OAR 410-122-0400: Pressure Reducing Support Surfaces

(1) Indications and limitations of coverage and medical appropriateness: (a) Group 1 (A4640, E0181–E0182, E0184–E0189, and E0196-E0199): (A) The Division may cover a Group 1 support surface when the client meets: (i) Criterion (I), or; (ii) Criteria (II) or (III) and at least one of criteria (IV)–(VII): (I) Completely immobile — i.e., client cannot make changes in body position without assistance; (II) Limited mobility — i.e., client cannot independently make changes in body position significant enough to alleviate pressure; (III) Any stage pressure ulcer on the trunk or pelvis; (IV) Impaired nutritional status; (V) Fecal or urinary incontinence; (VI) Altered sensory perception; (VII) Compromised circulatory status; (B) The Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) provider must provide a support surface in which the client does not "bottom out"; (C) The Division does not cover foam overlays or mattresses without a waterproof cover, since these are not considered durable; (D) The Division does not cover pressure reducing support surfaces for the prevention of pressure ulcers or pain control; (E) The allowable rental fee includes all equipment, supplies and services for the effective use of the pressure reducing support surface; (b) Group 2 (E0193, E0277, and E0371–E0373): (A) A Group 2 support surface may be covered for up to an initial three month rental period when the client meets: (i) Criterion (I) and (II) and (III), or; (ii) Criterion (IV), or; (iii) Criterion (V) and (VI); (I) Multiple stage II pressure ulcers located on the trunk or pelvis; (II) Client has been on a comprehensive ulcer treatment program for at least the past month which includes the following: use of an appropriate Group 1 support surface; education of the client, if appropriate, and caregiver on the prevention and/or management of pressure ulcers; regular assessment by a nurse, physician, or other licensed healthcare practitioner (usually at least weekly for a patient with a stage III or IV ulcer); appropriate turning and positioning; appropriate wound care (for a stage II, III, or IV ulcer); appropriate management of moisture/incontinence; and nutritional assessment and intervention consistent with the overall plan of care; (III) The ulcers have worsened or remained the same over the past month; (IV) Large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis A large wound is generally any wound of eight square centimeters (length x width) or more. Individual client circumstances may be weighed. Undermining and/or tunneling, anatomic location on the body and the size of the client may be taken into account; (V) Recent myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis (surgery within the past 60 days) (VI) The client has been on a Group 2 or 3 support surface immediately prior to a recent discharge from a hospital or nursing facility (discharge within the past 30 days); (B) The DMEPOS provider must provide a support surface in which the patient does not "bottom out"; (C) When a Group 2 surface is requested following a myocutaneous flap or skin graft, coverage generally is limited to 60 days from the date of surgery (D) The Division may cover continued use of a Group 2 support surface if healing continues; (E) The Division does not cover pressure reducing support surfaces for the prevention of pressure ulcers or pain control; (F) The allowable rental fee includes all equipment, supplies and services for the effective use of the pressure reducing support surface; (c) Division may consider coverage for bariatric pressure reducing support surfaces only coded as E1399 (durable medical equipment, miscellaneous) for a client residing in a nursing facility, subject to service limitations of Division rules, only when the following requirements are met: (A) The client meets the conditions of coverage as specified in this rule; and (B) The bariatric pressure reducing support surface has been assigned code E1399 by the Medicare Pricing, Data Analysis and Coding (PDAC) contractor; (d) Group 3: Air-fluidized beds (E0194) are not covered. (2) Definitions for Group 1 and Group 2: (a) Bottoming out: Finding that an outstretched hand, placed palm up between the undersurface of the overlay or mattress and the patient's bony prominence (coccyx or lateral trochanter), can readily palpate the bony prominence. This bottoming out criterion shall be tested with the client 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 side-lying position; (b) Plan of care: Written guidelines developed to identify specific problems and needs of the client and interventions/regimen necessary to assist the client to achieve optimal health potential. Developing the plan of care includes establishing measurable client and nursing goals with time lines and determining nursing/caregiver/other discipline-assigned interventions to meet care objectives; (c) The staging of pressure ulcers used in this rule is as follows: (A) 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; (B) 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; (C) 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; (D) 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; (3) Guidelines: (a) Group 1: (A) Codes E0185 and E0197–E0199 termed "pressure pad for mattress" describe non-powered pressure reducing mattress overlays and are designed to be placed on top of a standard hospital or home mattress; (B) A gel/gel-like mattress overlay (E0185) is characterized by a gel or gel-like layer with a height of two inches or greater; (C) An air mattress overlay (E0197) is characterized by interconnected air cells having a cell height of three inches or greater that are inflated with an air pump; (D) A water mattress overlay (E0198) is characterized by a filled height of three inches or greater; (E) A foam mattress overlay (E0199) is characterized by all of the following: (i) Base thickness of two inches or greater and peak height of three inches or greater if it is a convoluted overlay (e.g., egg crate) or an overall height of at least three inches if it is a non-convoluted overlay; and (ii) Foam with a density and other qualities that provide adequate pressure reduction; and (iii) Durable, waterproof cover; (F) Codes E0184, E0186, E0187 and E0196 describe non-powered pressure reducing mattresses; (G) A foam mattress (E0184) is characterized by all of the following: (i) Foam height of five inches or greater; (ii Foam with a density and other qualities that provide adequate pressure reduction; (iii) Durable, waterproof cover; and (iv) Can be placed directly on a hospital bed frame; (H) An air, water or gel mattress (E0186, E0187, E0196) is characterized by all of the following: (i) Height of five inches or greater of the air, water, or gel layer (respectively); (ii) Durable, waterproof cover; and (iii) Can be placed directly on a hospital bed frame; (I) Codes E0181, E0182, and A4640 describe powered pressure reducing mattress overlay systems (alternating pressure or low air loss) and are characterized by all of the following: (i) An air pump or blower which provides either sequential inflation and deflation of air cells or a low interface pressure throughout the overlay; (ii) Inflated cell height of the air cells through which air is being circulated is 2 inches or greater; and (iii) 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 client lift, reduce pressure and prevent bottoming out; (J) Alternating pressure mattress overlays or low air loss mattress overlays are coded using codes E0181, E0182, and A4640; (K) Code A4640 or E0182 may only be billed when they are provided as replacement components for a client-owned E0181 mattress overlay system; (L) A Column II code is included in the allowance for the corresponding Column I code when provided at the same time: Column I (Column II), E0181 (A4640, E0182); (b) Group 2: (A) Code E0277 describes a powered pressure reducing mattress (alternating pressure, low air loss, or powered flotation without low air loss) which is characterized by all of the following: (i) An air pump or blower which provides either sequential inflation and deflation of the air cells or a low interface pressure throughout the mattress; (ii) Inflated cell height of the air cells through which air is being circulated is five inches or greater; (iii) Height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure mattresses), and air pressure provide adequate patient lift, reduce pressure and prevent bottoming out; (iv) A surface designed to reduce friction and shear; and (v) Can be placed directly on a hospital bed frame; (B) Code E0193 describes a semi-electric or total electric hospital bed with a fully integrated powered pressure reducing mattress which has all the characteristics defined above; (C) Code E0371 describes an advanced non-powered pressure-reducing mattress overlay which is characterized by all of the following: (i) Height and design of individual cells which provide significantly more pressure reduction than a group 1 overlay and prevent bottoming out; (ii) Total height of three inches or greater; (iii) A surface designed to reduce friction and shear; and (iv) Documented evidence to substantiate that the product is effective for the treatment of conditions described by the coverage criteria for Group 2 support surfaces; (D) Code E0372 describes a powered pressure reducing mattress overlay (low air loss, powered flotation without low air loss, or alternating pressure) which is characterized by all of the following: (i) An air pump or blower which provides either sequential inflation and deflation of the air cells or a low interface pressure throughout the overlay; (ii) Inflated cell height of the air cells through which air is being circulated is 3.5 inches or greater; (iii) Height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure overlays), and air pressure to provide adequate patient lift, reduce pressure and prevent bottoming out; and (iv) A surface designed to reduce friction and shear; (E) Code E0373 describes an advanced non-powered pressure reducing mattress which is characterized by all of the following: (i) Height and design of individual cells which provide significantly more pressure reduction than a group 1 mattress and prevent bottoming out; (ii) Total height of five inches or greater; (iii) A surface designed to reduce friction and shear; (iv) Documented evidence to substantiate that the product