Department of Health and Human Services
 

OFFICE OF 

INSPECTOR GENERAL 

INAPPROPRIATE 


MEDICARE PAYMENTS FOR 


PRESSURE REDUCING 


SUPPORT SURFACES
 

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 

programs. This statutory mission is carried out through a nationwide network of audits, 

investigations, and inspections conducted by the following operating components: 

Office of Audit Services 

The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 

audits with its own audit resources or by overseeing audit work done by others. Audits 

examine the performance of HHS programs and/or its grantees and contractors in carrying 

out their respective responsibilities and are intended to provide independent assessments of 

HHS programs and operations. These assessments help reduce waste, abuse, and 

mismanagement and promote economy and efficiency throughout HHS. 

Office of Evaluation and Inspections 

The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 

HHS, Congress, and the public with timely, useful, and reliable information on significant 

issues. These evaluations focus on preventing fraud, waste, or abuse and promoting 

economy, efficiency, and effectiveness of departmental programs. To promote impact, OEI 

reports also present practical recommendations for improving program operations. 

Office of Investigations 

The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 

of fraud and misconduct related to HHS programs, operations, and beneficiaries. With 

investigators working in all 50 States and the District of Columbia, OI utilizes its resources 

by actively coordinating with the Department of Justice and other Federal, State, and local 

law enforcement authorities. The investigative efforts of OI often lead to criminal 

convictions, administrative sanctions, and/or civil monetary penalties. 

Office of Counsel to the Inspector General 

The Office of Counsel to the Inspector General (OCIG) provides general legal services to 

OIG, rendering advice and opinions on HHS programs and operations and providing all 

legal support for OIG’s internal operations. OCIG represents OIG in all civil and 

administrative fraud and abuse cases involving HHS programs, including False Claims Act, 

program exclusion, and civil monetary penalty cases. In connection with these cases, OCIG 

also negotiates and monitors corporate integrity agreements. OCIG renders advisory 

opinions, issues compliance program guidance, publishes fraud alerts, and provides other 

guidance to the health care industry concerning the anti-kickback statute and other OIG 

enforcement authorities. 
 

 

EXECUTIVE SUMMARY 

 

 

Δ EXECUTIVE SUMMARY 

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 

 O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES i 
 

 

 

 

E X E CUTIVE S U MMAR Y 

meet Medicare’s clinical coverage requirements, or (2) did not meet 

Medicare’s supplier documentation requirements. 

Based on an independent medical review, we found that 80 percent of 

group 2 support surface claims did not meet Medicare’s 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 

Medicare’s 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 

O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES ii 
 

 

 

 

 

EXE CUTIVE S U MMAR Y 

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 COMMENTS AND 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. 

O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES iii 
 

 

EXECUTIVE SUMMARY 

We support CMS’s efforts to address these issues and encourage it to 

continue to make progress in these areas. 

 O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES iv 
 

 

 O

 

 

 

 

E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES v

i 

Δ TABLE OF CONTENTS 

EXECUTIVE SUMMARY .................................... 
 

INTRODUCTION ........................................... 1 
 

FINDINGS ................................................ 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 
 

RECOMMENDATIONS ..................................... 17 
 

Agency Comments and Office of Inspector General Response . . . 18 

APPENDIXES ............................................. 20 
 

A: Local Coverage Determination for Pressure Reducing 

 Support Surfaces—Group 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 
 

ACKNOWLEDGMENTS .................................... 34 
 
 

 

 

Δ INTRODUCTION 

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 CMS’s Comprehensive Error Rate Testing (CERT) contractor calculated Medicare’s 

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 contractor’s medical review of 

DME claims calculated a higher DME error rate in the CERT sample—either 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. 

 O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 1 
 

 

 

 

 

INTROD U C T I O N 

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. 

O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 2 
 

 

 

 

 

INTROD U C T I O N 
 

Table 1: Group 2 Support Surface HCPCS Codes 

HCPCS Su pport Surface Name 

2007 Average Fee 

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 

mattress, standard mattress length and width $436 

E0372 Powered air overlay for mattress, 

standard mattress length and width $529 

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). 

