Department of Health and Human Services
 
OFFICE OF 

 
INSPECTOR GENERAL 

 
 
 
 
 
 
 
 
  INAPPROPRIATE  

M P
EDICARE  AYMENTS FOR 

P R  
RESSURE  EDUCING 

S S  
UPPORT  URFACES 

 
Daniel R. Levinson 
  
Inspector General 

 
August 2009 
 
OEI-02-07-00420 
   
 
 
Office of Inspector General

  http://oig.hhs.gov  
   
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as  
 
amended, is  to protect the integrity of the Department of  Health and Human Services  
(HHS)  programs, as well  as the health and welfare of beneficiaries  served by those 
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The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
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Office of Investiga tions 
 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
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The Office of Counsel to the  Inspector  General (OCIG) provides general legal services to 
 
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enforcement authorities.      
   
 E X  EE CX UE TC IUVTE I   VS EU  MSMUAMR MY A  R Y  
OBJECTIVES   
1. To assess the appropriateness of  Medicare payments for pressure  
reducing support surfaces.   
2. To determine what program safeguards are in place to ensure proper 
payments for pressure  reducing support surfaces. 
BACKGROUND 
Pressure reducing support surfaces (support surfaces) are used for the 
care or prevention of pressure ulcers.  A pressure ulcer, also known as a 
bedsore or decubitus ulcer, is an area of skin that breaks down when a 
person stays in one position for too long without shifting his or her 
weight. Pressure ulcers  commonly occur among  the elderly and among 
individuals with spinal cord injuries. 
The Centers for Medicare & Medicaid Services (CMS) categorizes 
support surfaces into three groups based on the complexity of their 
features.  This report focuses on group 2 support surfaces, which is the 
largest group. In 2007, Medicare payments for group 2 support surfaces 
totaled $109 million, which accounted for 80 percent of all support 
surface payments.  Medicare covers support surfaces under its durable 
medical equipment (DME) benefit.  
To assess the appropriateness of Medicare payments for group 2 support 
surfaces, we used a contractor to  conduct a medical record review of a 
stratified random sample of 363 claims. We also conducted a separate 
review of the documentation that suppliers are required to keep  on file  
for each claim.  Lastly,  we conducted structured telephone interviews  
with CMS contractor staff who process, review, and analyze DME 
claims. 
FINDINGS 
Eighty-six percent of the claims for group 2 support surfaces did 
not meet Medicare coverage criteria.  Based on a review of medical 
record documentation and supplier documentation, we found that  
86 percent of group 2 support surface claims for the first half of 2007 did 
not meet Medicare coverage criteria.  This amounted to an estimated 
$33 million in inappropriate payments during that time.  We considered 
a claim as not meeting Medicare coverage criteria if it either (1) did not 
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meet Medicares clinical coverage requirements, or (2) did not meet 
Medicares supplier documentation requirements. 
Based on an independent medical review, we found that 80 percent of 
group 2 support surface claims did not meet Medicares clinical coverage 
requirements. In addition, 33 percent of claims did not meet supplier 
documentation requirements. Over three-quarters of the claims that 
did not meet supplier documentation requirements also did not meet 
Medicares clinical coverage requirements.    
Specifically, 38 percent of the claims  were undocumented, 22 percent 
were medically unnecessary, 17 percent had insufficient documentation, 
and 3 percent had other billing errors. For the claims that did not meet  
supplier documentation requirements, the supplier delivered the 
support surface before obtaining the physician order, the supplier did 
not have a physician order, the supplier was missing the proof of 
delivery, or  the physician order was not dated. 
CMS contractors had limited program safeguards in place to 
prevent improper payments for group 2 support surfaces. CMS 
contractors reported that they relied primarily on two claims processing 
edits to prevent improper payments for support surfaces. One of the 
edits checked for the KX modifier, which a supplier uses to indicate that 
a claim meets Medicare coverage criteria and that adequate 
documentation exists. In our sample, all but one of the claims included  
the KX modifier, even though we found that 80 percent of the claims did  
not meet clinical coverage criteria.   In addition, none of the CMS 
contractors conducted any widespread medical reviews of support 
surface claims. Moreover, only half of the CMS contractors responsible 
for supplier education conducted any educational activities in recent 
years that focused on group 2 support surfaces.   
RECOMMENDATIONS 
Based on the findings in this report, we recommend that CMS: 
Ensure that claims for group 2 support surfaces meet Medicare coverage 
criteria and are paid appropriately. To address this recommendation, CMS 
should:  
 	  Conduct additional prepayment and postpayment medical 

reviews of group 2 support surface claims; 

 	  Educate suppliers and health care providers, such as home 
health agencies, about  Medicare coverage criteria for support 
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surfaces. Education should inform  suppliers and health care  
providers about the information that needs to be documented in 
the medical record for initial and continued coverage. Education 
should also focus on differences in the coverage criteria between 
group 1 and group 2 support surfaces; 
 	  Review the  use of the KX modifier as a program  safeguard; and  
 	  Conduct additional statistical analyses to monitor payments for 
group 2 support surfaces. 
Take appropriate action regarding the claims in our sample that  were 
inappropriate. CMS should follow up on the claims that were 
undocumented, medically unnecessary, insufficiently documented, or had 
billing errors in which the money was not already refunded to Medicare. 
CMS should also follow  up on claims in which the supplier delivered the 
support surface before obtaining the physician order, the supplier did not 
have a physician order, the supplier was missing the proof of delivery, or  
the physician order was not dated.   Finally, CMS should follow up on the 
suppliers that could not be located. To help CMS address this 
recommendation, we will forward information about these claims in a 
separate memorandum.    
AGENCY COMMENTSAND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
CMS concurred with all five of our recommendations. CMS stated that 
it will share our findings on inappropriate claims with its contractors 
for potential additional prepayment edits and prepayment medical 
review. It also noted that it will revise review instructions to clarify 
that the contractors may initiate widespread service-specific  
prepayment review without first conducting probe reviews for problem 
areas identified by various parties, including the Office of Inspector 
General. CMS also stated that it will issue a Medicare Learning 
Network Matters article to remind suppliers and health care  providers 
about Medicare coverage criteria for  support surfaces. Further, it 
mentioned that it is currently reviewing the utility and use of the KX 
modifier, including its application in DME. It also stated that it plans 
to share our recommendation about conducting additional statistical 
analyses with the appropriate contractors for their consideration in 
ongoing monitoring of these claims.   Lastly, CMS indicated that once it 
reviews the inappropriate claims and better understands the nature of 
these claims, it will forward them to  the appropriate contractors. 
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E X E C U T I V E   S U M M A R Y   
 
We support CMSs efforts to address these issues and encourage it to  
continue to  make progress in these areas. 
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  T A B L E   O F   C O N T E N T S  
 
 
EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
   i 
   
   
 
 
I N T RO DUC T IO N  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1 
  
   
 
 
F I N D IN G S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  11 
  
 
Eighty-six percent of the claims for group 2 support surfaces  
          
did not meet Medicare coverage criteria  . . . . . . . . . . . . . . . . . . . .  11 
  
 
  CMS contractors had limited program safeguards in place    
              
to prevent improper payments for group 2 surfaces  . . . . . . . . . . .  15 
  
 
 
 
 
R E  C O MMEN D A T ION S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  17 
  
   Agency Comments and Office of Inspector General Response . . .  18 

   
 
 
APPENDIXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  20 
  
 
  A: Local Coverage Determination for Pressure Reducing   
           
  Support SurfacesGroup 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  20 
  
 
   B:  Additional Details of the Medical Review. . . . . . . . . . . . . . . . .  25 
  
