Pressure Reducing Support Surfaces

Revised: July 24, 2026

· Overview

· Eligible Providers

· TPL and Medicare

· Eligible Members

· Covered Services

· Group 1 Pressure Reducing Support Surfaces

· Group 2 Pressure Reducing Support Surfaces

· Group 3 Pressure Reducing Support Surfaces

· Noncovered Services

· Authorizations

· Billing

· Legal References

Overview

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

Eligible Providers

The following 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 to assist members for whom Minnesota Health Care Programs (MHCP) is not the primary payer.

MHCP quantity limits and thresholds apply to all members unless only Medicare coinsurance or deductible is requested. Refer to the Medicare and Other Insurance section of the MHCP Provider Manual for more information.

Eligible Members

Pressure reducing support surfaces are covered for eligible Medical Assistance and MinnesotaCare members who require devices to prevent or treat pressure sores or decubitus ulcers.

Covered Services

Codes: A4640, E0181-E0189, E0193, E0194, E0196-E0199, E0277, E0371-E0373

MHCP covers the following equipment:

· Powered pressure reducing mattress overlays and pads (E0181)

· Powered pressure reducing underlays (E0183)

· Dry pressure mattresses (E0184)

· Air pressure mattresses (E0186)

· Water pressure mattresses (E0187)

· Powered air flotation beds (E0193)

· Air fluidized beds (E0194)

· Gel pressure mattresses (E0196)

· Powered pressure reducing air mattresses (E0277)

· Nonpowered advanced pressure reducing overlays (E0371)

· Powered air overlays (E0372)

· Nonpowered advanced pressure reducing mattresses (E0373)

· Supplies and replacement parts, including:

· Heel or elbow protectors (E0191)

· Replacement pumps (E0182) and pads (A4640) for alternating pressure pads

· Gel or gel-like pressure pads (E0185)

· Synthetic sheepskin pads (E0188)

· Lambswool sheepskin pads (E0189)

· Air pressure pads (E0197)

· Water pressure pads (E0198)

· Dry pressure pads (E0199)

Pressure reducing support surfaces are included in the per diem for members living in a nursing facility. Group 1 pressure reducing support surfaces are included in the per diem for members living in an intermediate care facility for people with developmental disabilities (ICF/DD). Group 2 and 3 pressure reducing support surfaces, including powered air flotation beds, air fluidized beds, powered pressure reducing air mattresses, powered air overlays, and nonpowered advanced pressure reducing overlays and mattresses, are not included in the ICF/DD per diem.

Review the following groups of pressure reducing support surfaces for specific coverage criteria and authorization requirements.

Group 1 Pressure Reducing Support Surfaces
Codes: A4640, E0181-E0189, E0196-E0199
Group 1 pressure reducing support surfaces are covered if one of the following criteria is met:

· The member is completely immobile; or

· The member 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; or

· History of pressure ulcers on the trunk or pelvis; or

· Impaired nutritional status; or

· Fecal or urinary incontinence; or

· Altered sensory perception; or

· Compromised circulatory status.

Group 1 pressure reducing support surfaces include powered pressure reducing mattresses and overlays (E0181), powered pressure reducing underlays (E0183), pressure mattresses (E0184, E0186, E0187), sheepskin pads (E0188, E0189), and replacement alternating pressure pumps (E0182) and pads (A4640).

Group 1 pressure reducing support surfaces may be purchased or rented. Authorization is not required, except for excess quantities.

Replacement pumps (E0182) and pads (A4640) are covered for member-owned alternating pressure pads when the original item no longer functions. Document in the medical record that the original item is no longer functional.

Group 2 Pressure Reducing Support Surfaces
Codes: E0193, E0277, E0371-E0373
Group 2 pressure reducing support surfaces are covered with authorization if one of the following criteria is met:

· The member has multiple stage II pressure ulcers located on the trunk or pelvis, has been on a comprehensive ulcer treatment for at least the past month, and has used lower-level support surface but ulcers have worsened; or

· The member has large stage III or IV pressure ulcers on the trunk or pelvis and the member cannot be positioned off the ulcer areas; or

· The member has 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 before discharge from a hospital or LTC facility. The surgery must have been performed within the past 60 days; or

· The member has been on a Group 2 or 3 support surface immediately before a recent discharge from a hospital or LTC facility. The discharge must have been performed within the past 30 days.

Group 2 pressure reducing support surfaces include powered air flotation beds (E0193), powered pressure reducing air mattresses (E0277), powered air overlays (E0372), and nonpowered advanced pressure reducing overlays (E0371) and mattresses (E0373).