O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 3 
 

 

 

 

INTROD U C T I O N 

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 patient’s 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. 

O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 

10 The four LCDs are entitled “LCD for Pressure Reducing Support Surfaces—Group 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. 

4 
 

 

 

 

INTRODUCTION 
 

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 Surfaces—Group 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 patient’s 

medical records contain sufficient documentation of medical necessity.11 

The supplier does not need to have documentation in the patient’s 

 O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 

11 CMS, “Medicare Program Integrity Manual” (PIM), ch.5, § 5.7 (as of Rev. 167; effective 

10-01-06). “LCD for Pressure Reducing Support Surfaces—Group 2.” PIM provisions cited 

were in effect during the period of this study. 

5 
 

 

 

 

 

 

 

INTROD U C T I O N 

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 patient’s 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 patient’s 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 physician’s 

order, information from the physician concerning the patient’s 

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 Surfaces—Group 2,” Documentation 

Requirements. 

18 If the criteria are not met, the supplier must include additional documentation with 

the claim to justify coverage. 

O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 6 
 

 

 

 

 

INTRODUCTION 

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 contractor’s 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 contractor’s payment 

determinations. OIG determined that Palmetto’s results did not provide 

assurance that the error rate was accurate. OIG found that Palmetto’s 

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 contractor’s 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 Contractor’s Review of Durable Medical Equipment Claims From 

the Fiscal Year 2008 Comprehensive Error Rate Testing Program,” A-01-09-00500, 

May 2009. 

 O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 7 
 

 

 

 

INTRODUCTION 

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 CMS’s 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. 

 O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 

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. 

8 
 

 

INTROD U C T I O N 

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 patient’s 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 

O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 9 
 

 

 

 

INTROD U C T I O N 

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 patient’s 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 President’s Council on Integrity and 

Efficiency and the Executive Council on Integrity and Efficiency (now 

Council of the Inspectors General on Integrity and Efficiency). 

O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 10 
 

 

 

 

 

 

Δ 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 meet Medicare’s 

clinical coverage requirements, or (2) did not meet Medicare’s supplier 

documentation requirements. 

Specifically, we found that 80 percent of group 2 support surface claims 

did not meet Medicare’s 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 Medicare’s 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 Medicare’s 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 

 O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 

Source: OIG analysis of medical review results, 2008. 

* Note: Relative precision equals 90 percent. 

11 
 

 

 

FINDING 
 S 

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 

 O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 

25 For information on the correct billing procedures for an upgrade, see CMS, “Medicare 

Claims Processing Manual,” ch.30, §§ 50.7.4–50.7.5 (as of Rev. 1; effective October 1, 2003). 

12 
 

 

 

 

 

 

FINDINGS 

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 

patient’s 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. 

 O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 

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. 

13 
 

 

 

 

 

 

FINDINGS 

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. 

 O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 

28 The supplier documentation analysis is based on 356 claims. 

29 PIM, § 5.8. 

30 Ibid. 

14 
 

 

 

 

 

F I NDING S 

CMS contractors had limited program 

safeguards in place to prevent improper 

payments for group 2 support surfaces 

group 2 support surface claims. 

The DME MACs and PSCs, as 

well as the SADMERC, had 

limited safeguards in place to 

prevent improper payments for 

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 

O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 

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. 

15 
 

 

 

FINDING 
 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. 

 O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 16 
 

 

 

 

 

Δ RECOMMENDATIONS 

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 Medicare’s clinical coverage requirements, or 

(2) did not meet Medicare’s supplier documentation requirements. 

Specifically, we found that 80 percent of group 2 support surface claims 

did not meet Medicare’s 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 Medicare’s 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 CMS’s 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. 

 O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 17 
 

 

 

 

 

 

 

RECOMMENDATIONS 

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 servicespecific 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 

 O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 18 
 

 

 

RECOMMENDATIONS 

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 CMS’s efforts to address these issues and encourage it to 

continue to make progress in these areas. The full text of CMS’s 

comments is provided in Appendix E. 