   C:  Confidence Intervals for Selected Estimates . . . . . . . . . . . . . .  26 
  
 
  D: Weighted Chi-Square Test for Initial and Continued Claims.  29 

 
  E:  Centers for Medicare & Medicaid Services Comments  . . . . . .  30 
  
 
 
   
A C K NO WL E D G M E N T S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  34 
  
 
 
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  I N T R O D U C T I O N  
OBJECTIVES 
1. To assess the appropriateness of  Medicare payments for pressure  
reducing support surfaces.   
2. To determine what program safeguards are in place to ensure proper 
payments for pressure  reducing support surfaces. 
BACKGROUND 
Pressure reducing support surfaces (support surfaces) are used for the 
care or prevention of pressure ulcers.  A pressure ulcer, also known as a 
bedsore or decubitus ulcer, is an area of skin that breaks down when a 
person stays in one position for too long without shifting his or her 
weight. Pressure ulcers  commonly occur among  the elderly and among 
individuals with spinal cord injuries. 
The Centers for Medicare & Medicaid Services (CMS) categorizes 
support surfaces into three groups based on the complexity of their 
features.  This report focuses on group 2 support surfaces, which is the 
largest group. In 2007, Medicare payments for group 2 support surfaces 
totaled $109 million, which accounted for 80 percent of all support 
surface payments. 
Medicare covers support surfaces under its durable medical equipment 
(DME) benefit. CMS reported that  Medicare expenditures for DME 
were $9.2 billion in fiscal year (FY) 2006.1  A sizable percentage of these 
expenditures were inappropriate overpayments.2  
 
 
 
 
1 Figure cited is for DME claims for the 12-month period ending September 30, 2006.  
Available online at https://www.cms.hhs.gov/apps/er_report/preview_er_report_print  
.asp?from=public&which =long&reportID=6. Accessed on December 5, 2008. 
2 CMSs Comprehensive Error Rate Testing (CERT) contractor calculated Medicares 
DME payment error rate to be 7.5 percent in FY 2006.  A subsequent Office of Inspector 
General (OIG) audit to determine the adequacy  of the CERT contractors medical review of 
DME claims calculated a higher DME error rate in the CERT sampleeither 17.3 percent 
or 28.9 percent, depending on the extent of documentation reviewed.  OIG, Medical Review  
of Claims for the Fiscal Year 2006 Comprehensive Error Rate Testing Program,  
A-01-07-00508, August 2008.  
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Support Surface Categories 
The three support surface groups have varying characteristics and 
include the following: 
 	  Group 1 support surfaces are generally designed  to be placed  on 
top of standard hospital or home mattresses and include 
pressure pads and mattress overlays (foam, air,  water, or gel). 
 	  Group 2 support surfaces, which can be special mattresses  used 
alone or placed directly over a bedframe, include powered air 
flotation beds, powered pressure reducing air mattresses, and 
nonpowered advanced pressure reducing mattresses.    
 	  Group 3 support surfaces are complete bed systems, known as 
air-fluidized beds, which simulate the movement of fluid by 
circulating filtered air through silicone-coated ceramic beads. 
If a physician determines that a support surface is medically necessary, 
the physician writes a prescription indicating the type  of support 
surface the beneficiary needs. Once a support surface is selected,  
prescribed, and ordered, a DME supplier delivers the item to the  
beneficiary and bills Medicare monthly for the rental. 
The supplier uses a Healthcare Common Procedure Coding System 
(HCPCS) code on a Medicare claim to designate  the type  of equipment it 
provided to the beneficiary.3  To bill for group 2 support surfaces, 
suppliers may use any of the five HCPCS codes listed in Table 1.4   The 
most commonly billed HCPCS code was for powered pressure reducing 
air mattresses (E0277), which represented 93 percent of all group 2 
support surface claims in the first half of 2007. 
 
 
3 HCPCS is a standardized coding system developed and updated by CMS to ensure  
uniform identification of and billing for medical products, supplies, and services furnished  
by physicians and other health care professionals. 
4 Group 2 support surfaces may also be billed under a sixth HCPCS code. We excluded  
this code (E1399) from our review because suppliers may also use this code to bill for 
group  2 support surface accessories and other DME items that are not related to support 
surfaces. 
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Table 1: Group 2 Support Surface HCPCS Codes 
2007 Average Fee 
HCPCS                              Support Surface Name  Schedule Amount  
E0193   Powered air flotation bed (low air loss therapy)  $886 
E0277  Powered pressure reducing air mattress  $693 
E0371  Nonpowered advanced pressure reducing overlay for 
$436 
mattress, standard mattress length and width 
E0372  Powered air overlay  for mattress, 
$529 
standard mattress length and width 
E0373  Nonpowered advanced pressure reducing mattress  $603 
Source: HCPCS Code Fee Schedule, 2007. 
Medicare Coverage for Support Surfaces 
Medicare covers group 2 support surfaces under  Part B as capped rental 
DME.5  Accordingly, Medicare pays suppliers for a specified number of 
months of continuous use if the equipment remains medically 
necessary.6  After the 13th month, the supplier must transfer the title of 
the group 2 support surface to the beneficiary.7  
Provisions of the Social Security Act (the Act) govern Medicare payment  
for all items or services, including support surfaces. Section 
1862(a)(1)(A) of the Act states that Medicare will cover only services 
considered reasonable and necessary for the diagnosis or treatment of 
illness or injury or to improve the functioning of a malformed body 
part.8  Further, Section 1833(e) of the Act requires that providers 
furnish such information as may be necessary in order to determine the 
amounts due to receive Medicare payment.9    
In addition, four DME Medicare Administrative Contractors (MAC), 
under contract with CMS, develop policies known as Local Coverage 
Determinations (LCD). The LCDs specify the clinical circumstances 
under which an item is considered to be reasonable and necessary. All 
 
5 42 CFR  414.229. 

6 Social Security Act  1834(a)(7)(A)(i)(I), 42 U.S.C.  1395m(a)(7)(A)(i)(I); 42 CFR
   
 414.229(d). 
7 Social Security Act  1834(a)(7)(A)(ii), 42 U.S.C.  1395m(a)(7)(A)(ii); 42 CFR 
 414.229(2)(ii).  
8 Social Security Act  1862(a)(1)(A), 42 U.S.C.  1395y(a)(1)(A). 
9 Social Security Act  1833(e), 42 U.S.C.  1395l(e). 
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four DME MACs issued four identical LCDs for group 2 support 
surfaces, making the policy uniform nationally.10  The LCD includes 
Medicare coverage criteria for initial use and continued use of group 2 
support surfaces. It does not provide specific criteria for the five 
HCPCS codes. Appendix A includes  relevant excerpts from the LCD. 
Initial Medicare coverage criteria. The LCD states that Medicare covers a 
group 2 support surface  for initial use if the patient meets any of the 
three situations described in Table 2. These three situations include a 
combination of six different clinical criteria. Several of these criteria 
relate to the stage and progress of the patients pressure ulcers. 
Pressure ulcers can range from stage I to stage IV, depending on their 
size and severity. See page 23 (Appendix A) for a complete explanation 
of pressure ulcer staging.    
The LCD also stipulates that there must be a care plan in the medical 
record, established by the physician  or home care nurse, that includes 
the following: patient and caregiver education on the prevention and  
management of pressure ulcers; regular assessment by a nurse, 
physician, or other licensed practitioner; appropriate turning and  
positioning; appropriate wound care for the ulcer type; appropriate  
management of moisture and incontinence; and nutritional assessment 
and intervention consistent with the overall plan of care.   
 
