of HCPCS codes for Group 1 support surfaces with product examples for each code:
· E0181 – Powered alternating pressure reducing mattress overlay/pad, with pump (includes heavy duty)
· E0182 – Pump for alternating pressure pad
· E0184 – Dry (foam) pressure mattress
· E0185 – Gel or gel-like pressure pad for mattress
· E0186 – Air pressure mattress
· E0187 – Water pressure mattress
· E0188 – Synthetic sheepskin pad
· E0189 – Lamb’s wool sheepskin pad
· E0196 – Gel pressure mattress
· E0197 – Air pressure pad for mattress
· E0198 – Water pressure pad for mattress
· E0199 – Dry (foam) pressure pad for mattress
In order to be categorized under a specific code, a product must meet the definition for that code as found in the Local Coverage Determination for Pressure-reducing Support Surfaces.
All therapeutic support surfaces must prevent bottoming out.
· Bottoming out is when the patient’s bony prominences sink into the therapeutic support surface such that they make contact with the underlying surface.
· To test for bottoming out, place an outstretched hand, palm up, between the undersurface of the overlay or mattress and the patient's bony prominence (coccyx or lateral trochanter). If you can readily palpate the bony prominence, the patient is bottoming out.
· The support surface should be tested for bottoming out with the patient in 3 different positions: 1) in supine with the head flat; 2) in supine with the head slightly elevated (no more than 30 degrees) and; 3) in side-lying.
Foam overlays or mattresses must have a waterproof cover to be reimbursed by Medicare
COVERAGE CRITERIA
To be eligible for a Group 1 support surface, the patient must meet criteria 1, 2 or 3 below:
1) Is completely immobile - patient cannot make changes in body position without assistance.
2) Has limited mobility - patient cannot independently make changes in body position significant enough to alleviate pressure
3) Has any stage pressure ulcer on the trunk or pelvis
If the patient meets criteria 2 or 3, he/she must also have 1 or more of the following:
a) Fecal or urinary incontinence
b) Altered sensory perception
c) Compromised circulatory status
d) Impaired nutritional status
If the patient meets criteria #3 above, the pressure ulcer must be on the trunk or pelvis. A patient with an ulcer only on the foot, ankle, elbow or head does not qualify for Group 1 support surface. A few examples of an ICD-9 Codes that support medical necessity are, but not limited to:
· 707.02 - Upper back, scapula
· 707.03 - Lower back, sacrum
· 707.04 - Hip
· 707.05 - Buttock
When the coverage criteria for a Group 1 overlay or mattress are not met, a claim will be denied as not medically necessary unless there is clear documentation to justify the medical necessity for the item in the individual case.
WHAT DOCUMENTATION IS REQUIRED FOR A GROUP 1?
· Dispensing Order or Verbal Order
o Description of the item
o Beneficiary’s name
o Prescribing Physician’s Name
o Date of order and start date, if different from date of order
o Physician’s signature (if written) or supplier signature (if verbal)
· Detailed Written Order
o Must be written PRIOR to delivery
o Includes: Beneficiary’s name, detailed description of type of support service, length of need, and start date, if different than date of order.
o Must be signed and dated by the treating physician prior to delivery
o Items delivered before a signed written order has been received must be submitted with an EY modifier added to the appropriate HCPCS code.
· Physician statement
o Must indicate which coverage criteria are met
o Must be completed, signed and dated by the treating physician
o Can be a supplier-generated form, but cannot be completed by the supplier or anyone with financial ties to the supplier
o Remember: this does not take the place of the beneficiary’s medical records
· Patient’s medical records
o Medical need for the support surface must be supported by information in the medical chart which should include a care plan (see below).
o This documentation should not be submitted with a claim but must be available upon request
What is a Care Plan?
A care plan must include each of the following elements as appropriate. The care plan must be documented in the patient’s medical record:
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. This should be at least weekly for a patient with a stage III or IV ulcer. Documentation in the medical record should include the size of the wound (length, width and depth)
3) A turning and positioning schedule
4) Appropriate wound care (for a Stage II, III, or IV ulcer).
5) Management of moisture and/or incontinence.
6) Nutritional assessment and intervention consistent with the overall plan of care.
The KX Modifier
Claims for Group 1 support surfaces that are billed without a KX modifier, will usually be denied as not medically necessary. However, suppliers may add a KX modifier to a claim only if the patient meets all of the necessary coverage criteria and the specified required documentation is available on file. If the patient does not meet the coverage criteria, the supplier may submit additional documentation to justify coverage, but must not use the KX modifier. If the documentation is not met, then a GA or GZ modifier needs to be properly executed. Appropriate use of the KX modifier is the responsibility of the supplier.
The supplier needs to maintain adequate communication on an ongoing basis with the treating clinician in order to accurately determine if the patient continues to meet the coverage criteria for a Group 1 support surface.
· Continued verification of medical necessity is required as long as the support surface is billed
· Medical documentation should not be submitted with a claim
Payment Category
Support surfaces are capped rental items. This means that the supplier is paid a monthly fee schedule and retains ownership of the support surface for the first 13 months of use by a patient, after which ownership transfers to the patient. Once the patient assumes ownership, Medicare will reimburse for services or repairs only if there is correct documentation and if the patient still meets the coverage criteria for a Group 1 support surface. If the patient no longer meets the coverage criteria for the product, then he/she must assume responsibility for the cost of repair or replacement.
A new order for a new 13-month rental period is needed if there is:
§ A break in service that is greater than 60 days
§ A change in medical condition that requires the patient to switch from a Group 1 overlay to a Group 1 mattress or vice versa.
§ A change in medical condition that requires the patient to switch from a Group 1 overlay or mattress to a Group 2 or Group 3 product.
§ New medical necessity information including statement describing the reason for the interruption.
A new 13 month rental period is not initiated if:
§ The break in service is < 60 days
§ This is actually considered a break in billing which normally means to pick up where the beneficiary left off.
§ The change in medical condition requires a switch from one kind of Group 1 overlay to another kind of Group 1 overlay or from one kind of Group 1 mattress to another kind of Group 1 mattress.
Definition of a Pressure Ulcer
(from the National Pressure Ulcer Advisory Panel)
A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated.
Pressure Ulcer Stages
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. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.
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. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. Stage I may indicate "at risk" persons (a heralding sign of risk)
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. Presents as a shiny or dry shallow ulcer without slough or bruising. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Bruising indicates suspected deep tissue injury.
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. The depth of a Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Stage III pressure ulcers. Bone and tendon is not visible or directly palpable.
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. The depth of a Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.
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. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed.
Please refer to The National Pressure Ulcer Advisory Panel website at www.npuap.org for more information on pressure ulcers.