Group 2 pressure reducing support surfaces are rental items only and are considered purchased after 13 months of rental. Repairs to member-owned Group 2 surfaces will be considered only if the member 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. Authorization is always required.

The member must have healing as the goal of treatment. The member’s attending physician must order based on a comprehensive assessment and evaluation of the member 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 every six months. If there has been no improvement in the member’s condition after six months on a Group 2 support surface, alternative treatments must be considered before additional monthly rental is authorized.

The member may be eligible for enteral nutritional support if the member is found to have a nutritional deficit. Refer to Nutritional Products and Related Supplies section of the MHCP Provider Manual.

Group 3 Pressure Reducing Support Surfaces
Code: E0194
Group 3 pressure reducing support surfaces are covered with authorization if all of the following criteria are met:

· The member has stage III or IV pressure sore(s) on the trunk or pelvis; and

· The member is bedridden or chair bound due to severely limited mobility; and

· Less costly equipment has been considered and eliminated.

Group 3 pressure reducing support surfaces include air fluidized beds (E0194).

Group 3 pressure reducing support surfaces are rental items only and are considered purchased after 13 months of rental. Repairs to member-owned Group 3 surfaces will be considered only if the member 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. Authorization is always required.

The member must have healing as the goal of treatment. The member’s attending physician must order the surface based on a comprehensive assessment and evaluation of the member after conservative treatment was tried without success. The physician must direct the home treatment regimen and reevaluate and recertify the need for the bed every six months. If there has been no improvement in the member’s condition after six months on a Group 3 support surface, alternative treatments must be considered before additional monthly rental is authorized.

The member may be eligible for enteral nutritional support if the member is found to have a nutritional deficit. Refer to Nutritional Products and Related Supplies section of the MHCP Provider Manual.

Noncovered Services

MHCP does not cover the following:

· HCPCS codes not reviewed by Medicare’s Pricing, Data Analysis and Coding (PDAC) contractor

· HCPCS codes that are reviewed by the PDAC contractor and found not to meet the definition of a Group 2 or Group 3 surface

· Group 2 surfaces for members without current pressure ulcers

· Group 3 surfaces for members with coexisting pulmonary disease

· Treatment with wet soaks or moist wound dressings that are not protected by an impervious covering, unless the member is undergoing aggressive treatment in a wound clinic and is showing measurable improvement

· Most pressure reducing support surfaces for members living in nursing facilities

Authorizations

Authorization is required for the following:

· Quantities over MHCP quantity limits

· Powered air flotation beds (E0193)

· Air fluidized beds (E0194)

· Powered pressure reducing air mattresses (E0277)

· Nonpowered advanced pressure reducing overlays (E0371)

· Powered air overlays (E0372)

· Nonpowered advanced pressure reducing overlays mattresses (E0373)

An additional six months may be authorized if there is improvement to the pressure sore or decubitus ulcer at the six-month interval. If there is no significant improvement to the pressure sore or decubitus ulcer at the six-month interval, additional authorization will be denied, and other treatments must be tried.

Submit authorization request and required documentation to the Medical Review Agent. Fax the MN–ITS response with the completed Specialized Wound Therapy Authorization Form (DHS-4045) (PDF).

Documentation must include a comprehensive treatment plan that details:

· Education of the patient and caregiver on prevention and management of pressure ulcers; and

· History of conservative treatment; and

· Regular assessment by a physician or other licensed practitioner; and

· Appropriate turning and positioning; and

· Appropriate management of moisture and incontinence; and

· Nutritional assessment and intervention; and

· Necessary medications when infection is present; and

· Treatment plan for care of the wound.

Billing

Providers are responsible to coordinate services. Refer to the Billing Policy Overview section of Provider Basics for general billing information.

Bill pressure reducing support surfaces using MN–ITS 837P. Refer to the Billing for Durable Medical Equipment, Medical Supplies, Prosthetics and Orthotics, and Augmentative Devices MN–ITS user manual for claim instructions.

· Use modifier NU for purchases.

· Use modifier RR for rentals.

· Use modifiers KH, KI, or KJ and RR as appropriate for capped rentals.

· Use X12 Batch or MN–ITS 837P Professional electronic claim.

· Report the ordering provider in the Other Provider Types section of the MN–ITS Interactive claim.

· If the member has Medicare, MHCP will pay the deductible or co-insurance on any units for which Medicare made payment.

· Use the correct HCPCS code and the modifiers as noted on the authorization.

· Shipping and delivery costs are included in the MHCP maximum allowable payment. Do not bill either MHCP or the member separately for these costs.

Legal References

Minnesota Statutes, 256B.0625, subdivision 31
Minnesota Rules, 9505.0310