 O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 19 
 

 

 

 

 

Δ APPENDIX~A 

Local Coverage Determination for 

Pressure Reducing Support Surfaces—Group 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-9 707.02–707.05). 

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-9 707.02–707.05). 

 O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 20 
 

 

 

 

 

APPENDIX ~ A 

5) Recent myocutaneous flap or skin graft for a pressure 

ulcer on the trunk or pelvis (surgery within the past 60 

days) (ICD-9 707.02–707.05). 

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 

 O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 21 
 

 

 

 

 

 

 

 

APPENDIX ~ 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

 707.02–707.05 

 Decubitus Ulcer, Upper Back – Decubitus Ulcer, Buttock 

 O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 

33 DMERCs have subsequently been replaced by DME MACs. 

22 
 

 

 

 

 

 

APPENDIX ~ 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 patient’s medical records will reflect 

the need for the care provided. The patient’s medical records 

include the physician’s office records, hospital records, 

nursing home records, home health agency records, records 

from other 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 1–6 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 patient’s 

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. 

 O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 23 
 

 

 

APPENDIX ~ 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. 

 O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 24 
 

 

 

Δ APPENDIX~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. 

 O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 25 
 

 

 

 

 

 

Δ APPENDIX~C 

Confidence Intervals for Selected Estimates 

Confidence intervals for percentages were made using the logic 

transformation. 

Estimate Description n 

Point 

Estimate 

95-Percent 

Confidence Interval 

Percentage of all group 2 support 

surface claims that did not meet 

Medicare coverage criteria 

363 85.8% 80.9%–89.6% 

Source: Office of Inspector General (OIG) analysis of medical review results, 2008. 

Estimate Description n 

Point 

Estimate 

95-Percent 

Confidence Interval 

Percentage of all group 2 support 

surface claims that did not meet 

clinical coverage requirements 

363 80.3% 74.8%–84.8% 

Percentage of undocumented 

claims 

363 38.2% 32.1%–44.8% 

Percentage of medically 

unnecessary claims 

363 22.2% 17.3%–28.1% 

Percentage of insufficiently 

documented claims 

363 17.2% 13.0%–22.5% 

Percentage of claims that had 

other types of billing errors 

363 2.6% 1.1%–5.8% 

Source: OIG analysis of medical review results, 2008. 

 O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 26 
 

 

 

APPENDIX ~ C 

Confidence Intervals for Selected Estimates (continued) 

Estimate Description n 

Point 

Estimate 

95-Percent 

Confidence Interval 

Percentage of claims that did 

not meet Medicare supplier 

documentation requirements 

363 32.8% 27.0%–39.2% 

Percentage of claims that were 

delivered before the physician 

order 

363 16.3% 12.0%–21.8% 

Percentage of claims missing 

the physician order 

363 13.0% 9.1%–18.2% 

Percentage of claims missing 

proof of delivery 

363 7.6% 4.8%–11.9% 

Percentage of claims missing 

the date on the physician order 

363 1.0% 0.2%–3.9% 

Source: OIG analysis of supplier documentation, 2008. 

 O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 27 
 

 

 

 

 

APPENDIX ~ C 

Confidence Intervals for Selected Estimates (continued) 

Estimate Description n 

Point 

Estimate 

95-Percent 

Confidence Interval 

Amount allowed for all group 2 

support surface claims that did not 

meet Medicare coverage criteria 

363 $33,486,732 $31,151,634–$35,821,830 

Estimate Description n 

Point 

Estimate 

95-Percent 

Confidence Interval 

Amount allowed for all group 2 

support surface claims that did not 

meet clinical coverage 

requirements 

363 $31,064,405 $28,623,437–$33,505,373 

Amount allowed for 

undocumented claims 

363 $14,413,237 $11,905,511–$16,920,963 

Amount allowed for medically 

unnecessary claims 

363 $8,882,785 $6,696,002–$11,069,568 

Amount allowed for insufficiently 

documented claims 

363 $7,022,886 $5,097,751–$8,948,022 

Amount allowed for claims that 

had other types of billing errors 

363 $745,497 $74,491–$1,416,503 

Source: OIG analysis of medical review results, 2008. 