 
10 The four LCDs  are entitled LCD for Pressure Reducing Support SurfacesGroup 2. 
The four relevant LCD policy numbers are L11564, L5068, L11579, and L27009. We used 
the version of the LCDs that was effective during our sample timeframe. Since all four 
LCDs are the same, we refer to them as the LCD for purposes of this report. 
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Table 2: Criteria Used To Determine Initial Coverage for Group 2 Support 
Surfaces 
 
Situation 1:  Patient must meet criteria 1, 2, and 3.  
 
(1) The patient has multiple stage II pressure ulcers located on the trunk or  
pelvis. 
 
(2) The patient is on a comprehensive ulcer treatment program for at least 
the past month that included the use of a group 1 support surface. 
 
(3) The ulcers have worsened or remained the same over the past month. 
 
Situation 2:  Patient must meet criterion 4. 
 
(4) The patient has large or multiple stage III or IV pressure ulcers on the 
trunk or pelvis. 
 
Situation 3:  Patient must meet criteria 5 and 6. 
 
(5) The patient had a recent myocutaneous flap or skin graft for a pressure 
ulcer on the trunk or pelvis (surgery within the past 60 days). 
 
(6) The patient has been on a group 2 or 3 support surface immediately 
before a recent discharge from a hospital or nursing facility (discharge 
within the past 30 days).  Coverage for this situation is generally limited to 
60 days from the date of surgery. 
Source: LCD for Pressure Reducing Support SurfacesGroup 2. 
Continued Medicare coverage criteria. The LCD states that Medicare 
covers a group 2 support surface for continued use until the ulcer is 
healed. If healing does not continue, there must be documentation in 
the medical record to show that: (1) other aspects of the care plan are 
being modified to promote healing, or (2) the use  of the group  2 support 
surface is medically necessary for wound management.  The LCD 
further requires that the support surface provided to the patient must  
not bottom out, a situation in which the mattress no longer supports 
the body.   
Medical record documentation requirements. Both the Medicare Program 
Integrity Manual (the Manual) and the LCD require that the patients 
medical records contain sufficient documentation of medical necessity.11   
The supplier does not need to have documentation in the patients 
 
11 CMS, Medicare Program Integrity Manual (PIM), ch.5,  5.7 (as of Rev. 167; effective 
10-01-06).  LCD for Pressure Reducing Support SurfacesGroup 2.  PIM provisions cited 
were in effect during the period of this study.  
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medical record sent to it routinely; however, the Medicare contractor 
may request this information from the supplier in selected cases.12   
According to the Manual, The supplier should also obtain as much 
documentation from the patients medical record as they determine they  
need to assure themselves that coverage criterion for an item has been 
met.13  If the contractor  does not receive the information when 
requested, or if the information in the patients medical record does not 
adequately support the medical necessity of the item, then the supplier 
may be liable for the dollar amount involved.14  
Supplier documentation requirements. The Manual stipulates that for all 
DME, the supplier must keep on file a number of documents before  
submitting a claim. These documents include a written physicians 
order, information from the physician concerning the patients 
diagnosis, and proof of delivery.15   The Manual also states that the 
supplier may not dispense any pressure reducing pads, overlays, 
mattresses,  or beds until it has obtained a written order that is signed 
and dated by the treating physician.16  In addition, the LCD states that 
the supplier must obtain a signed and dated statement from  the  
treating physician describing which criteria in the LCD the patient 
meets.17    
The LCD further notes that the supplier is responsible for using the 
KX modifier appropriately. The KX modifier indicates that the clinical 
conditions meet the criteria for coverage of a group 2 support surface 
and that adequate documentation exists in the medical record reflecting 
these conditions.18   
Claims Processing and Program Safeguard Activities 
In addition to developing LCDs, the four DME MACs are responsible for 
processing and paying all DME claims. They implement claims 
processing edits to prevent improper  payments. They also conduct 
outreach and education to suppliers and, subsequent to our data 
 
12 PIM,  5.7. 

13 Ibid.,  5.8. 

14 Ibid.,  5.7. 

15 Ibid.,  5.8. 

16 Ibid.,  5.2.3.1.
  
17 LCD for Pressure Reducing Support SurfacesGroup 2, Documentation 

Requirements. 
18 If the criteria are not met, the supplier must include additional documentation with 
the claim to justify coverage.   
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I N T R O D U C T I O N   
 
collection, have become responsible for conducting medical reviews of 
supplier claims.   
CMS also contracts with three DME Program Safeguard Contractors 
(PSC) that cover four jurisdictions.  The PSCs are responsible for  
conducting benefit integrity activities such as fraud investigations of 
claims.19  In addition, at the time  of our review, the Statistical Analysis 
Durable Medical Equipment Contractor (SADMERC) provided support 
to the DME MACs by identifying billing trends and offering guidance on 
the proper use of HCPCS codes.20  
Comprehensive Error Rate Testing Program 
CMS established the CERT program to monitor the accuracy of 
payments made in the Medicare Fee-for-Service (FFS) program. The  
CERT contractor conducts medical reviews periodically on a sample of  
paid claims to determine a paid claims error rate.  The error rate is the 
percentage of total dollars that Medicare FFS contractors erroneously 
paid or denied. For FY 2007, the CERT error rate for support surfaces 
was 18 percent.21    
Related Work 
In 2009, OIG released a report about an independent contractors review 
of DME claims from the FY 2008 CERT program.22  To provide 
assurance that the DME error rate was accurate, CMS contracted with 
Palmetto GBA (Palmetto) to  review  the CERT contractors payment 
determinations.  OIG determined that Palmettos results did not provide  
assurance that the error rate was accurate.  OIG found that Palmettos 
determinations differed from those of the CERT contractor because  of   
(1) incorrect medical necessity determinations by the CERT contractor  
and (2) differences in review standards and methodology.  These 
differences  were due to  the CERT contractors use of  clinical inference,  
or clinical review judgment, to make medical necessity determinations 
 
19 At the time of our review, the DME PSCs were responsible for the medical review  
function that has been transitioned to the DME MACs as of March 1, 2008.  CMS is 
currently implementing a new contracting strategy regarding Medicare fraud, waste, and 
abuse across all claim types called Zone Program Integrity Contractors.  
20 The Pricing, Data Analysis and Coding Contractor now conducts the activities that 
had been performed by the SADMERC prior to August 2008.  
21 CMS, Mid-Year Improper Medicare FFS Payments, May 16, 2008.   
22 OIG, Independent Contractors Review  of  Durable Medical Equipment Claims From  
the Fiscal Year 2008 Comprehensive Error Rate Testing Program, A-01-09-00500,         
May 2009. 
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I N T R O D U C T I O N   
 
based on its review of supplier documents, beneficiary claim histories,  
and limited medical records. 
Based on these findings, OIG recommended that CMS require the 
CERT contractor to develop a corrective action plan to reduce its 
incorrect determinations and to perform a complex medical review by 
obtaining and reviewing all medical records from all relevant providers.  
In its comments to the draft report,  CMS concurred with the 
recommendations.  It also issued a memorandum to its contractors 
stating that it will clarify its manual to be explicit that clinical review 
judgment may not override statutory, regulatory, ruling, national 
coverage decision provisions, or local coverage decision provisions; and 
that all documentation and policy requirements must be met before 
clinical review judgments apply.23  
METHODOLOGY 
We based this study on data from three sources:  (1) a medical record 
review of a random sample of group  2 support surface claims;   
(2) a review of supplier documentation for these claims; and  
(3) structured interviews with staff at the four DME MACs, the three 
DME PSCs, and the SADMERC. 
Sample Selection 
For the medical record review, we selected a stratified random sample of  
400 group 2 support surface claims from CMSs National Claims History 
file. The population from which we  sampled consisted of all paid  
group 2 claims that:  (1) had a service date between January 1 and  
June 30, 2007; and (2) were submitted to CMS by September 30, 2007.  
The universe consisted of 76,780 claims that represented $44 million in 
allowed payments.24  We selected 200 claims for initial coverage for the 
first stratum and 200 claims for continued coverage for the second 
stratum. We determined whether the claim was for initial or continued 
coverage based on a modifier on the claim that indicated whether it was 
for the initial month of rental or for subsequent months. 
 
 
 
23 CMS, Clarification of Medical Review Policy, March 30, 2009.   
24 The amount of allowed payments for group 2 support surfaces in the first half of 2007 
was less than the amount in the first half of 2006.  
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Medical Record Review  
We based our analysis on 363 of the 400 claims in our sample. We 
excluded 13 claims from our analysis because the suppliers were 
currently under investigation by OIG. In addition, we were  unable to 
locate the suppliers for 24 claims. We received documentation for all of 
the remaining 363 claims, representing a 94-percent response rate. 
We used a contractor to collect and review the medical records 
associated with each sampled claim. The contractor requested from  
each supplier all medical records related to the patients wound care 
including records from physicians, hospitals, home health agencies, 
skilled nursing facilities, and wound care clinics. The contractor 
requested this information for the 60 days before the service date on the 
claim. 
Two registered nurses conducted the medical record review, each of 
whom had at least 10 years of wound-care experience. The reviewers 
used a standardized data collection instrument to review the medical 
records and determine whether each  sampled claim met Medicare 
coverage criteria. The standardized instrument was developed in 
collaboration with the reviewers and tested on  a separate sample of 
claims. The reviewers conducted their medical record review between  
March and July 2008. Additional details of the medical review are 
provided in Appendix B.  
Based on the data from the medical review, we determined the 
percentage of claims that did not meet Medicare coverage criteria. We 
determined  the percentage of claims that were in the following 
categories:  undocumented, medically unnecessary, insufficiently 
documented, and other billing errors. We looked for statistically 
significant differences in error rates between initial and continued 
claims. Lastly, we calculated the projected error rates and dollars paid 
in error for support surface claims in the first half of 2007. 
Supplier Documentation  
We conducted a separate review of the documentation that the supplier 
is required to keep  on file for each claim. To accomplish this, the  
contractor requested from the supplier the physician order and proof of  
delivery for each sampled claim. 
We reviewed the documentation for each of the 363 claims to determine 
the percentage of claims  that did not meet Medicare supplier 
documentation requirements. Specifically, we determined the 
percentage of claims that did not have a signed and dated physician 
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II NN TT RR OO DD UU CC TT II OO NN    
  
order, a proof of delivery, or a physician  order  before  delivery.   We looked  
for statistically significant differences in error rates between initial and 
continued claims. We did not include in our review an analysis of 
whether the supplier had on file statements from the physician 
regarding the patients diagnosis and which of the six criteria in the 
LCD the patient met because these documents were reviewed as part of 
the medical record review. 
Structured Interviews and Supporting Documentation 
We conducted structured telephone interviews with staff at the four  
DME MACs, the three DME PSCs, and the SADMERC. We  asked staff 
at the DME MACs about any edits or other program safeguards in place  
to prevent improper payments for group 2 support surface claims. We  
asked staff at the DME PSCs about any medical reviews and fraud 
investigations of these  claims. We asked staff at the SADMERC about 
any guidance to suppliers on the use of HCPCS codes for group 2 
support surfaces. As part of these interviews, we requested and 
reviewed any supporting documentation of program safeguards that 
were specific to group 2 support surface claims. 
Limitations 
We did not independently verify the responses from the CMS 
contractors that we interviewed.   
Standards 
Our review was  conducted in accordance with the Quality Standards 
for Inspections issued by the Presidents Council on Integrity and 
Efficiency and the Executive Council on Integrity and Efficiency (now 
Council of the Inspectors General on Integrity and Efficiency). 
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  F I N D I N G S  
Eighty-six percent of the claims for   Based on a review of medical record 
group 2 support surfaces did not meet  documentation and supplier 
documentation, we found that  
Medicare coverage criteria 
86 percent of group 2 support 
surface claims for the first half of 2007 did not meet Medicare coverage 
criteria. This amounted to an estimated $33 million in inappropriate 
payments during that time.  We  considered a claim as not meeting 
Medicare coverage criteria if it either (1) did not meet Medicares 
clinical coverage requirements, or (2) did not meet Medicares supplier 
documentation requirements.   
Specifically, we found that 80 percent of group 2 support surface claims 
did not meet Medicares  clinical coverage requirements.  In addition,  
33 percent of claims did not meet supplier documentation requirements.  
Over three-quarters of the claims that did not meet supplier 
documentation requirements also did not meet Medicares clinical 
coverage requirements.    
Eighty percent of group 2 support surface claims did not meet clinical 
coverage requirements 
Our medical record review found that 80 percent of group 2 support 
surface claims for the first half of 2007 did not meet Medicares clinical 
coverage requirements. Table 3 describes the different types of errors, 
the error rates, and the estimated dollars paid in error.  Appendix  C  
provides the confidence intervals for  the key estimates.  
 
Table 3: Clinical Coverage Errors for Group 2 Support Surface  
Claims, First Half of 2007 
Type of Error  Percentage of Claims  Allowed Amount  
Undocumented  38%  $14,413,237 
Medically unnecessary   22%  $8,882,785 
Insufficient documentation  17%  $7,022,886 
Other  billing errors    3%   $745,497* 
 Total errors  80%   $31,064,405 
Source: OIG analysis of medical review results, 2008. 
* Note: Relative precision equals 90 percent. 
 
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Thirty-eight percent of all group 2 support surface claims in the first half of 
2007 were undocumented.  This represented $14.4 million in allowed 
payments.  For these claims, the suppliers either did not submit any 
medical records to document the claims or they  provided records that 
did not correspond to the time period of our review.  Claims that lack 
documentation to show that the care  was reasonable and necessary do 
not meet Medicare coverage criteria.   
Continued claims were more likely to be undocumented than initial 
claims. Forty-two percent of continued claims were undocumented, 
compared to 15 percent  of initial claims. This difference was 
statistically significant at the 95-percent confidence level.  See  
Appendix D for statistical correlations. 
Twenty-two percent of all group 2 support surface claims in the first half of 
2007 were not medically necessary.  This represented nearly $8.9 million 
in allowed payments.  For about half of these claims, there was no 
documentation of any pressure ulcers or there was documentation that 
showed that the wounds had  already healed before the service date on the 
claim. In one case, a physician clearly prescribed  the support surface for 
back pain.   
For one-quarter of these claims, the patient had a stage I or  II pressure  
ulcer, rather than multiple stage II pressure ulcers, as required.  In 
other instances, the pressure ulcers  were not located on the trunk or 
pelvis, as required (e.g., the wound was on the foot) or there was a small 
stage III or IV pressure ulcer on the trunk or pelvis, when one large or 
multiple stage III or IV pressure ulcers are required to meet the 
coverage criteria.   
Many of the claims that were not medically necessary met the  
less-restrictive criteria for group 1 support surfaces.  In these cases, the 
supplier provided a group 2 support surface when the beneficiary only  
qualified for a more basic and lower-cost group 1 support surface.  These 
claims may be instances in which the supplier provided an upgrade but 
did not bill for it appropriately.25  In total, these claims amounted to  
 
25 For information on the correct billing  procedures for an upgrade, see CMS, Medicare 
Claims Processing Manual, ch.30,  50.7.450.7.5 (as of Rev. 1; effective October 1, 2003). 
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F I N D I N G S  
 
