Pressure Reducing Mattress Group I

A Gel Flotation Mattress (E0196-E0197) is a long pad made of a firm gel, which is placed on the bed under the sheet. A Water Flotation Mattress (E0184) has a foam border with water filled inserts, which are covered with a foam pad. Check with the product manufacturer for exact coding guidance per product.

HCPCS Code:

E0196-E0197
E0184-E0187

Category:

Capped Rental

Common Diagnosis:

(check for current coding)

340.0 Multiple Sclerosis (MS)
432.9 Intra Cerebral Hemorrhage
342.9 Hemiplegia Right/Left
344.0 Quadriplegia
355.2 Amyotrophic Lateral Sclerosis

Coverage Information

Requires a detailed written order dated prior to delivery (WOPD) AND Group I physician’s statement

WOPD is detailed written order that is signed AND dated by the physician. It may be a faxed copy of a basic order that includes a length of need, but MUST be in hand, dated prior to the delivery date of the item (same day or before). The Group I physician statement may be obtained later, but is necessary prior to filing the claim.

Covered if the following criteria are met:

A group 1 mattress overlay or is covered if the patient meets either scenario A or B below:
Scenario A The patient is completely immobile - patient cannot make changes in body position without assistance. This is sufficient to qualify.

Scenario B
1. The patient has limited mobility - patient cannot independently make changes in body position significant enough to alleviate pressure AND
The patient has one of the following risk factors that may cause or contribute to skin breakdown:
 Impaired nutritional status
 Fecal or urinary incontinence
 Altered sensory perception
 Compromised circulatory status
OR

2. The patient has any stage pressure ulcer on the trunk or pelvis (obtain HHA wound care nursing notes that have documented the staging of the ulcer). AND

The patient has one of the following risk factors that may cause or contribute to skin breakdown:
 Impaired nutritional status
 Fecal or urinary incontinence
 Altered sensory perception
 Compromised circulatory status

Note 1: A care plan should be established either by a physician or a home health nurse that includes a comprehensive ulcer treatment program. A comprehensive ulcer treatment program is defined as including the following elements according to Medicare coverage criteria:

A. Education of the patient and caregiver on the prevention and/or management of pressure ulcers
B. Regular assessment by a nurse, physician, or other licensed healthcare practitioner
C. Appropriate turning and positioning
D. Appropriate wound care (for a stage II, III, or IV ulcer)
E. Appropriate management of moisture/incontinence
F. Nutritional assessment and intervention consistent with the overall plan of care

Note 2: Add KX modifier to claim to signify that coverage criteria are met. Note 3: All support surfaces, whether overlay or replacement mattress, must be placed on a hospital bed. Patient must meet criteria for hospital bed in order to qualify for a support surface of any type.

Documentation Requirements: in addition to the basic Medicare documentation (proof of delivery, AOB, detailed written order, etc.)

1. Written Order Prior to Delivery (WOPD)
2. Group I Physician's Statement with questions answered to reflect that one of the scenarios noted above have been met.
3. Optional, but strongly recommended: Copies of the plan of care that describes the comprehensive ulcer treatment program, and the staging of the pressure ulcer if scenario B is used as qualifying criteria.

Pressure Ulcer Staging: Although you will not be involved in the actual staging of pressure ulcers, you may want to be acquainted with how pressure ulcers are staged.

Stage I - Observable pressure related alteration of intact skin whose indicators as compared to the adjacent or opposite area on the body may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel) and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.

Stage II - Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.

Stage III - Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. Stage IV - Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers.