Tuesday, February 21, 2017

CPT A9270, E1399 - Pressure reducing support surfaces

HCPCS CODES:


Group 1 Codes:

A4640 REPLACEMENT PAD FOR USE WITH MEDICALLY NECESSARY ALTERNATING PRESSURE PAD OWNED BY PATIENT

A9270 NON-COVERED ITEM OR SERVICE

E0181 POWERED PRESSURE REDUCING MATTRESS OVERLAY/PAD, ALTERNATING, WITH PUMP, INCLUDES HEAVY DUTY

E0182 PUMP FOR ALTERNATING PRESSURE PAD, FOR REPLACEMENT ONLY

E0184 DRY PRESSURE MATTRESS

E0185 GEL OR GEL-LIKE PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

E0186 AIR PRESSURE MATTRESS

E0187 WATER PRESSURE MATTRESS

E0188 SYNTHETIC SHEEPSKIN PAD

E0189 LAMBSWOOL SHEEPSKIN PAD, ANY SIZE

E0196 GEL PRESSURE MATTRESS

E0197 AIR PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

E0198 WATER PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

E0199 DRY PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

E1399 DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS


Elevating/stair climbing power wheelchairs are class III devices. The DMERCs have been instructed in transmittal 35, dated December 24, 2003, that claims for the base power wheelchair portion of this device are to be billed using HCPCS code K0011 (programmable power wheelchair base) with modifier KF for claims received on or after April 1, 2004, with dates of service on or after January 1, 2004. For claims with dates of service on or after January 1, 2004, the elevation feature for this device should be billed using HCPCS code E2300 and the stair climbing feature for this device should be billed using HCPCS code A9270.

Regional Home Health Intermediaries (RHHIs) will not be able to implement the KF modifier until January 1, 2005. Therefore, for claims with dates of service prior to January 1, 2005, RHHIs should advise their HHAs that claims for the base power wheelchair portion of stair climbing wheelchairs must be submitted with HCPCS code E1399. The fee schedule amounts for K0011 with and without the KF modifier appear on the fee schedule file referenced at www.cms.hhs.gov/providers/pufdownload/default.asp#dme. For claims with dates of service prior to January 1, 2005, RHHIs should pay claims for stair climbing wheelchair bases billed with code E1399 using the fee schedule amounts for K0011 with the KF modifier. All other claims for programmable power wheelchair bases should be paid using the fee schedule amounts for K0011 without the KF modifier.


Effective for claims with dates of service on or after January 1, 2005, HHAs must submit modifier KF along with the applicable HCPCS code for all DME items classified by the FDA as class III devices.


Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity

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. For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.

Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare Fee For Service (FFS) program. When a beneficiary receiving a DMEPOS item from another payer (including Medicare Advantage plans) becomes eligible for the Medicare FFS program, Medicare will pay for continued use of the DMEPOS item only if all Medicare coverage, coding and documentation requirements are met. Additional documentation to support that the item is reasonable and necessary, may be required upon request of the DME MAC.

While this Standard Documentation language makes reference to “Affordable Care Act Section 6407 (ACA 6407) requirements”, technically these requirements are found in the Social Security Act Section 1843(a)(11)(B) and its implementing regulation at 42 CFR 410.38. The CMS regulation contains the details for the face-to-face examination, written order prior to delivery and the list of items subject to these requirements.

For an item to be covered by Medicare, a detailed written order (DWO) must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed DWO, the item will be denied as not reasonable and necessary.

For some items in this policy to be covered by Medicare, a written order is required to be in the supplier’s file prior to delivery of the specified item(s). There are two differing order requirements that may apply depending upon the specific item prescribed:
The Affordable Care Act Section 6407 (ACA 6407) specifies the five elements that must be contained in this written order. For purposes of this policy, this order is termed the 5-element order (5EO).

A written order prior to delivery (WOPD) that meets all of the requirements of a standard detailed written order (DWO).


If the supplier delivers an item addressed in this policy without first receiving the completed order, the item will be denied. Refer to the DOCUMENTATION REQUIREMENTS section of this LCD and/or to the NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section of the related Policy Article for information about these prescription requirements and the type of denial that will result from non-compliance.

A Group 1 mattress overlay or mattress (E0181-E0189, E0196-E0199, and A4640) is covered if one of the following three criteria are met:
The beneficiary is completely immobile - i.e., beneficiary cannot make changes in body position without assistance, or

The beneficiary has limited mobility - i.e., beneficiary cannot independently make changes in body position significant enough to alleviate pressure and at least one of conditions A-D below, or

The beneficiary has any stage pressure ulcer on the trunk or pelvis and at least one of conditions A-D below.
Conditions for criteria 2 and 3 (in each case the medical record must document the severity of the condition sufficiently to demonstrate the medical necessity for a pressure reducing support surface):

Impaired nutritional status

Fecal or urinary incontinence

Altered sensory perception

Compromised circulatory status

When the coverage criteria for a Group 1 mattress overlay or mattress are not met, the claim will be denied as not reasonable and necessary.

The support surface provided for the beneficiary should be one in which the beneficiary does not "bottom out". Bottoming out is the finding that an outstretched hand, placed palm up between the undersurface of the mattress overlay or mattress and the beneficiary's bony prominence (coccyx or lateral trochanter), can readily palpate the bony prominence. This bottoming out criterion should be tested with the beneficiary 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 side-lying position.

