evekhm/cms_iom_500 huggingface dataset:
Article - Pressure Reducing Support Surfaces - Group 1 - Policy Article (A52489)
CMS National Coverage PolicyN/AArticle TextNONMEDICAL NECESSITY COVERAGE AND PAYMENT RULESFor any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act Section 1862(a)(1)(A) provisions (i.e. "reasonable and necessary").Pressure-reducing support surfaces are covered under the Durable Medical Equipment benefit (Social Security Act Section 1861(s)(6)). In order for a beneficiarys DME to be eligible for reimbursement, the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.A foam overlay or mattress which does not have a waterproof cover is not considered durable and will be denied as non-covered.REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217)Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The required Face-to-Face Encounter and Written Order Prior to Delivery List is availablehere.Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD, it will be eligible for coverage.POLICY SPECIFIC DOCUMENTATION REQUIREMENTS
Article - Pressure Reducing Support Surfaces - Group 1 - Policy Article (A52489)
POLICY SPECIFIC DOCUMENTATION REQUIREMENTSIn addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below.RELATED CLINICAL INFORMATIONA beneficiary needing a pressure reducing support surface should have a care plan which has been established by the beneficiary'streating practitioneror home care nurse, which is documented in the beneficiary's medical records, and which generally should include the following:Education of the beneficiary and caregiver on the prevention and/or management of pressure ulcersRegular assessment by a nurse,treating practitioner, or other licensed healthcare practitionerAppropriate turning and positioningAppropriate wound care (for a stage 2, 3 or 4 ulcer)Appropriate management of moisture/incontinenceNutritional assessment and intervention consistent with the overall plan of careMODIFIERSKX, GA AND GZ MODIFIERSSuppliers must add a KX modifier to a code only if all of the criteria in the "Coverage Indications, Limitations and/or Medical Necessity" section of the related LCD have been met and evidence of such is maintained in the supplier's files. This information must be available upon request.If all of the criteria in the Coverage Indications, Limitations and/or Medical Necessity section have not been met, the GA or GZ modifier must be added to the code. When there is an expectation of a denial as not reasonable and necessary, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or the GZ modifier if they have not obtained a valid ABN.Claim lines billed without a KX, GA, or GZ modifier will be rejected as missing information.When code E1399 is billed, the claim must include a narrative description of the item, the manufacturer, the product name/number, and information justifying the medical necessity for the item.CODING GUIDELINES
Article - Pressure Reducing Support Surfaces - Group 1 - Policy Article (A52489)
When code E1399 is billed, the claim must include a narrative description of the item, the manufacturer, the product name/number, and information justifying the medical necessity for the item.CODING GUIDELINESCodes E0185, E0197, E0198 and E0199 termed "pressure pad for mattress" describe nonpowered pressure reducing mattress overlays. These devices are designed to be placed on top of a standard hospital or home mattress.A gel/gel-like mattress overlay (E0185) is characterized by a gel or gel-like layer with a height of 2 inches or greater.An air mattress overlay (E0197) is characterized by interconnected air cells having a cell height of 3 inches or greater that are inflated with an air pump.A water mattress overlay (E0198) is characterized by a filled height of 3 inches or greater.A foam mattress overlay (E0199) is characterized by all of the following:Base thickness of 2" or greater and peak height of 3" or greater if it is a convoluted overlay (e.g., eggcrate) or an overall height of at least 3 inches if it is a non-convoluted overlay, andFoam with a density and other qualities that provide adequate pressure reduction, andDurable, waterproof coverCodes E0184, E0186, E0187 and E0196 describe nonpowered pressure reducing mattresses.A foam mattress (E0184) is characterized by all of the following:Foam height of 5 inches or greater, andFoam with a density and other qualities that provide adequate pressure reduction, andDurable, waterproof cover, andCan be placed directly on a hospital bed frameAn air, water or gel mattress (E0186, E0187, E0196) is characterized by all of the following:Height of 5 inches or greater of the air, water, or gel layer (respectively), andDurable, waterproof cover, andCan be placed directly on a hospital bed frameCodes E0181, E0182, and A4640 describe powered pressure reducing mattress overlay systems (alternating pressure or low air loss). They are characterized by all of the following:
Article - Pressure Reducing Support Surfaces - Group 1 - Policy Article (A52489)
Codes E0181, E0182, and A4640 describe powered pressure reducing mattress overlay systems (alternating pressure or low air loss). They are characterized by all of the following:An air pump or blower which provides either sequential inflation and deflation of air cells or a low interface pressure throughout the overlay, andInflated cell height of the air cells through which air is being circulated is 2.5 inches or greater, andHeight of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure overlays), and air pressure provide adequate patient lift, reduce pressure and prevent bottoming outA foam overlay or mattress which does not have a waterproof cover should be coded using A9270. Other Group 1 support surfaces which do not meet the characteristics specified in this section should be billed using code E1399.Alternating pressure mattress overlays or low air loss mattress overlays are coded using codes E0181, E0182, and A4640.Code A4640 or E0182 should only be billed when they are provided as replacement components for a beneficiary-owned E0181 mattress overlay system.A Column II code is included in the allowance for the corresponding Column I code when provided at the same time.Column IColumn IIE0181A4640, E0182Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.
