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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.
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.
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.
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
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.
Request needs to identify:
Providers need to include the following:
Documentation that the beneficiary meets at least one of the following three criteria
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.
The supplier or the Medicare patient may submit the prior authorization request. The request can be:
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.
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.
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.
PRSS Group 2 HCPCS – E0193 Semi or total electric bed with powered pressure reducing mattress
PRSS Group 2 HCPCS – E0277 Powered pressure reducing air mattress
PRSS Group 2 HCPCS – E0371 Advanced non-powered pressure reducing mattress overlay
PRSS Group 2 HCPCS – E0372 Powered air mattress overlay
PRSS Group 2 HCPCS – E0373 Advanced non-powered pressure reducing mattress
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
It is important for WOC nurses to understand the process to ensure their patients receive the appropriate durable medical equipment for their condition.
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