A support surface which does not meet the characteristics specified in the Coding Guidelines section of the Policy Article will be denied as not reasonable and necessary.

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

N/A

CPT/HCPCS Codes

Group 1 Paragraph: The appearance of a code in this section does not necessarily indicate coverage.

HCPCS MODIFIERS:

EY – No physician or other licensed health care provider order for this item or service

GA – Waiver of liability statement issued as required by payer policy, individual case

GZ – Item or service expected to be denied as not reasonable and necessary

KX - Requirements specified in the medical policy have been met




Coverage Indications, Limitations, and/or Medical Necessity - Group 2

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. For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.

Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare Fee For Service (FFS) program. When a beneficiary receiving a DMEPOS item from another payer (including Medicare Advantage plans) becomes eligible for the Medicare FFS program, Medicare will pay for continued use of the DMEPOS item only if all Medicare coverage, coding and documentation requirements are met. Additional documentation to support that the item is reasonable and necessary, may be required upon request of the DME MAC.

For an item to be covered by Medicare, a detailed written order (DWO) must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed DWO, the item will be denied as not reasonable and necessary.

A group 2 support surface is covered if the beneficiary meets at least one of the following three Criteria (1, 2 or 3):
The beneficiary has multiple stage II pressure ulcers located on the trunk or pelvis (described by the diagnosis codes listed in the table below) which have failed to improve over the past month, during which time the beneficiary has been on a comprehensive ulcer treatment program including each of the following:
Use of an appropriate group 1 support surface, and
Regular assessment by a nurse, physician, or other licensed healthcare practitioner, and
Appropriate turning and positioning, and
Appropriate wound care, and
Appropriate management of moisture/incontinence, and
Nutritional assessment and intervention consistent with the overall plan of care

The beneficiary has large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis (described by the diagnosis codes listed in the table below),

The beneficiary had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days (described by the diagnosis codes listed in the table below), and has been on a group 2 or 3 support surface immediately prior to discharge from a hospital or nursing facility within the past 30 days
If the beneficiary 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 beneficiary should be one in which the beneficiary does not "bottom out" (see Appendices section).

When a group 2 surface is covered following a myocutaneous flap or skin graft, coverage generally is limited to 60 days from the date of surgery.

When the stated coverage criteria for a group 2 mattress or bed are not met, a claim will be denied as not reasonable and necessary.

A support surface which does not meet the characteristics specified in the Coding Guidelines section of the Pressure Reducing Support Surfaces – Group 2 Policy Article will be denied as not reasonable and necessary. (See Coding Guidelines and Documentation sections concerning billing of E1399.)

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 reasonable and necessary for wound management.

Appropriate use of the KX modifier (see Documentation section) is the responsibility of the supplier. The supplier should maintain adequate communication on an ongoing basis with the clinician providing the wound care in order to accurately determine that use of the KX modifier still reflects the clinical conditions which meet the criteria for coverage of a group 2 support surface, and that adequate documentation exists in the medical record reflecting these conditions. Such documentation should not be submitted with a claim but should be available upon request.



HCPCS MODIFIERS:

EY – No physician or other licensed health care provider order for this item or service
GA – Waiver of liability statement issued, as required by payer policy, individual case
GZ – Item or service expected to be denied as not reasonable and necessary
KX - Requirements specified in the medical policy have been met

HCPCS CODES:


Group 1 Codes:

E0193 POWERED AIR FLOTATION BED (LOW AIR LOSS THERAPY)
E0277 POWERED PRESSURE-REDUCING AIR MATTRESS
E0371 NONPOWERED ADVANCED PRESSURE REDUCING OVERLAY FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH
E0372 POWERED AIR OVERLAY FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH
E0373 NONPOWERED ADVANCED PRESSURE REDUCING MATTRESS
E1399 DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS


Billing Guidelines with Modifiers


C. Use of the GA, GY, and GZ Modifiers for Items and Supplies Billed to DMERCs.--The GY modifier must be used when suppliers want to indicate that the item or supply is statutorily noncovered (as defined in the PIM Chapter 1, §2.3.3.B) or is not a Medicare benefit (as defined in the PIM, Chapter 1, §2.3.3.A).

The GZ modifier must be used when suppliers want to indicate that they expect that Medicare will deny an item or supply as not reasonable and necessary and they have not had an Advance Beneficiary Notification (ABN) signed by the beneficiary.

The GA modifier must be used when suppliers want to indicate that they expect that Medicare will deny an item or supply as not reasonable and necessary and they do have on file an ABN signed by the beneficiary.

The GY and GZ modifiers should be used with the specific, appropriate HCPCS code when one is available. In cases where there is no specific procedure code to describe items or supplies, an NOC must be used with either the GY or GZ modifiers.

D. Use of the A9270.--Effective January 1, 2002, the A9270, Non-covered item or service, under no circumstances will be accepted for services or items billed to local carriers. However, in cases where there is no specific procedure code for an item or supply and no appropriate NOC code available, the A9270 must continue to be used by suppliers to bill DMERCS for statutorily non-covered items and items that do not meet the definition of a Medicare benefit.

E. Claims Processing Instructions.--At carrier and DMERC discretion, claims submitted using the GY modifier may be auto-denied. If the GZ and GA modifiers are submitted for the same item or service, treat the item or service as having an invalid modifier and therefore unprocessable.


ICD-10 Codes that Support Medical Necessity


ICD-10 CODE DESCRIPTION

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
N/A

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