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December 12, 2013

Status Report for Quarter 3 - 2013 HCPCS Code E0277

The Medical Review Department of CGS, the Jurisdiction C DME MAC, began a service-specific prepayment edit for HCPCS code E0277 (Powered Pressure-Reducing Support Surface) in April 2010. This edit is the result of data demonstrating a high claims payment error rate for this product category.

A summary report for claims reviewed between July 1, 2013 and September 30, 2013 follows:

	Current Quarter	Previous Quarter
Denial Rate	62%	67%
Allowed Dollars Error Rate	67%	64%

Non-response Rate to Additional Documentation Requests – 38%

An analysis of the claim denials showed that the top 10 reasons a determination was made not to pay the claim were:

Medical records did not provide a wound assessment concurrent with the date of service under review.
No medical records were provided.
None of the medical records in the file were dated prior to the initial date of service. Therefore, based on the information that was received, the reviewer could not determine if the beneficiary met coverage criteria for a group 2 support surface prior to the initial date of service.
The medical records that were provided lacked sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.
The detailed written order in the file was not obtained prior to delivery.
There was no detailed written order in the file.
The medical records that were provided did not document any pressure ulcers on the trunk or pelvis.
The medical records did not establish that the beneficiary had been on a comprehensive ulcer treatment program for at least one month (30 days) prior to being placed on a group 2 support surface, and that this treatment included the use of a group 1 support surface.
Medical records did not establish that the beneficiary had either a large or multiple stage 3 or 4 pressure ulcer(s) on the trunk or pelvis.
Only one stage 2 pressure ulcer was documented on the trunk or pelvis and the policy requirement is that there are multiple (2 or more) stage 2 ulcers on the trunk or pelvis.

Case Study

L.V. – 82 year old female
Initial Date of Service – 01/16/2013
Date of Service Reviewed – 01/16/2013

Delivery Documentation: The delivery slip listed a product which, according to the PDAC DME Classification System was appropriately coded E0277. The document was signed by the beneficiary's husband on 01/16/2013.

Detailed Written Order: There was an order in the file that was signed and dated on 01/26/2013. The ordering physician listed the items to be dispensed as a semi-electric hospital bed and an alternating pressure mattress.

Dispensing Order: N/A – Group 2 support surfaces require that suppliers obtain a detailed written order prior to delivery (WOPD).

Medical Records: Medical documentation consisted of a progress note dated 01/16/2013. This note documented one stage II pressure ulcer on the left buttock. The size (length, width, depth) of the ulcer was not documented. The progress note did not document details of any treatment plan that was being followed prior to the order for the E0277.

Medical Review Decision: Deny the claim:

A detailed written order was not obtained prior to delivery. The support surface (E0277) was delivered on 01/16/2013 but the order was not signed until 01/26/13. When suppliers fail to obtain a WOPD in situations where one is required, the claim for the initial DOS and all subsequent DOS will be denied as statutorily non-covered.
Only one stage II pressure ulcer was documented on the trunk or pelvis. The policy states that multiple (two or more) stage II pressure ulcers are required.
The medical records did not document that the beneficiary was on a comprehensive ulcer treatment program for a minimum of one month (30 days) prior to the beginning of group 2 therapy. This program must include use of an appropriate group 1 support surface.
The medical records did not include any information about the status of pressure ulcers on the trunk or pelvis in the month prior to initial group 2 use. A group 2 support surface is not covered for stage II pressure ulcers unless documentation verifies that, over the past 30 days, the ulcers showed no improvement.