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Pressure Reducing Support Surfaces

Revised: 01-29-2013

  • Overview
  • Eligible Providers
  • Eligible Recipients
  • Covered Services
  • Noncovered Services
  • Authorizations
  • Billing
  • Legal References
  • Overview

    Pressure reducing support surfaces are used to prevent and treat pressure sores/decubitus ulcers.

    Eligible Providers

    The following providers may provide pressure reducing support surfaces:

  • • Federally Qualified Health Center
  • • Home health agencies
  • • Indian Health Services
  • • Medical suppliers
  • • Pharmacies
  • • Rural Health Clinic
  • TPL and Medicare

    Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare in order to assist recipients for whom MHCP is not the primary payer.

    Eligible Recipients

    Pressure reducing support surfaces are covered for eligible recipients who do not live in nursing facilities.

    Covered Services

    Group 1

    Codes: A4640, E0181 – E0189, E0196 – E0199
    Group 1 may be purchased or rented. Authorization is not required.

    Criteria for Group 1
    Provider’s documentation must indicate one of the following:

  • • Recipient is completely immobile
  • • Recipient cannot independently make changes in body position significant enough to alleviate pressure and has one of the following conditions:
  • • Current pressure ulcer on the trunk or pelvis
  • • History of pressure ulcers on the trunk or pelvis
  • • Impaired nutritional status
  • • Fecal or urinary incontinence
  • • Altered sensory perception
  • • Compromised circulatory status
  • Group 2

    Codes: E0193, E0277, E0371, E0372, E0373
    Authorization is always required.

    Group 2 is rental only and is considered purchased after 13 months of rental. Authorization is always required. Repairs to recipient-owned Group 2 surfaces will be considered only if the recipient currently has pressure ulcers or otherwise meets criteria for a Group 2 surface, or if the repair is less costly than purchase of a Group 1 surface.

    Criteria for Group 2
    The recipient’s attending physician must order based on a comprehensive assessment and evaluation of the recipient after conservative treatment was tried without success. The physician must direct the home treatment regimen, and reevaluate and re-certify the need for the bed on a monthly basis. Must have healing as the goal of treatment and any one of the following:

  • • Multiple stage II pressure ulcers located on the trunk or pelvis; recipient has been on a comprehensive ulcer treatment for at least the past month and recipient has used lower level support surface and ulcers have worsened
  • • Large stage III or IV pressure ulcer(s) on the trunk or pelvis and the recipient cannot be positioned off the ulcer areas
  • • Recent mycutaneous flap or skin graft for pressure ulcer on the trunk or pelvis and they have been on a pressure reducing support surface immediately prior to discharge from a hospital or LTC facility (surgery within past 60 days)
  • • Recipient has been on a group 2 or 3 support surface immediately prior to a recent discharge from a hospital or LTC facility (discharge within past 30 days)
  • • After 6 months on a Group 2 support surface and there has been no improvement in the recipient's condition, alternative treatments must be considered before additional monthly rental will be authorized
  • If the recipient is found to have a nutritional deficit, the recipient may be eligible for enteral nutritional support. Refer to Nutritional Products and Related Supplies policy.

    Group 3 Air Fluidized Beds

    Codes: E0194
    Authorization is always required.

    Group 3 is rental only and is considered purchased after 13 months of rental. Repairs to recipient-owned Group 3 surfaces will be considered only if the recipient currently meets criteria for coverage of a Group 2 or Group 3 surface, or if the repair is less costly than purchase of a Group 1 surface.

    Criteria for Group 3
    The recipient’s attending physician must order the surface based on a comprehensive assessment and evaluation of the recipient after conservative treatment was tried without success. The physician must direct the home treatment regimen, and reevaluate and re-certify the need for the bed on a monthly basis. Must have healing as the goal of treatment and all of the following:

  • • Stage III or IV pressure sore on the trunk or pelvis
  • • All other alternative equipment has been considered and ruled out
  • • Recipient is bedridden or chair bound as a result of severely limited mobility
  • • After 6 months on a group 3 support surface and there has been no improvement in the recipient’s condition, alternative treatments must be considered before additional rental will be authorized (e.g., negative pressure wound therapy)
  • If the recipient is found to have a nutritional deficit, the recipient may be eligible for enteral nutritional support. Refer to Nutritional Products and Related Supplies policy.

    Noncovered Services

    Group 2 or Group 3 Surfaces

  • • Not reviewed by Medicare’s Pricing, Data Analysis and Coding (PDAC) contractor
  • • Reviewed by the PDAC contractor and found not to meet the definition of a Group 2 or Group 3 surface
  • • For recipients without current pressure ulcers
  • Group 3 Surfaces for Recipients

  • • With co-existing pulmonary disease
  • • That require treatment with wet soaks or moist wound dressings not protected with an impervious covering unless the recipient is undergoing aggressive treatment in a wound clinic and is showing measurable improvement
  • Authorizations

    Authorization is required for all Group 2 and Group 3 surfaces.

    Authorization Requests

    Submit authorization request through MN–ITS (authorization request 278). Fax the MN–ITS response with the completed Specialized Wound Therapy Authorization Form (DHS-4045), required documentation and physician’s order to the authorization medical review agent. Document the MN–ITS Authorization Request number assigned on every page of each document.

    For paper authorization, fax or mail the authorization medical review agent the completed MHCP Authorization Form (DHS-4695), the completed Specialized Wound Therapy Authorization Form (DHS-4045), required documentation, and physician’s orders.

    Submit the comprehensive treatment plan that must include:

  • • Education of the patient and caregiver on prevention and management of pressure ulcers
  • • History of conservative treatment
  • • Regular assessment by a physician or other licensed practitioner
  • • Appropriate turning and positioning
  • • Appropriate management of moisture/incontinence
  • • Nutritional assessment and intervention
  • • Necessary medications when infection is present
  • • Treatment plan for care of the wound
  • Billing

    When billing with an approved authorization:

  • • Use MN–ITS 837P Professional
  • • Report the ordering provider in the Other Provider Types section of the MN–ITS Interactive claim
  • • Use the correct HCPCS code and the modifiers as noted on the authorization
  • Legal References

    MS 256B.0625, subd.31
    Minnesota Rules 9505.0310

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