15 percent of all group 2 support surface claims in the first half of 
2007.26  
An additional 17 percent of all group 2 support surface claims in the first 
half of 2007 were insufficiently documented.  This represented   
$7.0 million in allowed payments.  For half of these claims, there was no 
documentation of the characteristics of the wound such as the stage of 
the pressure ulcer or the measurements of the wound.  For another   
one-fifth of the claims, there was no  documentation of the healing 
progress of the pressure  ulcer.   For  several other claims in this category, 
the reviewers noted that the supplier may not have submitted the 
medical records from all appropriate providers to  substantiate the 
claim. Medicare may hold  suppliers liable if the information in the 
patients medical record, as submitted by the supplier, does not 
adequately support the medical necessity of the support surface.27    
Initial claims were more likely to  be insufficiently documented than 
continued claims.  Twenty-eight percent of initial claims were 
insufficiently documented, compared to 16 percent of continued claims.  
This difference was statistically significant at the 95-percent confidence 
level. 
Another 3 percent of the claims in the first half of 2007 were for other billing 
errors.  This represented $745,000 in allowed payments.  For these 
claims, the suppliers stated that they had used the wrong HCPCS code, 
incorrectly billed for a patient who was deceased or for patients who 
were in skilled nursing homes or hospitals, or had made other types of  
errors.  In all of these cases, the suppliers had either already refunded  
the money to Medicare or said that they were planning to do so. In a 
few cases, it was apparent that the suppliers had contacted Medicare to 
refund the money only after we had requested the medical records for  
that claim. In total, we received documentation of a refund for almost 
half of the claims in this category.   
 
 
 
26 We were unable to calculate the total dollars allowed for these claims.  In these 
instances, the medical reviewers were unable to  determine which group 1 support surface  
was appropriate and therefore we could not determine the corresponding  payment amount.       
27 PIM,  5.7. 
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F I N D I N G S  
 
Thirty-three percent of group 2 support surface claims did not meet supplier 
documentation requirements 
Based on a review of supplier documentation, we found that 33 percent 
of all group 2 support surface claims for the first half of 2007 did not 
meet supplier documentation requirements.28  Medicare requires the 
supplier to keep on file a number of documents, including the signed 
and dated physician order and proof of delivery for each claim.29   
Medicare also requires that the supplier have the physician order before 
delivering the support surface.30    
As shown in Table 4, for 16 percent of  the claims, the supplier delivered 
the support surface to the beneficiary before obtaining the physician 
order.   For 13 percent of  the claims, the supplier did not have a 
physician order.  For 8 percent of the claims, the supplier did not have 
proof that the support surface was delivered to the beneficiary.  For  
1 percent of  the claims, the physician order was not dated.  
Continued claims were less likely to  meet the supplier documentation 
requirements than initial claims.  Thirty-four percent of continued 
claims did not meet these requirements, compared to 23 percent of 
initial claims. This difference was statistically significant at the  
95-percent confidence level.   
Table 4: Supplier Documentation Errors for Group 2  
Support Surface Claims, First Half of 2007 
Type of Error  Percentage of Claims 
Delivery before physician order  16% 
Physician order missing  13% 
Proof of delivery  missing  8% 
Physician order not dated  1% 
 Total   33%*  
*Note:  The percentages do not add  up to 33 percent because some claims had 
more than one type of error.   
Source: OIG analysis of supplier documentation, 2008. 
 
 
28 The supplier documentation analysis is based on 356 claims.   

29 PIM,  5.8. 

30 Ibid. 

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FF II NN DD II NN GG SS  

  
The DME MACs and PSCs, as 
CMS contractors had limited program 
well as the SADMERC, had 
safeguards in place to prevent improper 
limited safeguards in place to 
payments for group 2 support surfaces 
prevent improper payments for 
group 2 support surface claims. 
Staff at the four DME MACs reported that they relied primarily on two 
claims processing edits to prevent improper payments for support 
surfaces. The DME MACs each had an edit in place that checked  
whether the diagnosis code supported the medical necessity  of claims.31   
Also, they each had an edit in place that checked for the KX modifier on  
a claim.32  Staff at the DME MACs explained that claims that did not 
have the KX modifier were flagged for possible review. In our sample, 
all but one of the claims  included the KX modifier, even though we 
found that 80 percent of the claims did not meet clinical coverage 
criteria.    
To varying degrees, staff at the DME MACs also noted that they had 
other,  more  general edits in place. These edits included checks to 
ensure that the beneficiary was covered by Medicare, that there were no  
duplicate claim submissions, that the beneficiary did not have similar 
DME, and that payments did not exceed the allowed capped rental 
payment. 
In addition, none of the three PSCs conducted any widespread medical 
reviews of support surface claims. Staff at two of the PSCs, which 
covered three regions, reported conducting limited medical reviews for 
only a small number of suppliers. One of these PSCs reviewed claims 
for seven suppliers in 2005. The other PSC reviewed claims for five 
suppliers in 2006. 
Moreover, only two of the four DME  MACs conducted supplier education  
activities in recent years that focused on group 2 support surfaces. In 
March 2007, one DME MAC conducted an open house and reviewed 
group 2 support surface  documentation requirements, the criteria for  
medical necessity, and the use of the KX modifier. Staff at another  
DME MAC reported that, in April 2005, the previous contractor for the 
region provided information to suppliers on group 2 support surfaces in 
 
31 The LCD specifies certain diagnosis codes that support medical necessity. 
32 As noted earlier, the supplier uses the KX modifier to indicate that a claim meets 
Medicare coverage criteria and that adequate documentation exists in the medical record. 
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F I N D I N G
  S  
 
its bulletin.  This same DME MAC also maintains information on its 
Web site about the coverage criteria for group 2 support surfaces.   
Staff at the SADMERC further reported that they had not conducted any 
recent analyses of group  2 support surface claims.  They did note, 
however, that an analysis they conducted of Florida suppliers whose 
Medicare billing privileges were revoked showed  that support surfaces 
made up  the top DME group billed  by these suppliers.   
 
 
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  R E C O M M E N D A T I O N S  
 
 
Based on a review of medical record documentation and supplier 
documentation, we found that 86 percent of group 2 support surface 
claims for the first half of 2007 did not meet Medicare coverage criteria.  
This resulted in an estimated $33 million in inappropriate payments.  
We considered a claim as not meeting Medicare coverage criteria if it 
either (1) did not meet Medicares clinical coverage requirements, or   
(2) did not meet Medicares supplier documentation requirements.   
Specifically, we found that 80 percent of group 2 support surface claims 
did not meet Medicares  clinical coverage requirements.  In addition,  
33 percent of claims did not meet supplier documentation requirements.  
Over three-quarters of the claims that did not meet supplier 
documentation requirements also did not meet Medicares clinical 
coverage requirements.   Lastly, we found that CMS contractors had 
limited program safeguards in place to prevent improper payments for 
group 2 support surfaces.   
Taken together, the results show that CMSs current program safeguard 
activities are not sufficient and that additional steps are needed to 
reduce the high error rate for group 2 support surface claims.    
Based on the findings in this report, we recommend that CMS: 
Ensure that claims for group 2 support surfaces meet Medicare coverage 
criteria and are paid appropriately  
To address this recommendation, CMS should: 
 	  Conduct additional prepayment and postpayment medical 
reviews of group 2 support surface claims;   
 	  Educate suppliers and health care providers such as home 
health agencies about Medicare coverage criteria for support  
surfaces.  Education should inform  suppliers and health care  
providers about the information that needs to be documented in 
the medical record for initial and continued coverage and point 
out that claims that do not meet  the coverage criteria should not 
be submitted. Education should also focus on differences in the 
coverage criteria between group 1 and group 2 support surfaces; 
 	  Review the  use of the KX modifier as a program  safeguard; and  
 	  Conduct additional statistical analyses to monitor payments for 
group 2 support surfaces. 
 
