Wound management professionals should take a leadership role in providing the documentation to support medical necessity for Group 2 pressure-reducing support surfaces needed by their patients for use at home. As you know, patients acquire these support surfaces from durable medical equipment (DME) suppliers. These DME suppliers must follow Medicare’s local coverage determinations (LCDs) and articles for Group 1 (L33830/A52489),1,2 Group 2 (L33642/A52490),3,4 and Group 3 (L33692/A52468)5,6 pressure-reducing support surfaces, as well as the article (A55426)7 that outlines the standard documentation requirements for all claims submitted to DME Medicare Administrative Contractors (MACs). These LCDs and articles have been in effect since 1993 and are periodically updated.
Unfortunately, many patients who could benefit from support surfaces (1) cannot acquire them or (2) must pay for them out of pocket because the documentation in their medical records does not support medical necessity. In addition, many DME suppliers who provide the support surfaces experience repayments even though the patients’ medical records do not include adequate medical necessity documentation. Therefore, the Centers for Medicare & Medicaid Services (CMS) added the Group 2 Healthcare Common Procedure Coding System (HCPCS) codes (Table 1) for pressure-reducing support surfaces to the Required Prior Authorization List.8 A complete description of the required characteristics of each of the Group 2 pressure-reducing support surfaces is detailed in the local coverage article.4
Many wound management stakeholders already have experience with Medicare prior authorization (PA), which 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. The PA helps to ensure that all applicable Medicare coverage, payment, and coding rules are met before an item is furnished. A provisional affirmative decision is a preliminary finding that a claim submitted to Medicare for the Group 2 pressure-reducing support surface will likely meet Medicare’s coverage, coding, and payment requirements for that patient.
The Group 2 pressure-reducing support surface PA process is being implemented in two phases:
- Phase I only includes claims for patients whose permanent addresses are in California, Indiana, New Jersey, and North Carolina. Phase I is required for the Group 2 pressure-reducing support surfaces delivered on and after July 22, 2019. The DME MACs began to accept PA requests on July 8, 2019.
- Phase II will expand PA to the remaining states and territories for dates of delivery on and after October 21, 2019. The DME MACs will begin to accept PA requests on October 7, 2019.
The Medicare coverage policies and documentation requirements are unchanged. The PA process does not create new documentation requirements. The regularly required documentation must be submitted by the DME suppliers before they deliver Group 2 pressure-reducing support surfaces. The PA request should include:
- beneficiary information: name, Medicare Beneficiary Identifier, date of birth, address, place of service, diagnosis code(s);
- supplier information: name, National Supplier Clearinghouse number, National Provider Identification, address, and phone number;
- requestor’s information: name, telephone number, National Provider Identification (if applicable), and address;
- submission date;
- HCPCS code;
- if the request is an initial or resubmission review; and
- if the request is expedited and the reason why.
Most important, the PA request must include the following information from the wound management professional:
- a Detailed Written Order (DWO) and
- medical record documentation that supports the medical necessity of the Group 2 pressure-reducing support surface.
The DME MACs are sensitive to the importance of Group 2 pressure-reducing support surfaces for qualified beneficiaries and have committed to providing PA determinations within 5 business days of receiving a PA request. For situations in which the standard 5 business-day time frame could jeopardize the life or health of the Medicare patient, the DME MAC will communicate a PA determination within 2 business days of receipt of an expedited PA request. The DME MAC will send the PA determination letter to the DME supplier that submitted the PA request. If the Medicare beneficiary and/or the prescribing physician request(s) a copy of the PA decision letter, the DME MAC will supply them.
By now, physicians and other qualified healthcare professionals (QHPs) should know that they play an important part in obtaining PA for Group 2 pressure-reducing support surfaces for their Medicare beneficiaries. This author highly recommends physicians and QHPs read the pertinent LCD3 and articles4,7 to gain an appreciation of the required medical record documentation and the information that should be included in their DWOs for these items. The DWO must include:
- beneficiary’s name;
- date of the written order;
- description of the Group 2 pressure-reducing support surface, which can either be a general description, an HCPCS code, an HCPCS code narrative, or a brand name/model number; and
- prescribing physician/QHP’s signature and date (reminder: signature and date stamps are not allowed).
The medical record must include:
- patient’s diagnosis (the article4 includes a complete list of covered diagnoses) and
- documentation that the beneficiary meets at least one of three criteria (Table 2).
The LCD3 includes additional information that should guide physicians/QHPs in their documentation:
- If a beneficiary is already on a Group 2 surface, a plan of care that includes the elements above should be established by the physician or home care nurse. In addition, the Group 2 support surface provided should be one in which the beneficiary does not “bottom out.”
- When a Group 2 support surface is covered following a myocutaneous flap or skin graft, coverage is generally limited to 60 days from the date of surgery.
- Continued use of a Group 2 support surface is covered until the ulcer is healed. If healing does not continue, there is documentation in the medical record to show that (1) other aspects of the plan of care are being modified to promote healing, or (2) the use of the Group 2 support surface is reasonable and necessary for wound management.
Prescribers and hospital discharge planners should begin planning for the patient’s discharge upon admission. They should contact the DME supplier to let them know that they will be sending a signed and dated written order and copy of the pertinent portions of the medical record for the DME supplier to obtain PA from the DME MAC.
Readers may be wondering if the PA for Group 2 pressure-reducing support surfaces applies to all claim types submitted to the CMS. There are several exclusions: Veterans Affairs, Indian Health Services, Medicare Advantage, and Part A and Part B Demonstrations.
Because Group 2 pressure-reducing support surfaces are expensive, this new PA process will reassure Medicare beneficiaries and DME suppliers when the delivered item is covered. Wound management prescribers must do their part to diagnose the patient properly, clearly “paint the picture” of medical necessity in the patient’s medical record, contact the DME supplier when the need for the support surface is first identified, write and sign the DWO, and submit the documentation to the DME supplier early enough for them to obtain PA before the patient actually needs the support surface delivered. Because this PA process for Group 2 pressure-reducing support surfaces is new, take the time to educate your wound management team members on how to plan and communicate with the DME suppliers as early as possible before a patient needs a Group 2 pressure-reducing support surface at home.