Pressure Reducing Support Surfaces

Revised: May 5, 2025

· Overview

· Eligible Providers

· Eligible Members

· Covered Services

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

Eligible Members

Pressure reducing support surfaces are covered for eligible Medical Assistance and MinnesotaCare members 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:

· Member is completely immobile

· 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

· 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-E0373
Authorization is always required.

Group 2 is rental only and is 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.

Criteria for Group 2
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. 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, member has been on a comprehensive ulcer treatment for at least the past month and member 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 member 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 before discharge from a hospital or LTC facility (surgery within past 60 days)

· Member has been on a Group 2 or 3 support surface immediately before a recent discharge from a hospital or LTC facility (discharge within past 30 days)

· After six months on a Group 2 support surface and there has been no improvement in the member’s condition, alternative treatments must be considered before additional monthly rental will be authorized

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

Group 3

Codes: E0194
Authorization is always required.

Group 3 is rental only and is 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.

Criteria for Group 3
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. 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

· Member is bedridden or chair bound due to severely limited mobility

· After six months on a Group 3 support surface and there has been no improvement in the member’s condition, alternative treatments must be considered before additional rental will be authorized (for example, negative pressure wound therapy)

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

Noncovered Services

Group 2 Surfaces

MHCP does not cover the following:

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

· Codes that are reviewed by the PDAC contractor and found not to meet the definition of a Group 2 surface

· Group 2 surfaces for members without current pressure ulcers

Group 3 Surfaces

MHCP does not cover the following:

· Codes not reviewed by Medicare’s PDAC contractor

· Codes that are reviewed by the PDAC contractor and found not to meet the definition of a Group 3 surface

· Group 3 surfaces for members with coexisting pulmonary disease

· Treatment with wet soaks or moist wound dressings not protected with an impervious covering unless the member 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. If there is improvement to the pressure sore or decubitus ulcer at the six-month interval, an additional six months may be authorized. 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.

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 Medical Review Agent. Document the MN–ITS Authorization Request number assigned on every page of each document.

Submit a 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 and incontinence

· Nutritional assessment and intervention

· Necessary medications when infection is present

· 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.

· 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

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