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R E C O M M E N D A T I O N S  
Take appropriate action regarding the claims in our sample that  were 
inappropriate 
CMS should follow up on the claims that were undocumented, medically 
unnecessary, insufficiently documented, and had billing errors in which 
the money  was not already refunded to Medicare.  CMS should also 
follow up on the claims in which the supplier delivered  the  support  
surface before obtaining the physician order, the  supplier  did  not  have  a  
physician order, the supplier was missing the proof of delivery, or the 
physician order was not dated.  Finally, CMS should follow up on the 
suppliers that could not be located.  To help CMS address this 
recommendation, we will forward information about these claims in a 
separate memorandum.    
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
CMS concurred with all five of our recommendations.  In response to our  
first recommendation, CMS stated that it will share our findings on 
inappropriate claims with the DME MACs for potential additional 
prepayment edits and prepayment medical review.  CMS also noted that 
it will forward the list of questionable claims to the Recovery Audit 
Contractors (RAC) and DME MACs.  The RACs review Medicare  claims 
on a postpayment basis and are tasked with identifying inappropriate 
payments. CMS further commented that it will revise the MAC review  
instructions to clarify that all MACs may initiate widespread service-
specific prepayment review without first conducting probe reviews for 
problem areas identified by various parties, including OIG.  
In response to our second recommendation, CMS stated that it will 
issue a Medicare Learning Network  Matters article to remind suppliers 
and health care providers, such as home health agencies, about 
Medicare coverage criteria for support surfaces.    
In response  to our third  recommendation, CMS stated that it is 
currently reviewing the utility and use of the KX modifier, including its 
application in DME.  This review includes an analysis of claims 
submitted with the modifier, discussions with contractors, and outreach  
to other CMS components with policy responsibilities related to the KX 
modifier.   
In response to our fourth recommendation, CMS stated that it will 
share our recommendation about conducting additional statistical 
analyses with the appropriate contractors for their consideration in 
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R E C O M M E N D A T I O N S  
ongoing monitoring of these claims.  CMS further noted that an internal  
data analysis team recently completed an analysis on support surfaces 
and that the team will continue to monitor data periodically to look for 
suspicious trends.   
In response  to our fifth recommendation, CMS noted that once it 
reviews the inappropriate claims and better understands the nature of 
these claims, it will forward them to  the appropriate contractors.   
We support CMSs efforts to address these issues and encourage it to  
continue to  make progress in these areas.  The full text of CMSs 
comments is provided in Appendix E. 
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  A P P E N D I X ~ A
 
Local Coverage Determination for  
Pressure  Reducing Support SurfacesGroup 2 
The text quoted below contains the coverage and payment rules and the 
supplier documentation requirements that were  effective between 
March 1, 2006, and June 30, 2007, for group 2 support surfaces as they 
appeared in the Local Coverage Determination (LCD) issued by all four 
Durable Medical Equipment (DME) Medicare Administrative 
Contractors  (MAC).  We have included only sections of the LCD that are 
relevant to  our study.   
The full text of the LCDs from  all DME MACs can be found at 
http://www.cms.hhs.gov/mcd/search.asp. The four relevant LCD policy 
numbers are L11564, L5068, L11579, and L27009.   
 
  Indications and Limitations of Coverage and/or Medical 
Necessity 
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.  For  the items addressed in this 
medical policy, the criteria for reasonable and necessary 
are defined by the following indications and limitations of 
coverage and/or medical necessity. 
A group 2 support surface is covered if the patient meets: 
                a) Criterion 1  and 2 and 3, or  
                b) Criterion 4,  or  
                c)  Criterion 5  and 6.  
1) Multiple stage II pressure ulcers located on the trunk 
or pelvis [International Classification of Diseases (ICD), 
9th Revision] (ICD-9 707.02707.05).  
2) Patient has been on a comprehensive ulcer treatment 
program for at least the past month which has included 
the use of an appropriate group 1 support surface.  
3) The ulcers have worsened  or remained the same over 
the past month. 
4) Large or multiple stage III or IV pressure ulcer(s) on 
the trunk or pelvis (ICD-9 707.02707.05).  
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5) Recent myocutaneous flap or skin graft for a pressure 
ulcer on the trunk or pelvis (surgery  within the past 60 
days) (ICD-9 707.02707.05).  
6) The patient 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).     
The comprehensive ulcer treatment described in #2 above 
should generally include: 
i) Education of the patient and caregiver on the 
prevention and/or management of pressure ulcers.   
ii) Regular assessment by a nurse, physician, or other 
licensed health care practitioner (usually at least weekly
for a patient with a stage III or IV ulcer). 
iii) Appropriate turning and positioning.  
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.  
If the patient is on a group 2 surface, there should be a care 
plan established by the physician or home care nurse which 
includes the above elements.  The support surface provided 
for the patient should be one in which the patient does not 
bottom out (see Appendices section). 
When a group 2 surface is covered following a myocutaneous 
flap or skin graft, coverage generally is limited to 60 days 
from the date of surgery.  
When the stated coverage criteria for a group 2 mattress or 
bed are not met, a claim will be denied as not medically 
necessary unless there is clear documentation which justifies 
the medical necessity for the item in the individual case. A 
group 2 support surface billed without a KX modifier (see 
Documentation section) will usually be denied as not 
medically necessary. 
Continued use of a group 2 support surface is covered until 
the ulcer is  healed or, if healing does not continue, there is 
documentation in the medical record to show that: (1) other 
aspects of the care plan are being modified to promote 
healing, or (2) the use of the group 2 support surface is 
medically necessary for wound management.  
Appropriate use of the KX modifier (see Documentation 
section) is the responsibility of the supplier billing the 
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A P P E N D I X   ~   A  
 
[Durable Medical Equipment Regional Carrier] DMERC.33  
The supplier should  maintain adequate communication on 
an ongoing basis with the clinician providing the wound care 
in order to accurately determine that use of the  KX modifier 
still reflects the clinical conditions which meet the criteria 
for coverage of a group 2 support surface, and that adequate 
documentation exists in the medical record reflecting these 
conditions.   Such documentation should not be submitted 
with a claim but should be available for review if requested 
by the DMERC. 
 
Coding Information  
  [Current Procedural Terminology] CPT / 

      [Healthcare Common Procedure Coding System] HCPCS Codes 

The appearance of a code in this section does not necessarily 

indicate coverage. 

E0193  Powered Air Flotation Bed (Low Air Loss Therapy) 

E0277  Powered Pressure Reducing Air Mattress 

E0371  Nonpowered Advanced Pressure Reducing Overlay 

for Mattress, Standard Mattress Length and Width 

E0372  Powered Air Overlay for Mattress, Standard 

Mattress Length and Width 

E0373  Nonpowered Advanced Pressure Reducing Mattress 

E1399   Durable Medical Equipment, Miscellaneous 

 
  HCPCS Modifier 
      KX - Specific required documentation on file. 
 