is effective for the treatment of conditions described by the coverage criteria for Group 2 support surfaces; and (v) Can be placed directly on a hospital bed frame; (F) The only products that may be coded and billed using code E0371 or E0373 are those products for which a written coding determination specifying the use of these codes has been made by PDAC; (G) Alternating pressure mattresses and low air loss mattresses are coded using code E0277; (H) Products containing multiple components are categorized according to the clinically predominant component (usually the topmost layer of a multi-layer product). For example, a product with three powered air cells on top of a three foam base would be coded as a powered overlay (code E0181), not as a powered mattress (E0277). (4) Documentation requirements: Submit the following information with the prior authorization request: (a) Initial Requests: (A) For all pressure reducing support surfaces, other than a Group I for a completely immobile client or a Group 2 surface following a myocutaneous flap or skin graft: (i) An order for each item requested, signed and dated by the attending practitioner; (ii) Documentation that supports conditions of coverage are met as specified in this rule; (iii) A plan of care which has been established by the client's practitioner or home care nurse (by the RN resident care manager for a client in a nursing facility), which generally includes the following: (I) Education of the client, if appropriate, and caregiver on the prevention and/or management of pressure ulcers; (II) Regular assessment by a nurse, physician, or other licensed healthcare practitioner; (III) Appropriate turning and positioning including the number of hours per 24-period that the client will utilize the support surface; (IV) Appropriate wound care (for a stage II, III, or IV ulcer); (V) Appropriate management of moisture/incontinence; (VI) Nutritional assessment and intervention consistent with the overall plan of care by a licensed healthcare practitioner (by a registered dietitian for a client in a nursing facility) within the last 90 days; (VII) Client’s weight and height (approximation is acceptable, if unable to obtain); (VIII) Description of all pressure ulcers, which includes number, locations, stages, sizes and dated photographs; (iv) Lab reports, if relevant; (v) Other treatments and products that have been tried and why they were ineffective; Interventions and goals for stepping down the intensity of support surface therapy; (vi) For pressure ulcers on extremities, why pressure cannot be relieved by other methods; (B) For a Group I surface for a completely immobile client: (i) An order for each item requested, signed and dated by the attending practitioner; (ii) A plan of care which has been established by the client's practitioner or home care nurse (by the RN resident care manager for a client in a nursing facility), which generally includes the following: (I) Education of the client, if appropriate, and caregiver on the prevention of pressure ulcers; (II) Regular assessment by a nurse, physician, or other licensed healthcare practitioner (III) Appropriate turning and positioning including the number of hours per 24-period that the client will utilize the support surface; (IV) Appropriate management of moisture/incontinence, if appropriate; (C) For a Group 2 surface following a myocutaneous flap or skin graft: (i) An order for each item requested, signed and dated by the treating practitioner; (ii) Operative report; (iii) Hospital discharge summary; (iv) Plan of care; (F) Required documentation may not be completed by the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) provider or anyone in a financial relationship of any kind with the DMEPOS provider; (G) Medical records must corroborate that all criteria in this rule are met when dispensing and billing for an item in Table 122-0400-1 and Table-122-400-2; (H) Medical records must be kept on file by the DMEPOS provider and made available to the Division upon request; (b) Subsequent Requests: May be authorized contingent on progress towards healing: (A) For all pressure reducing support surfaces, other than a Group I surface for a completely immobile client or a Group 2 surface following a myocutaneous flap or skin graft: (i) Progress notes from the attending practitioner; (ii) Description of all pressure ulcers, including progress towards healing, by a licensed healthcare practitioner (by the RN resident care manager for a client in a nursing facility) which includes number, locations, stages, sizes and dated photographs; (iii) Current plan of care; (iv) Any other relevant documentation; (B) For a Group I surface for a completely immobile client: (i) Progress notes from the attending practitioner; (ii) Current plan of care; (iii) Any other relevant documentation; (C) For a Group 2 surface following a myocutaneous flap or skin graft: (i) Progress notes from the attending practitioner; (ii) Current plan of care; (iii) Any other relevant documentation. (4) Table 122-0400-1 — Group 1. (5) Table 122-0400-2 — Group 2. [ED. NOTE: Tables referenced are available from the agency.] [ED. NOTE: To view attachments referenced in rule text, click here to view rule.]