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Pressure Reducing Support Surfaces Prior Authorization
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Pressure Reducing Support Surfaces Prior Authorization

URGENT: An upcoming process change will make it mandatory to submit prior authorization for pressure reducing support surfaces as of October 21, 2019. WOC nurses must act to educate, collaborate and advocate with other medical professionals, case managers and DME companies about this process to ensure patients receive the appropriate medical equipment for their condition.

Background

Section 1834(a)(15) of the Social Security Act (the Act) authorizes the Secretary of Health and Human Services to develop and periodically update a list of DMEPOS that the Secretary determines, on the basis of prior payment experience, are frequently subject to unnecessary utilization and to develop a prior authorization process for these items. CMS announced in December 30, 2015 a finalized rule creating a prior authorization (PA) process for certain DMEPOS items and now include Pressure Reducing Support Surfaces (PRSS). Prior authorization helps to ensure that all applicable Medicare coverage, payment, and coding rules are met before an item is provided. Prior authorization is a process through which a request for provisional affirmation of coverage is submitted for review before an item is provided to a Medicare patient and before a claim is submitted for payment. This FAQ document is intended to help WOCN members comply with these new requirements.

  • Who Submits the Prior Authorization Request?

  • When planning for discharge for patients that you believe may need a PRSS you will need to obtain prior authorization. When these items are ordered, the DME supplier must submit a prior authorization request which includes all required documentation from the provider prior to furnishing the item to the Medicare beneficiary.

    • Which DMEPOS Items are Included?

    • E0193: Powered air flotation bed (low air loss therapy)

      E0277: Powered pressure-reducing air mattress

      E0371: Non-powered advanced pressure reducing overlay for mattress, standard mattress length and width

      E0372: Powered air overlay for mattress, standard mattress length and width

      E0373: Non-powered advanced pressure reducing mattress

      • When Does This Go Into Effect?

      • Prior authorization of these items is a condition of payment when furnished to beneficiaries in California, Indiana, New Jersey, and North Carolina, on or after July 22, 2019 and Nationwide October 21, 2019. States are assigned based upon the beneficiary’s permanent address.

        • What Information is Required in the Prior Authorization Process?

        • Request needs to identify:

          • The beneficiary’s name, Medicare Beneficiary Identifier (MBI), date of birth, address
          • The supplier’s name, NSC number, NPI number, address, and phone number
          • The requester’s name, telephone number, NPI (if applicable), and address
          • Submission date
          • Healthcare Common Procedure Coding System (HCPCS) code
          • Indicate if the request is an initial or resubmission review
          • Indicate if the request is expedited and the reason why

          Providers need to include the following:

          • A Detailed Written Order (DWO)
          • Documentation from the medical record to support the medical necessity of the item.
          • A Prior Authorization Request (PAR) Coversheet which is available on the websites of each DME Medicare Administrative Contractor.

          Documentation that the beneficiary meets at least one of the following three criteria 
          (1, 2, or 3):

          1. The beneficiary has multiple stage II pressure ulcers located on the trunk or pelvis which have failed to improve over the past month, during which time the beneficiary has been on a comprehensive ulcer treatment program, including each of the following:

                      a. Use of an appropriate group 1 support surface; and,

                      b. Regular assessment by a nurse, physician, or other licensed healthcare practitioner; and,

                      c. Appropriate turning and positioning; and,

                      d. Appropriate wound care; and,

                      e. Appropriate management of moisture/incontinence; and,

                      f. Nutritional assessment and intervention consistent with the overall plan of care.

          2. The beneficiary has large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis; or,

          3. The beneficiary had a myocutaneous flap or skin graft for a pressure ulcer/injury on the trunk or pelvis within the past 60 days and has been on a group 2 or 3 support surface immediately prior to discharge from a hospital or nursing facility within the past 30 days.

          • How is the Prior Authorization Form Processed?

          • The supplier or the Medicare patient may submit the prior authorization request. The request can be:

            • Mailed
            • Faxed
            • Submitted through the Electronic Submission of Medical Documentation (esMD) system
            • Submitted through the MAC’s provider portal
            • How Long Does the Review Process Take?

            • Initial Requests

              • The DME MAC will ensure the written determination is faxed, postmarked, or delivered electronically within 5 business days.

