The following are considered Group 1 support surfaces: pressure pads for mattresses, non-powered pressure reducing mattresses, and powered pressure reducing mattress overlay systems.

For any item to be covered, 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 statutory and regulatory requirements.

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

These items require a written order prior to delivery. Refer to Documentation Requirements section of this policy for additional information on orders.

A Group 1 mattress overlay or mattress (E0181-E0189, E0196-E0199, A4640) is covered if one of the following three criteria are met:

1. The patient is completely immobile - i.e., patient cannot make changes in body position without assistance; or,
   
   
2. The patient has limited mobility - i.e., patient cannot independently make changes in body position significant enough to alleviate pressure and at least one of conditions A-D below; or,
   
   
3. The patient 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): 

1. Impaired nutritional status;
2. Fecal or urinary incontinence;
3. Altered sensory perception;
4. 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 medically necessary.

The support surface provided for the patient should be one in which the patient 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 patient's bony prominence (coccyx or lateral trochanter), can readily palpate the bony prominence. This bottoming out criterion should be tested with the patient 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 sidelying position.

A support surface which does not meet the characteristics specified in the Coding Guidelines section of this policy will be denied as not medically necessary.

Reasons for Noncoverage

Pressure-reducing support surfaces are covered under the Durable Medical Equipment benefit based on Social Security Act 1861(s)(6). In order for a member's DME to be eligible for reimbursement, the medical necessity requirements documented in this medical policy must be met.

For an item addressed in this policy to be covered, a written signed and dated order must be received by the supplier prior to delivery of the item. If the supplier delivers the item prior to receipt of a written order, it will be denied as non-covered. If the written order is not obtained prior to delivery, payment will not be made for that item even if a written order is subsequently obtained. If a similar item is subsequently provided by an unrelated supplier who has obtained a written order prior to delivery, it will be eligible for coverage.

A foam overlay or mattress which does not have a waterproof cover (A9270) is not considered durable and will be denied as non-covered.

Services that do not meet the medical necessity guidelines will be denied as not medically necessary. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

Documentation Requirements

An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request. Items delivered before a signed written order has been received by the supplier must be submitted with an EY modifier added to each affected procedure code. Items submitted with an EY modifier will be denied as not medically necessary.

The supplier must obtain information concerning which, if any, of the criteria listed in the Indications and Limitations section of this policy the patient meets in a signed and dated statement from the treating physician. Questions pertaining to medical necessity on any form used to collect this information may not be completed by the supplier or anyone in a financial relationship with the supplier. This statement must be supported by information in the patient's medical record which must be available upon request. Do not submit this form unless specifically requested.

KX, GA, and GZ Modifiers
Suppliers must add a KX modifier to a code only if all of the criteria in the “Indications and Limitations of Coverage” section of this policy 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 Indications and Limitations of Coverage section have not been met, the GA or GZ modifier must be added to the code. When there is an expectation of a medical necessity denial, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Pre-Service Denial Notice or the GZ modifier if they have not obtained a valid Pre-Service Denial Notice. Services submitted with a GA modifier will be denied as not medically necessary and are billable to the member. Services submitted with a GZ modifier will be denied as not medically necessary and are not billable to the member.

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 a narrative description of the item, the manufacturer, the product name/number, and information justifying the medical necessity for the item.

Related Clinical Information
Patients needing pressure reducing support surfaces should have a care plan which has been established by the patient's physician or home care nurse, which is documented in the patient's medical records, and which generally should include the following:

1. Education of the patient and caregiver on the prevention and/or management of pressure ulcers.
2. Regular assessment by a nurse, physician, or other licensed healthcare practitioner.
3. Appropriate turning and positioning.
4. Appropriate wound care (for a stage II, III, or IV ulcer).
5. Appropriate management of moisture/incontinence.
6. Nutritional assessment and intervention consistent with the overall plan of care.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Foam mattress overlay
A foam mattress overlay (E0199) is characterized by all of the following:

1. Base thickness of 2" or greater and peak height of 3" or greater if it is a convoluted overlay (e.g., eggcrate) or an overall height of at least 3 inches if it is a non-convoluted overlay; and
   
   
2. Foam with a density and other qualities that provide adequate pressure reduction; and
   
   
3. Durable, waterproof cover.

Codes E0184, E0186, E0187 and E0196 describe nonpowered pressure reducing mattresses.

Foam mattress
A foam mattress (E0184) is characterized by all of the following:

1. Foam height of 5 inches or greater; and
   
   
2. Foam with a density and other qualities that provide adequate pressure reduction; and
   
   
3. Durable, waterproof cover; and
   
   
4. Can be placed directly on a hospital bed frame.

Air, water or gel mattress
An air, water or gel mattress (E0186, E0187, E0196) is characterized by all of the following:

1. Height of 5 inches or greater of the air, water, or gel layer (respectively); and
   
   
2. Durable, waterproof cover; and
   
   
3. Can be placed directly on a hospital bed frame.

Powered pressure reducing mattress overlay systems
Codes E0181, E0182, and A4640 describe powered pressure reducing mattress overlay systems (alternating pressure or low air loss). They are characterized by all of the following:

1. An air pump or blower which provides either sequential inflation and deflation of air cells or a low interface pressure throughout the overlay; and
   
   
2. Inflated cell height of the air cells through which air is being circulated is 2.5 inches or greater; and
   
   
3. Height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure overlays), and air pressure provide adequate patient lift, reduce pressure and prevent bottoming out.

A foam overlay or mattress which does not have a waterproof cover should be coded using A9270. Other Group 1 support surfaces which do not meet the characteristics specified in this section should be billed using code E1399.

A Column II code is included in the allowance for the corresponding Column I code when provided at the same time. Modifier 59 may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day. When modifier 59 is reported, the patient’s records must support its use in accordance with CPT guidelines.

Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items. https://www.dmepdac.com/

Provider News

Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider." It is expected that the patient's medical records will reflect the need for the care provided. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.

CMS Publication 100-3, Medicare National Coverage Determinations Manual, Chapter 1, Section 280.1