L89.42 — Pressure ulcer of contiguous site of back, buttock and hip, stage 2
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- A prior face-to-face encounter and a Written Order Prior to Delivery (WOPD) must be obtained before delivery for the HCPCS codes specified under Final Rule 1713 and evidence must be maintained in supplier files.
- Suppliers must maintain documentation showing that all LCD Coverage Indications, Limitations, and Medical Necessity criteria have been met to support use of the KX modifier and must make such documentation available upon request.
- When expecting denial as not reasonable and necessary, suppliers must use modifier GA if a properly executed Advance Beneficiary Notice (ABN) was obtained or modifier GZ if no valid ABN was obtained; documentation of the ABN must be retained.
- When billing HCPCS E1399 the claim must include the manufacturer and model name/number on the claim.
Key Coverage Criteria
- Pressure-reducing support surfaces are covered under the Durable Medical Equipment benefit when the item is eligible under Medicare, meets the reasonable and necessary (R&N) criteria in the related Local Coverage Determination (LCD), and satisfies applicable Medicare statutory and regulatory requirements.
- HCPCS E0277 (powered pressure-reducing mattress) is payable when the product has an air pump/blower providing sequential inflation/deflation or low interface pressure, inflated cell height >= 5 inches, design that provides beneficiary lift/reduces pressure/prevents bottoming out, a surface to reduce friction and shear, can be placed on a hospital bed frame, and R&N LCD criteria are met.
- HCPCS E0193 (semi-electric or total electric hospital bed with fully integrated powered pressure-reducing mattress) is payable when the integrated mattress meets the E0277 characteristics and R&N LCD criteria are met.
- HCPCS E0371 (advanced nonpowered pressure-reducing mattress overlay) is payable when individual cell height/design provide significantly more pressure reduction than group 1 overlays and prevent bottoming out, total height >= 3 inches, surface reduces friction/shear, documented evidence of effectiveness exists, the product is listed on the PDAC Product Classification List (PCL) with a written Coding Verification Review (CVR), and R&N LCD criteria are met.
- HCPCS E0372 (powered pressure-reducing mattress overlay) is payable when an air pump/blower provides sequential inflation/deflation or low interface pressure, inflated cell height >= 3.5 inches, chamber geometry and cycling provide lift/reduce pressure/prevent bottoming out, surface reduces friction/shear, and R&N LCD criteria are met.
- HCPCS E0373 (advanced nonpowered pressure-reducing mattress) is payable when individual cell height/design provide significantly more pressure reduction than group 1 mattresses and prevent bottoming out, total height >= 5 inches, surface reduces friction/shear, documented evidence of effectiveness exists, the product is listed on the PDAC PCL with a written CVR, can be placed on a hospital bed frame, and R&N LCD criteria are met.
20 Active Policies
L37228 — Wound Care
J05
A55909 — Billing and Coding: Wound Care
J05
A56566 — Billing and Coding: Outpatient Physical and Occupational Therapy Services
J06
L33631 — Outpatient Physical and Occupational Therapy Services
J06
A52490
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