              Resubmitted Requests

              • The request should be submitted with additional documentation after the initial prior authorization request was non-affirmed.
              • The DME MAC will ensure the written determination is faxed, postmarked, or delivered electronically within 5 business days.

              Expedited Circumstances

              • If it is determined that delays in receipt of a Prior Authorization decision could jeopardize the life or health of the beneficiary, then the DME MAC will process the PAR under an “expedited” timeframe.
              • The DME MAC will communicate a determination within 2 business days of receipt of the expedited request.
              • Suppliers are encouraged to use fax, esMD, or the MAC Portal to avoid delays with mailing.

               

              • How will we be notified?

              • DME MACs will send the requester of the prior authorization (i.e., the entity who will submit the claim for payment) a letter providing their prior authorization decision (i.e., affirmative or non-affirmative).  Medicare patients can receive a copy, upon request. DME MACs may also send these letters voluntarily.  Prescribing physicians can receive a copy of the decision letter upon request.  If the request is non-affirmed, the letter will provide a detailed explanation for the decision.  Decision letters for both affirmed and non-affirmed decisions will contain a Unique Tracking Number (UTN).  Claims submitted must include the UTN to receive payment.

                • What happens if the request is denied?

                • A requester can resolve the non-affirmative reasons described in the decision letter and resubmit the prior authorization request.  Unlimited resubmissions are allowed; however, a non-affirmative prior authorization request decision is not appealable.  A requester can also forego the resubmission process, provide the DMEPOS item(s), and submit the claim for payment.  The claim will be denied but all appeal rights are available.

                  • What happens if a request is not submitted?

                  • If an item is selected for required prior authorization under the program, then submitting a prior authorization request is a condition of payment.  Claims for items subject to required prior authorization submitted without a prior authorization determination and a corresponding UTN will be automatically denied.

                    • Additional Information on HCPCS Codes Requiring Prior Authorization

                    • PRSS Group 2 HCPCS – E0193 Semi or total electric bed with powered pressure reducing mattress

                      • Air pump or blower provides inflation and deflation of air cells, and
                      • Inflated cell height is 5 inches or greater, and
                      • Surface designed to reduce friction and shear

                      PRSS Group 2 HCPCS – E0277 Powered pressure reducing air mattress

                      • Air pump or blower provides inflation and deflation of air cells, and
                      • Inflated cell height is 5 inches or greater, and
                      • Surface designed to reduce friction and shear, and
                      • Can be placed directly on hospital bed frame, and
                      • Reduces pressure and prevents bottoming out

                      PRSS Group 2 HCPCS – E0371 Advanced non-powered pressure reducing mattress overlay

                      • Height and design of individual cells prevent bottoming out, and
                      • Total height is 3 inches or greater, and
                      • Surface designed to reduce friction and shear, and
                      • Documented evidence product is effective for coverage criteria for group 2 PRSS
                      • Needs written coding determination from PDAC

                      PRSS Group 2 HCPCS – E0372 Powered air mattress overlay

                      • Air pump or blower provides inflation and deflation of air cells, and
                      • Inflated cell height is 3.5 inches or greater, and
                      • Reduces pressure and prevents bottoming out, and
                      • Surface designed to reduce friction and shear

                      PRSS Group 2 HCPCS – E0373 Advanced non-powered pressure reducing mattress

                      • Height and design of individual cells prevent bottoming out, and
                      • Total height 5 inches or greater, and
                      • Surface designed to reduce friction and shear, and
                      • Documented evidence product is effective for coverage criteria for group 2 PRSS, and can be placed directly on hospital bed frame
                      • Needs written coding determination from PDAC

                       

                      • CMS Resources

                      • Local Coverage Decision (LCD) and Policy Article for Pressure Reducing Support Surfaces - Group 2, available at: LCD 33642

                        Prior Authorization Web Site: go.cms.gov/DMEPOSPA

                        • What Can WOC Nurses Do to Impact this Issue?

                        • It is important for WOC nurses to understand the process to ensure their patients receive the appropriate durable medical equipment for their condition.

                          • Please share this document with your colleagues in all care settings as it doesn’t just affect one aspect of health care.    
                          • Please contact the WOCN Society Public Policy Coordinator, Kate Lawrence, or the Society’s Director of Government Relations, Chris Rorick, at info@wocn.org if you have feedback or have witnessed concerns about this policy change in your work environment. 
                          •  



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