  ICD-9 Codes that Support Medical Necessity  
     707.02707.05 
      Decubitus Ulcer, Upper Back  Decubitus Ulcer, Buttock  
 
33  DMERCs have subsequently been replaced by  DME MACs. 
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A P P E N D I X   ~   A  
 
      Documentation Requirements  
  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 (42 U.S.C. section 1395l(e)).
It is expected that the patients medical records will reflect 
the need for  the care provided.  The  patients medical records 
include the physicians office records, hospital records, 
nursing home records, home health agency records, records 
from other health care professionals and test reports. This  
documentation must be available to the DMERC upon 
request. 
  An order for each item billed must be signed and dated by 
the treating physician, kept on file by the supplier, and 
made available to the DMERC upon request.   
  The supplier must obtain information concerning which, if 
any, of criteria 16 listed in the Coverage and Payment 
Rules section of this policy the patient meets in a signed and 
dated statement from the treating physician.  A suggested 
form for collecting this information is attached.  Questions 
pertaining to medical necessity on any form used to obtain 
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 patients 
medical record which would be available to the DMERC on  
request.  Do not send this form to the DMERC unless 
specifically requested. 
   Suppliers must add a KX modifier to a code  only if all of the 
criteria in the Indications and Limitations of Coverage 
and/or Medical Necessity section of  this policy have been 
met.   
  When code E1399 is billed, the claim must include a 
narrative description of the item, the manufacturer, the 
model name or number (if applicable), and information 
justifying the medical necessity for the item. 
  Refer to the Supplier Manual for more information on 
documentation requirements. 
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A P P E N D I X   ~   A  
 
Staging of Pressure Ulcers 
The staging of pressure ulcers used in this policy is as 
follows: 
  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.   
  Bottoming out is the finding that an outstretched hand can 
readily palpate the bony prominence (coccyx or lateral 
trochanter) when it is placed palm up beneath the 
undersurface of the mattress or overlay and in an area 
under 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. 
 
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  A P P E N D I X ~ B
 
Additional  Details of the Medical Review  
 
Data Collection Instrument   
The data collection instrument that the reviewers used to review the  
medical records was computer-based and included automated skip 
patterns and quality control checks.  The reviewers entered data 
directly into the system.  The instrument included questions based on 
the criteria in the Local Coverage Determination.  For example, it asked  
about the characteristics of the wound for which the support surface 
was prescribed and included specific questions depending on the wound  
type and whether the claim was for initial or continued coverage.   
Test Review  
To test the data collection instrument, the reviewers conducted a 
preliminary medical review of 15 claims that we randomly selected from 
the universe of all claims in the first half of 2007. This sample was 
separate from the sample of 400 claims that were used for the main 
review, and all claims were available for selection in both samples.  
None of the claims was in both samples.  Each reviewer reviewed the 
medical records for 10 claims; both reviewers reviewed five of the same  
claims. We discussed the results with the reviewers to ensure that they  
were making consistent determinations about whether the claims met 
Medicare coverage criteria.    
 
   
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  A P P E N D I X ~ C
 
Confidence Intervals for Selected Estimates 
Confidence intervals for percentages were made using the logic 
transformation. 
 
 
Point  95-Percent 
Estimate Description       n  Estimate  Confidence Interval 
 
Percentage of all group 2 support 
363              85.8%   80.9%89.6%  
surface claims that did not meet  
Medicare coverage criteria 
Source: Office of Inspector General (OIG) analysis of medical review results, 2008.  
 
 
 
Point  95-Percent 
Estimate Description      n  Estimate  Confidence Interval 
 
Percentage of all group 2 support 
363  80.3%   74.8%84.8%  
surface claims that did not meet  
clinical coverage requirements  
 
Percentage of undocumented    363  38.2%  32.1%44.8% 
claims 
 
Percentage of medically   363  22.2%  17.3%28.1% 
unnecessary claims 
 
Percentage of insufficiently    363  17.2%  13.0%22.5% 
documented claims 
 
Percentage of claims that had  363  2.6%  1.1%5.8% 
other types of billing errors   
Source: OIG analysis of medical review results, 2008.  
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A P P E N D I X   ~   C  
Confidence  Intervals  for Selected Estimates (continued) 
 
 
     
Point  95-Percent 
Estimate Description  n  Estimate  Confidence Interval 
 
Percentage of claims that did  
363  32.8%   27.0%39.2%  
not meet Medicare supplier 
documentation requirements 
 
Percentage of claims that were 
363  16.3%  12.0%21.8% 
delivered before the physician 
order 
 
Percentage of claims missing  363  13.0%  9.1%18.2% 
the physician order 
 
Percentage of claims missing  363  7.6%  4.8%11.9% 
proof of delivery 
 
Percentage of claims missing  363  1.0%  0.2%3.9%  
the date on the physician order 
Source: OIG analysis of supplier documentation, 2008.  
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A P P E N D I X   ~   C  
 
Confidence  Intervals  for Selected Estimates (continued) 
 
   
Point  95-Percent 
Estimate Description       n  Estimate  Confidence Interval 
 
Amount allowed for all group 2 
363  $33,486,732  $31,151,634$35,821,830 
support surface claims that did not 
meet Medicare coverage criteria 
 
 
   
Point  95-Percent 
Estimate Description       n  Estimate  Confidence Interval 
 
Amount allowed for all group 2 
support surface claims that did not  363  $31,064,405  $28,623,437$33,505,373 
meet clinical coverage 
requirements 
 
Amount allowed for  363  $14,413,237  $11,905,511$16,920,963 
undocumented claims 
 
Amount allowed for medically   363  $8,882,785  $6,696,002$11,069,568 
unnecessary claims 
 
Amount allowed for insufficiently   363  $7,022,886  $5,097,751$8,948,022 
documented claims 
 
Amount allowed for claims that  363  $745,497  $74,491$1,416,503 
had other types of billing errors 
Source: OIG analysis of medical review results, 2008. 
 
 
 
 
 
 
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  A P P E N D I X ~ D
 
Weighted Chi-Square Test for Initial and Continued Claims 
 
  Weighted Chi-Square Test for Initial and Continued Claims  
     
          Claim Type   Undocumented   P-Value  
Difference in      
percentage of claims      Initial claim  15.1%   
that were      < 0.0001 
undocumented, by   Continued claim   41.6%   
type of claim   
Insufficiently  
 
Claim Type   documented   P-Value  
 
Difference in      
percentage of claims      Initial claim  27.6%   
that were insufficiently       0.0057 
documented,   Continued claim   15.7%   
by type of claim   
  Did not meet  supplier  
  documentation  
  Claim Type   requirements   P-Value  
       
Difference in      Initial claim  22.7%   
percentage of claims      0.0142 
that did not meet   Continued claim   34.3%   
supplier documentation   
requirements,   
by type of claim  
 
Source: Office of Inspector General analysis of medical review results and supplier 
documentation, 2008. 
 
 
 
