February 18, 2010
HCPCS Code E0277 – Service-Specific Pre-pay Review
CGS, the Jurisdiction C DME MAC, will be implementing a service-specific Medical Review edit for Healthcare Common Procedure Coding System (HCPCS) code E0277 (POWERED PRESSURE-REDUCING AIR MATTRESS). This edit is the result of data demonstrating a high claims payment error rate for this product category.
Claims subjected to this edit will be developed for additional documentation. Suppliers receiving a development letter should follow the instructions contained in the letter for the specific documentation requested. Suppliers will be asked to submit documentation including, but not limited to:
- Physician's detailed written order,
- Relevant medical records verifying that the beneficiary met medical necessity
criteria for a group 2 support surface as specified in the Local Coverage
Determination ( LCD ). These records should show:
- The beneficiary had multiple stage II pressure ulcers located on the trunk or pelvis, and had been on a comprehensive ulcer treatment program for at least one month prior to use of the group 2 support surface, and the ulcers worsened or remained the same over the previous month; or
- The patient had large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis; or
- The patient had a recent (within the past 60 days) myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis and the patient was on a group 2 or 3 support surface immediately prior to a recent (within the past 30 days) discharge from a hospital or nursing facility.
- Delivery documentation with the beneficiary's name and address and the description (manufacturer, model number, etc.) of the equipment provided.
- Any other pertinent records
Relevant medical records consist of physician notes, non-physician clinical notes, and non-physician clinical evaluations that verify that the patient's condition meets coverage criteria for HCPCS code E0277. The source of these records may be a physician's office, hospital, nursing home, home health agency, wound clinic, etc. Evaluations used to determine coverage must have been performed and recorded prior to delivery and performed by a clinician who does not have a financial relationship with the supplier.
The information must be received within 30 days of the date of the letter or the claim will be denied. Additional information on this and other documentation requirements for code E0277 may be found on the CGS Medical Review website at http://www.cgsmedicare.com/jc/coverage/mr/ssr.html.