Pressure Reducing Support Surfaces - Group 3- Policy Article

**NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES**  
  
For any item to be covered by Medicare, 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 Medicare statutory and
regulatory requirements. Information provided in this policy article relates
to determinations other than those based on Social Security Act 1862(a)(1)(A)
provisions (i.e. "reasonable and necessary").  
  
Pressure-reducing support surfaces are covered under the Durable Medical
Equipment benefit (Social Security Act 1861(s)(6)). In order for a
beneficiary's DME to be eligible for reimbursement, the reasonable and
necessary (R&N) requirements set out in the related Local Coverage
Determination must be met. In addition, there are specific statutory payment
policy requirements, discussed below, that also must be met.  
  

**REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO  FINAL RULE 1713 (84 Fed.
Reg Vol 217) **

Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a
Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the
DME MACs provide a list of the specified codes, which is periodically updated.
The required Face-to-Face Encounter and Written Order Prior to Delivery List
is available [here](https://www.cms.gov/Research-Statistics-Data-and-
Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-
Review/FacetoFaceEncounterRequirementforCertainDurableMedicalEquipment).

Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol
217) that do not meet the face-to-face encounter and WOPD requirements
specified in the LCD-related Standard Documentation Requirements Article
(A55426) will be denied as not reasonable and necessary.

If a supplier delivers an item prior to receipt of a WOPD, it will be denied
as not reasonable and necessary. If the WOPD is not obtained prior to
delivery, payment will not be made for that item even if a WOPD is
subsequently obtained by the supplier. If a similar item is subsequently
provided by an unrelated supplier who has obtained a WOPD prior to delivery,
it will be eligible for coverage.  
  
  
 **POLICY SPECIFIC DOCUMENTATION REQUIREMENTS**  
  
In addition to policy specific documentation requirements, there are general
documentation requirements that are applicable to all DMEPOS policies. These
general requirements are located in the DOCUMENTATION REQUIREMENTS section of
the LCD.  
  
Refer to the LCD-related Standard Documentation Requirements article, located
at the bottom of this Policy Article under the Related Local Coverage
Documents section for additional information regarding GENERAL DOCUMENTATION
REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed
below.  
  
  
 **MODIFIERS**  
  
KX, GA, AND GZ MODIFIERS  
  
Suppliers must add a KX modifier to E0194 on the initial claim only if all of
the criteria in the "Coverage Indications, Limitations and/or Medical
Necessity" section of the related LCD have been met and evidence of such is
retained in the supplier's files and available to the DME MAC upon request.  
  
For each subsequent month's claim use a KX modifier only if the treating
practitioner's monthly certification indicates that continued use is
necessary. Discontinue use of the KX modifier if the coverage criteria are not
met or use is discontinued.  
  
In all of the situations above describing use of the KX modifier, if all of
the specific coverage criteria have not been met, the GA or GZ modifier must
be added to the code. When there is an expectation of a denial as not
reasonable and necessary, suppliers must enter the GA modifier on the claim
line if they have obtained a properly executed Advance Beneficiary Notice
(ABN) or the GZ modifier if they have not obtained a valid ABN.  
  
Claims lines billed with codes without a KX, GA or GZ modifier will be
rejected as missing information.  
  
  
 **MISCELLANEOUS**  
  
On a monthly basis, the treating practitioner must document the need for the
equipment with a written statement specifying:

  1. The size of the ulcer;

  2. If the ulcer is not healing, what other aspects of the care plan are being modified to promote healing;

  3. Continued use of the bed is reasonable and necessary for wound management.

This monthly treating practitioner statement must be kept on file by the
supplier and be available for inspection upon request.  
  
Refer to the Supplier Manual for additional information on documentation
requirements.  
  
  
 **CODING GUIDELINES**  
  
An air-fluidized bed (E0194) is a device employing the circulation of filtered
air through silicone coated ceramic beads creating the characteristics of
fluid.

Heavy duty and bariatric devices are included in the Group 3 pressure reducing
support surfaces coded E0194.

Suppliers should contact the Pricing, Data Analysis and Coding (PDAC)
Contractor for guidance on the correct coding of these items.