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  A P P E N D I X ~ E
Agency Comments 
(J-.
#,I'V1Ctl
DEPARTMENTOFHEALlH& HUMANSEVICPS CenterstorMedicare&MedicaidServices
Administrator
Washington,DC 20201
JUL 022009
DATE:
TO: DanielR, Levinson
, InspectorGeneral
0,-iuJJ/~ ;;;)-y-;3~ ,~
FROM: CharleneFrizzera
ActingAdministrator
SUBJECT: OfficeofInspectorGeneral(OIG)DraftReport:"InappropriateMedicare
PaymentsforPressureReducingSupportSurfaces"OEI-02-07-00420
Thankyoufortheopportunitytoreviewandcommentontheabove-referencedOIGdraft
report.
MedicarePartBcoverspressurereducingsupportservicesasdurablemedicalequipment
(DME). Pressurereducingsupportsurfacesarecategorizedintothreegroupsbasedon
thecomplexityoftheirfeatures. In2007,Medicarespent$109millionongroup2
supportsurfaces,accountingfor80percentofallsupportsurfacepayments. TheOIG
examinedasampleofclaimsfromthefirsthalfof2007andfoundthat86percentof
group2supportsurfaceclaimsdidnotmeetMedicarecoveragecriteria. Basedontheir
review,aclaimdidnotmeetMedicarecoveragecriteriaifitdidnoteitherI)meet
clinicalcoveragerequirementsor2)meetsupplierdocumentationrequirements.
TheOIGestimatedtheinappropriategroup2supportsurfaceclaimsamountedto$33
millionininappropriatepayments. TheOIGalsoexpressedconcernthattheCentersfor
Medicare& MedicaidServices(CMS)contractorshadlimitedprogramsafeguardsin
placetopreventimproperpaymentsforgroup2supportsurfaces.
TheOIGfound 38percentoftheirsampleofgroup2supportsurfaceclaimstobe
undocumentedand 17percentofgroup2supportsurfacestobeinsufficiently
documented. Inaddition,22percentofgroup2supportsurfaceclaimswerefoundtobe
notmedicallynecessary. TheOIGfound that,formanyofthemedicallyunnecessary
claims,thebeneficiaryqualifiedforamorebasicandlower-costgroup 1supportsurface
ratherthanthegroup2supportsurface.
TheOIGmadethefollowingrecommendations:
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Page2- DanielR.Levinson
OIGRecommendation
Ensurethatclaimsforgroup2supportsurfacesmeetMedicarecoveragecriteriaandare
paidappropriately. CMSshould:
Conductadditionalprepaymentandpost-paymentmedicalreviewsofgroup2support
surfaceclaims.
CMSResponse
TheCMSconcurswiththerecommendationandwillsharetheOIGfindingson
inappropriategroup2supportsurfaceclaimswiththeDurableMedicalEquipment
MedicareAdministrativeContractors(DMEMACs)forpotentialadditionalprepayedits
andprepaymedicalreview. CMSwillinformDMEMACsofthisissuesothattheymay
consideritwhenprioritizingtheirmedicalreviewstrategiesaspartoftheCMSeffortto
protecttheMedicareTrustFunds.
TheCMSwillalsotakeappropriateactiontoforwardthelistingofquestionableclaimsto
theRecoveryAuditContractors(RACs)andDMEMACs. TheRACsreviewMedicare
claimsonapostpaymentbasisandaretaskedwithidentifyinginappropriatepayments.
WhileCMSdoesnotmandateareasforRACreview,wewillsharethisinformationwith
themandencouragethemtoconsiderthesefindingsastheydecidewhatclaimsto
review.
TheCMSwillalsorevisetheMACreviewinstructionstoclarifythatallMACscan
initiatewidespreadservice-specificprepayreviewwithoutfirstconducting"probe"
reviewsforproblemareasidentifiedbyCMS,ComprehensiveErrorRateTesting
(CERT),RACs,GAOand/orOIG. Weexpecttoreleasethisnewinstructionduring
fiscal year2009.
OIGRecommendation
Educatesuppliersandhealthcareproviders,suchashomehealthagencies,about
Medicarecoveragecriteriaforsupportsurfaces. Educationshouldinformsuppliersand
healthcareprovidersabouttheinformationthatneedstobedocumentedinthemedical
recordforinitialandcontinuedcoverage. Educationshouldalsofocusondifferencesin
thecoveragecriteriabetweengroup Iandgroup2supportsurfaces.
CMSResponse
TheCMSconcursandwillissueanMLNMattersarticletoremindsuppliersandhealth
careproviders,suchashomehealthagencies,aboutMedicarecoveragecriteriafor
supportsurfaces. Itwillspecificallya)addresstheinformationthatneedstobe
documented,b)remindsuppliersnottosubmitclaimsifcoveragecriteriaarenotmet,
andc)highlightthedifferencesincoveragecriteriaforgroup Iandgroup2support
surfaces. CMSexpectstoreleasethisarticleinthesummerof2009.
OIGRecommendation
ReviewtheuseoftheKXmodifierasaprogramsafeguard.
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Page3- DanielR. Levinson
CMSResponse
TheCMSconcurswiththerecommendationandiscurrentlyreviewingtheutilityanduse
oftheKXmodifierincludingitsapplicationinDME. Thisreviewincludesananalysisof
claimssubmittedwiththemodifier,discussionswithcontractors,andoutreachtoother
CMScomponentswithpolicyresponsibilitiesrelatedtotheKXmodifier.
OIGRecommendation
Conductadditionalstatisticalanalysestomonitorpaymentsforgroup2supportsurfaces.
CMSResponse
TheCMSconcursandwillsharethisrecommendationwithappropriatecontractors
includingthePrice,DataAnalysisandCodingcontractor,fortheirconsiderationin
ongoingmonitoringoftheseclaims. Itshouldbenotedthataninternaldataanalysisteam
recentlycompletedananalysisonsupportsurfacedevices~ Theteamwillcontinueto
monitordataperiodicallyto lookforsuspicioustrends,andwillconductanalysesonany
futurereferralsregardingthesetypesofdevices.
OIGRecommendation
Takeappropriateactionregardingtheclaimsinoursamplethatwereinappropriate. CMS
shouldfollowupontheclaimsthatwereundocumented,medicallyunnecessary,
insufficientlydocumented,andthathadbillingerrorswherethemoneywasnotalready
refundedtoMedicare. CMSshouldalsofollowupontheclaimswherethesupplier
deliveredthesupportsurfacebeforeobtainingthephysicianorder,thesupplierdidnot
haveaphysicianorder,thesupplierwasmissingtheproofofdelivery,orthephysician
orderwasnotdated. Finally,CMSshouldfollowuponthesuppliersthatcouldnotbe
located. TohelpCMSaddressthisrecommendation,wewillforwardinformationabout
theseclaimsinaseparatememorandum.
CMSResponse
TheCMSconcursthatactionshouldbetakenregardinginappropriateclaims. CMS
cannotcommittospecificactionsatthistimeaswedonotknowhowresourceintensive
theappropriateactionswillbe. OnceCMShasreviewedtheseclaimsandbetter
understandsthenatureoftheclaims,CMSwillforwardthemtotheappropriate
contractors.
TheCMSrequeststheOIGtofurnishthenecessarydata(Medicarecontractornumbers,
providernumbers,claimsinformationincludingthepaiddate, HICnumbers,andany
otherrelevantmaterials)sothatCMScaninitiateactionsoneachinappropriateclaim. In
addition,MedicarecontractorspecificdatashouldbewrittentoseparateCD-ROMsor
separatehardcopyworksheetsinordertobetterfacilitatethetransferofinformationto
theappropriatecontractors.
Finally,CMSwillreviewtheinformationprovidedbytheOIGandwillensurethatthe
suppliersindentifiedbyOIGcontinuetomeetthesupplierstandardsfound inFederal
regulationsat42CFR424.57(c).
 
OOEEII--0022--0077--0000442200     IINNAAPPPPRROOPPRRIIAATTEE    MMEEDDIICCAARREE    PPAAYYMMEENNTTSS  FFOORR    PPRREESSSSUURREE  RREEDDUUCCIINNGG    SSUUPPPPOORRTT    SSUURRFFAACCEESS    3322     
   
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Page4 - DanielR. Levinson
TheCMSthankstheOIGfor itseffortsonthisreportandforhighlightingthispotential
vulnerabilityintheMedicareprogram. CMSiscommittedtocontinuallyreviewingand
refiningourprocessesto improvetheMedicareprogram,andwewill takethefindingsof
thisreportunderconsiderationaswecontinuetostrengthenouroversighteffortsto
furtherreduceimproperpaymentsintheMedicareprogram. Welookforwardto
continuingtowork withtheOIGto identifyandpreventfraud, waste,andabuseinthe
Medicareprogram. .
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  A C K N O W L E D G M E N T S
 
This report was prepared under the direction of Jodi Nudelman, 

Regional Inspector General for Evaluation and Inspections in the  

New York regional office, and Meridith Seife, Deputy Regional Inspector 
 
General. 

Judy Kellis served as the team leader for this study.  Other principal 

Office of Evaluation and Inspections staff from the New York regional 

office who contributed to the report include Christine Moundas and 

David Rudich; central office staff who contributed include  

Robert Gibbons and Scott Manley. 

 
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