Article - Pressure Reducing Support Surfaces - Group 2 - Policy Article (A52490)
CMS National Coverage PolicyN/AArticle Text
Article - Pressure Reducing Support Surfaces - Group 2 - Policy Article (A52490)
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULESFor any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act Section 1862(a)(1)(A) provisions (i.e. reasonable and necessary).Pressure-reducing support surfaces are covered under the Durable Medical Equipment benefit (Social Security Act Section 1861(s)(6)). In order for a beneficiarys DME to be eligible for reimbursement, the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217)Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The required Face-to-Face Encounter and Written Order Prior to Delivery List is availablehere.Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD, it will be eligible for coverage.POLICY SPECIFIC DOCUMENTATION REQUIREMENTSIn addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.
Article - Pressure Reducing Support Surfaces - Group 2 - Policy Article (A52490)
POLICY SPECIFIC DOCUMENTATION REQUIREMENTSIn addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below.MODIFIERSKX, GA, AND GZ MODIFIERSSuppliers must add a KX modifier to a code only if all of the criteria in the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD have been met and evidence of such is maintained in the supplier's files. This information must be available upon request.If all of the criteria in the Coverage Indications, Limitations and/or Medical Necessity section have not been met, the GA or GZ modifier must be added to the code. When there is an expectation of a denial as not reasonable and necessary, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or the GZ modifier if they have not obtained a valid ABN.Claim lines billed without a KX, GA, or GZ modifier will be rejected as missing information.When code E1399 is billed, the claim must include the manufacturer and the model name/number.CODING GUIDELINESHeavy duty and bariatric devices are included in the codes for pressure reducing support surfaces: E0193, E0277, E0371, E0372 and E0373.Code E0277 describes a powered pressure reducing mattress (alternating pressure, low air loss, or powered flotation without low air loss) which is characterized by all of the following:
Article - Pressure Reducing Support Surfaces - Group 2 - Policy Article (A52490)
An air pump or blower which provides either sequential inflation and deflation of the air cells or a low interface pressure throughout the mattress, andInflated cell height of the air cells through which air is being circulated is 5 inches or greater, andHeight of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure mattresses), and air pressure provide adequate beneficiary lift, reduce pressure and prevent bottoming out, andA surface designed to reduce friction and shear, andCan be placed directly on a hospital bed frame.Code E0193 describes a semi-electric or total electric hospital bed with a fully integrated powered pressure reducing mattress which has all the characteristics defined above.Code E0371 describes an advanced nonpowered pressure-reducing mattress overlay which is characterized by all of the following:Height and design of individual cells which provide significantly more pressure reduction than a group 1 overlay and prevent bottoming out, andTotal height of 3 inches or greater, andA surface designed to reduce friction and shear, andDocumented evidence to substantiate that the product is effective for the treatment of conditions described by the coverage criteria for group 2 support surfaces.Code E0372 describes a powered pressure reducing mattress overlay (low air loss, powered flotation without low air loss, or alternating pressure) which is characterized by all of the following:An air pump or blower which provides either sequential inflation and deflation of the air cells or a low interface pressure throughout the overlay, andInflated cell height of the air cells through which air is being circulated is 3.5 inches or greater, andHeight of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure overlays), and air pressure to provide adequate beneficiary lift, reduce pressure and prevent bottoming out, andA surface designed to reduce friction and shear.Code E0373 describes an advanced nonpowered pressure reducing mattress which is characterized by all of the following:Height and design of individual cells which provide significantly more pressure reduction than a group 1 mattress and prevent bottoming out, andTotal height of 5 inches or greater, andA surface designed to reduce friction and shear, andDocumented evidence to substantiate that the product is effective for the treatment of conditions described by the coverage criteria for group 2 support surfaces, andCan be placed directly on a hospital bed frame.