 O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 28 
 

 

 

 

 

 

 

 

Δ APPENDIX~D 

Weighted Chi-Square Test for Initial and Continued Claims 

 Weighted Chi-Square Test for Initial and Continued Claims 

Difference in 

percentage of claims 

that were 

undocumented, by 

type of claim 

Claim Type 

Initial claim 

Continued claim 

Undocumented 

15.1% 

41.6% 

P-Value 

< 0.0001 

Difference in 

percentage of claims 

that were insufficiently 

documented, 

by type of claim 

Claim Type 

Initial claim 

Continued claim 

Insufficiently 

documented 

27.6% 

15.7% 

P-Value 

0.0057 

Difference in 

percentage of claims 

that did not meet 

supplier documentation 

requirements, 

by type of claim 

Claim Type 

Initial claim 

Continued claim 

Did not meet supplier 

documentation 

requirements 

22.7% 

34.3% 

P-Value 

0.0142 

Source: Office of Inspector General analysis of medical review results and supplier 

documentation, 2008. 

 O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 29 
 

 

#,¢I'V1Ctl (J-.DEPARTMENT OF HEALlH & HUMAN SE«VICPS Centers tor Medicare & Medicaid Services

Administrator

Washington, DC 20201

DATE:

TO:

FROM:

JUL 022009

Daniel R, Levinson

, Inspector General

0,-iuJJ/~ ;;;)-y-; 3~ ,~ Charlene Frizzera

Acting Administrator

SUBJECT: Office ofInspector General (OIG) Draft Report: "Inappropriate Medicare

Payments for Pressure Reducing Support Surfaces" OEI-02-07-00420

Thank you for the opportunity toreview and comment on the above-referenced OIG draft

report.

Medicare Part B covers pressure reducing support services as durable medical equipment

(DME). Pressure reducing support surfaces are categorized into three groups based on

the complexity oftheir features. In 2007, Medicare spent $109 million on group 2

support surfaces, accounting for 80 percent of all support surface payments. The OIG

examined a sample of claims from the first half of 2007 and found that 86 percent of

group 2 support surface claims did not meet Medicare coverage criteria. Based on their

review, a claim did not meet Medicare coverage criteria if it did not either I) meet

clinical coverage requirements or 2) meet supplier documentation requirements.

The OIG estimated the inappropriate group 2 support surface claims amounted to $33

million in inappropriate payments. The OIG also expressed concern that the Centers for

Medicare & Medicaid Services (CMS) contractors had limited program safeguards in

place to prevent improper payments for group 2 support surfaces.

The OIG found 38 percent oftheir sample of group 2 support surface claims to be

undocumented and 17 percent of group 2 support surfaces to be insufficiently

documented. In addition, 22 percent of group 2 support surface claims were found to be

not medically necessary. The OIG found that, for many ofthe medically unnecessary

claims, the beneficiary qualified for a more basic and lower-cost group 1 support surface

rather than the group 2 support surface.

The OIG made the following recommendations:

Δ APPENDIX~E 

Agency Comments 

 O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 30 
 

 

Page 2 - Daniel R. Levinson

OIG Recommendation

Ensure that claims for group 2 support surfaces meet Medicare coverage criteria and are

paid appropriately. CMS should:

Conduct additional prepayment and post-payment medical reviews of group 2 support

surface claims.

CMS Response

The CMS concurs with the recommendation and will share the OIG findings on

inappropriate group 2 support surface claims with the Durable Medical Equipment

Medicare Administrative Contractors (DME MACs) for potential additional prepay edits

and prepay medical review. CMS will inform DME MACs ofthis issue so that they may

consider it when prioritizing their medical review strategies as part ofthe CMS effort to

protect the Medicare Trust Funds.

