E0371 — Nonpowered advanced pressure reducing overlay for mattress, standard mattress length and width
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted; for DMEPOS base items requiring WOPD, a signed WOPD must be received before delivery.
- For DMEPOS base items with separately billed options/accessories, the WOPD must list the base item and may list associated separately billed options/accessories prior to delivery.
- When a beneficiary is on a group 2 surface, there should be a care plan established by the treating practitioner or home care nurse that documents the comprehensive ulcer treatment program elements (group 1 surface use, regular assessment, turning/positioning, wound care, moisture/incontinence management, nutritional assessment/intervention).
- Suppliers must maintain adequate ongoing communication with the clinician providing wound care and retain medical record documentation supporting use of the KX modifier; this documentation should not be submitted with the claim but must be available upon request.
Key Coverage Criteria
- Beneficiary has multiple stage 2 pressure ulcers on the trunk or pelvis that have failed to improve over the past 1 month while on a comprehensive ulcer treatment program that includes a group 1 support surface, regular clinician assessment, turning/positioning, wound care, moisture/incontinence management, and nutritional assessment/intervention.
- Beneficiary has a large or multiple stage 3 or stage 4 pressure ulcer(s) on the trunk or pelvis.
- Beneficiary had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days and was on a group 2 or group 3 support surface immediately prior to discharge from a hospital or nursing facility within the past 30 days.
- Continued use of a group 2 support surface is covered until the ulcer is healed or, if healing is not continuing, when medical record documentation shows that other care plan aspects are being modified to promote healing or that continued group 2 use is reasonable and necessary for wound management.
- The provided support surface must be one in which the beneficiary does not 'bottom out' and must meet the characteristics specified in the Policy Article coding guidelines.
- A group 1 mattress overlay or mattress is considered medically necessary DME when the member meets: Altered sensory perception
4 Active Policies
L33642 — Pressure Reducing Support Surfaces - Group 2
J19
DME101.001 — Hospital Beds and Related Equipment
AETNA-CPB-0430 — Pressure Reducing Support Surfaces
ANTHEM-CG-DME-16 — CG-DME-16 Pressure-Reducing Support Surfaces
Related Codes
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