Article - Pressure Reducing Support Surfaces - Group 2 - Policy Article (A52490)
The only products that may be billed using codes E0371 or E0373 are those for which a written coding verification review (CVR) has been made by the Pricing, Data Analysis, and Coding (PDAC) contractor and subsequently published on the Product Classification List (PCL). Information concerning the documentation that must be submitted to the PDAC for a Coding Verification Request can be found on the PDAC web site or by contacting the PDAC. A PCL with products that have received a coding verification can be found on the PDAC web site. If a product is billed to Medicare using a HCPCS code that requires written CVR, but the product is not on the PCL for that particular HCPCS code, then the claim line will be denied as incorrect coding.Group 2 support surfaces are coded based on the characteristics specified in the above definitions. Products which do not meet these definitional characteristics but meet the characteristics for another support surface grouping (i.e., Group 1 support surfaces) will be coded based on the characteristics specified in the Coding Guidelines section of the Group 1 Pressure Reducing Support Surfaces related Policy Article. Products which do not meet the characteristics specified in either the Group 1 or Group 2 Support Surfaces related Policy Article must be coded using code E1399.Either alternating pressure mattresses or low air loss mattresses are coded using code E0277.Products containing multiple components are categorized according to the clinically predominant component (usually the topmost layer of a multi-layer product). For example, a product with 3" powered air cells on top of a 3" foam base would be coded as a powered overlay (code E0181) not as a powered mattress (E0277).Suppliers should contact the PDAC contractor for guidance on the correct coding of these items.
Article - Tracheostomy Care Supplies - Policy Article (A52492)
CMS National Coverage PolicyN/AArticle TextNON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULESFor any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act 1862(a)(1)(A) provisions (i.e. reasonable and necessary).Tracheostomy Supplies are covered under the Prosthetic Benefit (Social Security Act 1861(s)(8)). In order for a beneficiarys supplies to be eligible for reimbursement, the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.Supplies for care of a tracheostomy site are covered for a beneficiary following an open surgical tracheostomy which has been open or is expected to remain open for at least three months. The quantities of supplies included in a tracheostomy care kit are to provide all necessary quantities for the care of the tracheostomy site and there must not be any additional quantity billed of these codes for this purpose. Additional supplies may be billed, as appropriate and necessary, only for care other than for a tracheostomy site, such as for speaking valves.Claims for tape (A4450 or A4452) or for wipes or swabs (A5120) that are billed without an AU modifier will be rejected as missing information.
Article - Tracheostomy Care Supplies - Policy Article (A52492)
Claims for tape (A4450 or A4452) or for wipes or swabs (A5120) that are billed without an AU modifier will be rejected as missing information.REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217)Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The required Face-to-Face Encounter and Written Order Prior to Delivery List is availablehere.Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD, it will be eligible for coverage.POLICY SPECIFIC DOCUMENTATION REQUIREMENTSIn addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below.The diagnosis code that justifies the need for these items must be included on each claim.CODING GUIDELINESA tracheostomy care or cleaning starter kit (A4625) contains the following:ItemNumber includedplastic tray1basin1sterile gloves1 pairtube brush1pipe cleaners3pre-cut tracheostomy dressing1gauze1 roll4x4 sponges4cotton tip applicators2twill tape30 inchesA tracheostomy care kit for an established tracheostomy (A4629) contains the following:ItemNumber includedtube brush1pipe cleaners2cotton tip applicators2twill tape30 inches4x4 sponges2
Article - Tracheostomy Care Supplies - Policy Article (A52492)
ItemNumber includedtube brush1pipe cleaners2cotton tip applicators2twill tape30 inches4x4 sponges2A Column II code is included in the allowance for the corresponding Column I code when provided at the same time.Column IColumn IIA4625A4626A4629A4626Tracheostomy care kits provided in the first two postoperative weeks should be coded as A4625.Tracheostomy care kits provided after the first two postoperative weeks should be coded as A4629.When codes A4450, A4452 and A5120 are used with Tracheostomy Care Supplies, they must be billed with the AU modifier. For this policy, codes A4450, A4452 and A5120 are the only codes for which the AU modifier may be used.A7526 is a tracheostomy collar/holder that is used to secure the tracheostomy tube's positioning, minimize movement of the tracheostomy tube and reduce the risk of cannula disruption or decannulation. Fastener tabs attach to the tracheostomy tube to hold the collar in place. A7526 should not be used for billing twill ties, or twill tape or equivalent fabric or plastic supplies.Heat/Moisture ExchangersHeat/Moisture Exchangers (HME; see below for specific component codes) are a type of stoma cover which help laryngectomees partially restore functions previously performed by the nose and upper airway. During exhalation, warmth and humidity are conveyed from the lungs and deposited into the filter. During inhalation, the warmth and moisture are picked back up by incoming air and returned to the lungs.HME consist of a plastic cassette/holder that contains a filter. The holder fits into a plastic housing which is held in place over the tracheostoma by adhesive. An HME may be used by itself or in addition to a tracheostoma valve (A7501).A4481 is a small filter usually having adhesive along one edge which is attached to the skin and simply covers the tracheostoma to keep large piece of debris out. It is not an HME.A4483 is a moisture exchanger that is used only with an invasive mechanical ventilator and should not be billed as an HME over a tracheostoma.