The CMS will also take appropriate action to forward the listing of questionable claims to

the Recovery Audit Contractors (RACs) and DME MACs. The RACs review Medicare

claims on a post payment basis and are tasked with identifying inappropriate payments.

While CMS does not mandate areas for RAC review, we will share this information with

them and encourage them to consider these findings as they decide what claims to

review.

The CMS will also revise the MAC review instructions to clarify that all MACs can

initiate widespread service-specific prepay review without first conducting "probe"

reviews for problem areas identified by CMS, Comprehensive Error Rate Testing

(CERT), RACs, GAO and/or OIG. We expect to release this new instruction during

fiscal year 2009.

OIG Recommendation

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. Education should also focus on differences in

the coverage criteria between group I and group 2 support surfaces.

CMS Response

The CMS concurs and will issue an MLN Matters article to remind suppliers and health

care providers, such as home health agencies, aboutMedicare coverage criteria for

support surfaces. It will specifically a) address the information that needs to be

documented, b) remind suppliers not to submit claims if coverage criteria are not met,

and c) highlight the differences in coverage criteria for group I and group 2 support

surfaces. CMS expects to release this article in the summer of 2009.

OIG Recommendation

Review the use ofthe KX modifier as a program safeguard.

APPENDIX ~ E 

 O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 31 
 

 

Page 3 - Daniel R. Levinson

CMS Response

The CMS concurs with the recommendation and is currently reviewing the utility and use

ofthe 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.

OIG Recommendation

Conduct additional statistical analyses to monitor payments for group 2 support surfaces.

CMS Response

The CMS concurs and will share this recommendation with appropriate contractors

including the Price, Data Analysis and Coding contractor, for their consideration in

ongoing monitoring ofthese claims. It should be noted that an internal data analysis team

recently completed an analysis on support surface devices~ The team will continue to

monitor data periodically to look for suspicious trends, and will conduct analyses on any

future referrals regarding these types of devices.

OIG Recommendation

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 that had billing errors where the money was not already

refunded to Medicare. CMS should also follow up on the claims where 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.

CMS Response

The CMS concurs that action should be taken regarding inappropriate claims. CMS

cannot commit to specific actions at this time as we do not know how resource intensive

the appropriate actions will be. Once CMS has reviewed these claims and better

understands the nature ofthe claims, CMS will forward them to the appropriate

contractors.

The CMS requests the OIG to furnish the necessary data (Medicare contractor numbers,

provider numbers, claims information including the paid date, HICnumbers, and any

other relevant materials) so that CMS can initiate actions on each inappropriate claim. In

addition, Medicare contractor specific data should be written to separate CD-ROMs or

separate hardcopy worksheets in order to better facilitate the transfer ofinformation to

the appropriate contractors.

Finally, CMS will review the information provided by the OIG and will ensure that the

suppliers indentified by OIG continue to meet the supplier standards found in Federal

regulations at 42 CFR 424.57(c).

A P P E N D I X ~ E 

O E I - 0 2 - 0 7 - 0 0 4 2 0 I O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE NAPPROPRIATE MEDICARE EDICARE PAYMENTS FOR AYMENTS FOR P RESSURE RESSURE REDUCING EDUCING S UPPORT S URFACES URFACES 32 
 

 

Page 4 - Daniel R. Levinson

The CMS thanks the OIG for its efforts on this report and for highlighting this potential

vulnerability in the Medicare program. CMS is committed to continually reviewing and

refining our processes to improve the Medicare program, and we will take the findings of

this report under consideration as we continue to strengthen our oversight efforts to

further reduce improper payments in the Medicare program. We look forward to

continuing to work with the OIG to identify and prevent fraud, waste, and abuse in the

Medicare program. .

APPENDIX ~ E 

 O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 33 
 

 

Δ ACKNOWLEDGMENTS 

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. 

 O E I - 0 2 - 0 7 - 0 0 4 2 0 I NAPPROPRIATE MEDICARE PAYMENTS FOR P RESSURE REDUCING S UPPORT S URFACES 34