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 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.
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:
- 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
- Inflated cell height of the air cells through which air is being circulated is 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 mattresses), and air pressure provide adequate beneficiary lift, reduce pressure and prevent bottoming out, and
- A surface designed to reduce friction and shear, and
- 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:
- Height and design of individual cells which provide significantly more pressure reduction than a group 1 overlay and prevent bottoming out, and
- Total height of 3 inches or greater, and
- A surface designed to reduce friction and shear, and
- 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:
- 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
- Inflated cell height of the air cells through which air is being circulated is 3.5 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 to provide adequate beneficiary lift, reduce pressure and prevent bottoming out, and
- 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:
- Height and design of individual cells which provide significantly more pressure reduction than a group 1 mattress and prevent bottoming out, and
- Total height of 5 inches or greater, and
- A surface designed to reduce friction and shear, and
- 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
- 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.
