October 21, 2008
Lessons Learned: Group 2 Support Surfaces
The CGS' Medical Review staff recently completed a widespread probe review of 193 randomly selected HCPCS code E0277 post payment claims. These claims were submitted by 40 suppliers and each supplier had 2-5 claims in the sample.
The widespread probe review was conducted because analysis of reports from the Comprehensive Error Rate Testing (CERT) contractor showed a high paid claims error rate for HCPCS code E0277. The CGS review confirmed CERT findings. While four suppliers had no denials, all the claims from twenty-two suppliers failed to meet one or more coverage criterion. The overall error rate was 72% with an identified overpayment of $77,574.07.
The following points are based on common problems identified by the probe review:
- Medical Necessity Documentation
- Suppliers are required to obtain information concerning which coverage criteria the beneficiary meets. The online LCD includes a link to the Statement of Ordering Physician Group 2 Support Surfaces which is a suggested but not mandatory form; however, if the supplier chooses to create their own form, it must have, at a minimum, the information in the DME MAC suggested form.
- The medical information on the Statement of Ordering Physician, or any alternative form the supplier uses, cannot be completed by the supplier or anyone in a financial relationship with a supplier.
- Neither the Statement of Ordering Physician nor a supplier generated form is an actual medical record. Medical records are physician progress notes, hospital records, wound clinic records, home health notes, etc. While suppliers are not required to routinely obtain medical records prior to dispensing a group 2 support surface, they are required to send copies of these records in the event that the claim is reviewed by a Medicare contractor. Therefore, as a protection against claim denials and overpayment assessments, the DME MAC suggests that suppliers ascertain that the appropriate medical records do exist prior to providing the equipment.
- If asked to provide medical records, the time period covered should be at least the month preceding initial E0277 use as well as the time immediately prior to the date of service under review. It is important that the medical records include wound assessments that provide the stage, location and measurements of the wound(s).
- Appropriate use of the KX modifier is the responsibility of the supplier. The supplier should maintain adequate communication on an ongoing basis with the clinician providing the wound care in order to accurately determine that use of the KX modifier is still appropriate.
- Medical Necessity Coverage Criteria
- Group 2 support surfaces are not covered for decubitus ulcer prevention. They are also not covered if the only ulcers on the trunk or pelvis are stage I pressure ulcers or for any stage pressure ulcer that is not located on the trunk or pelvis.
- One stage II decubitus ulcer on the trunk or pelvis does not meet coverage criteria. The group 2 support surface LCD states that there must be multiple stage II pressure ulcers located on the trunk or pelvis.
- The LCD further states that, if the patient has stage II pressure ulcers, he/she must be placed on a comprehensive ulcer treatment program prior to group 2 support surface use. This program must have been tried for at least one month (not less than 30 days) prior to E0277 use. Furthermore, the comprehensive ulcer treatment program must include documented use of a group 1 support surface for a minimum of one month (at least 30 days) immediately prior to beginning group 2 therapy. Finally, there must be documentation to show that, during that month, the ulcers either remained the same or worsened.
- While one stage III or IV pressure ulcer on the trunk or pelvis may qualify a beneficiary for group 2 support surface coverage, the policy states that this single ulcer must be a "large ulcer". The Jurisdiction C DME MAC Medical Review staff, when reviewing medical records, generally considers any wound of 8 square centimeters (length X width) or more as meeting the definition of "large". Other wounds are considered individually. We take into account, for example, whether undermining and/or tunneling are present, the anatomic location on the body and the size of the patient.
- Continued use of a group 2 support surface is covered until the ulcer is healed or, if healing does not continue, there is documentation in the medical record to show that: (1) other aspects of the care plan are being modified to promote healing, or (2) the use of the group 2 support surface is medically necessary for wound management. Once the wound is healed, the group 2 support surface is no longer covered.
- Written Order Prior to Delivery
- Suppliers must have a valid detailed written order prior to delivering a group 2 support surface. If the supplier does not obtain an order prior to delivery, modifier EY should be appended to the code and the claim will be denied as excluded by statute.
- The written order should contain sufficient detail to establish that the physician prescribed the item that was delivered. An order that simply states "air mattress" or "pressure pad" can be interpreted to mean a variety of group 1 or group 2 products.
- The Statement of Ordering Physician, as printed, cannot serve as a substitute for a written order. If a supplier chooses to use this form as a written order, modifications are required to make sure all elements of a detailed written order are included.
- Place of Service
- For purposes of rental and purchase of DME, a beneficiary's home may be his/her own dwelling, an apartment, a relative's home, a home for the aged, or some other type of institution. However, an institution may not be considered a beneficiary's home if it is a hospital or a skilled nursing facility.
- If an individual is a patient in an institution or distinct part of an institution that meets the definition of a hospital or SNF, the individual is not entitled to have separate Part B payment made for rental or purchase of DME. This is because such an institution may not be considered the individual's home. This concept applies even if the patient resides in a bed or portion of the institution not certified for Medicare.
- Place of Service 54 should only be billed if the patient is mentally retarded and residing in an Intermediate Care Facility for the Mentally Retarded. A diagnosis of Alzheimer's disease, Dementia, etc. does not meet this qualification.
- Suppliers should perform periodic status checks in order to lessen the chance of billing for a date of service that does not meet Medicare coverage criteria. Suppliers should make certain that the beneficiary is still using the mattress and has not been moved to a noncovered place of service (acute care hospital, SNF, etc.) or died.
- If a beneficiary is not in a covered place of service on the usual date of service billed, claim submissions should be discontinued until the day the beneficiary returns to a covered place of service.
- If suppliers have knowledge that they received payment for a date of service not meeting coverage criteria, it is their responsibility to voluntarily refund the money
- Proof of Delivery
- Suppliers are required to maintain proof of delivery documentation in their files. The documentation should include a detailed description of the item being delivered (manufacturer and model name/number) and the serial number. Suppliers should refer to Chapter Three of the DME MAC Jurisdiction C Supplier Manual for additional proof of delivery requirements.
- A supplier may deliver an item to a patient's home approximately 2 days prior to an anticipated discharge from a hospital or nursing facility. However, in this circumstance, the date of service billed on the claim should be the date of discharge not the date of delivery.
CGS Medical Review has developed a Documentation Checklist to aid suppliers in complying with documentation requirements regarding group 2 support surfaces. This checklist is available online at: http://www.cgsmedicare.com/jc/coverage/mr/PDF/MR_checklist_grp2_support_surfaces.pdf