NONMEDICAL 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.
A foam overlay or mattress which does not have a waterproof cover is not considered durable and will be denied as non-covered.
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 required Face-to-Face Encounter and Written Order Prior to Delivery List is available here.
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.
RELATED CLINICAL INFORMATION
A beneficiary needing a pressure reducing support surface should have a care plan which has been established by the beneficiary's treating practitioner or home care nurse, which is documented in the beneficiary's medical records, and which generally should include the following:
- Education of the beneficiary and caregiver on the prevention and/or management of pressure ulcers
- Regular assessment by a nurse, treating practitioner, or other licensed healthcare practitioner
- Appropriate turning and positioning
- Appropriate wound care (for a stage 2, 3 or 4 ulcer)
- Appropriate management of moisture/incontinence
- Nutritional assessment and intervention consistent with the overall plan of care
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 a narrative description of the item, the manufacturer, the product name/number, and information justifying the medical necessity for the item.
CODING GUIDELINES
Codes E0185, E0197, E0198 and E0199 termed "pressure pad for mattress" describe nonpowered pressure reducing mattress overlays. These devices are designed to be placed on top of a standard hospital or home mattress.
A gel/gel-like mattress overlay (E0185) is characterized by a gel or gel-like layer with a height of 2 inches or greater.
An air mattress overlay (E0197) is characterized by interconnected air cells having a cell height of 3 inches or greater that are inflated with an air pump.
A water mattress overlay (E0198) is characterized by a filled height of 3 inches or greater.
A foam mattress overlay (E0199) is characterized by all of the following:
- Base thickness of 2" or greater and peak height of 3" or greater if it is a convoluted overlay (e.g., eggcrate) or an overall height of at least 3 inches if it is a non-convoluted overlay, and
- Foam with a density and other qualities that provide adequate pressure reduction, and
- Durable, waterproof cover
Codes E0184, E0186, E0187 and E0196 describe nonpowered pressure reducing mattresses.
A foam mattress (E0184) is characterized by all of the following:
- Foam height of 5 inches or greater, and
- Foam with a density and other qualities that provide adequate pressure reduction, and
- Durable, waterproof cover, and
- Can be placed directly on a hospital bed frame
An air, water or gel mattress (E0186, E0187, E0196) is characterized by all of the following:
- Height of 5 inches or greater of the air, water, or gel layer (respectively), and
- Durable, waterproof cover, and
- Can be placed directly on a hospital bed frame
Codes E0181, E0182, and A4640 describe powered pressure reducing mattress overlay systems (alternating pressure or low air loss). They are characterized by all of the following:
- An air pump or blower which provides either sequential inflation and deflation of air cells or a low interface pressure throughout the overlay, and
- Inflated cell height of the air cells through which air is being circulated is 2.5 inches or greater, and
- Height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure overlays), and air pressure provide adequate patient lift, reduce pressure and prevent bottoming out
A foam overlay or mattress which does not have a waterproof cover should be coded using A9270. Other Group 1 support surfaces which do not meet the characteristics specified in this section should be billed using code E1399.
Alternating pressure mattress overlays or low air loss mattress overlays are coded using codes E0181, E0182, and A4640.
Code A4640 or E0182 should only be billed when they are provided as replacement components for a beneficiary-owned E0181 mattress overlay system.
A Column II code is included in the allowance for the corresponding Column I code when provided at the same time.
| Column I |
Column II |
| E0181 |
A4640, E0182 |
Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.
