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Phone: ...919.876.4336
.....Fax: .......919.876.4485
.....Address: 3430 Tarheel Drive,
...................Suite 104
...................Raleigh, NC 27609


 


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THERAPEUTIC SUPPORT SURFACES
ALTERNATING PRESSURE MATTRESS
Indications and Limitations of Coverage and/or Medical Necessity
Documentation Requirements
ALTERNATING PRESSURE PAD
Indications and Limitations of Coverage and/or Medical Necessity
Documentation Requirements

 

ALTERNATING PRESSURE MATTRESS

Indications and Limitations of Coverage and/or Medical Necessity

A group 2 support surface is covered if the patient meets:

a) Criterion 1 and 2 and 3, or
b) Criterion 4, or
c) Criterion 5 and 6.

1) Multiple stage II pressure ulcers located on the trunk or pelvis.

2) Patient has been on a comprehensive ulcer treatment program for at least the past month which has included the use of an appropriate group 1 support surface.

3) The ulcers have worsened or remained the same over the past month.

4) Large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis.

5) Recent myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis (surgery within the past 60 days).

6) The patient has been on a group 2 or 3 support surface immediately prior to a recent discharge from a hospital or nursing facility (discharge within the past 30 days).

The comprehensive ulcer treatment described in #2 above should generally include:

i) Education of the patient and caregiver on the prevention and/or management of pressure ulcers.

ii) Regular assessment by a nurse, physician, or other licensed healthcare practitioner (usually at least weekly for a patient with a stage III or IV ulcer).

iii) Appropriate turning and positioning.

iv) Appropriate wound care (for a stage II, III or IV ulcer).

v) Appropriate management of moisture/incontinence.

vi) Nutritional assessment and intervention consistent with the overall plan of care.

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Documentation Requirements

An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available to the DMERC upon request.

The supplier must obtain information concerning which, if any, of criteria 1-6 listed in the Coverage and Payment Rules section of this policy the patient meets in a signed and dated statement from the treating physician.

The staging of pressure ulcers used in this policy is as follows:

Stage I - Observable pressure related alteration of intact skin whose indicators as compared to the adjacent or opposite area on the body may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel) and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.

Stage II - Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.

Stage III - Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.

Stage IV - Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers.

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ALTERNATING PRESSURE PAD

Indications and Limitations of Coverage and/or Medical Necessity

A group 1 mattress overlay or mattress (E0180-E0189, E0196-E0199, A4640) is covered if the patient meets:

a) Criterion 1, or
b) Criteria 2 or 3 and at least one of criteria 4-7.

1) Completely immobile - i.e., patient cannot make changes in body position without assistance.

2) Limited mobility - i.e., patient cannot independently make changes in body position significant enough to alleviate pressure.

3) Any stage pressure ulcer on the trunk or pelvis.

4) Impaired nutritional status.

5) Fecal or urinary incontinence.

6) Altered sensory perception.

7) Compromised circulatory status.

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Documentation Requirements

An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available to the DMERC upon request.

The supplier must obtain information concerning which, if any, of criteria 1-7 listed in the Coverage and Payment Rules section of this policy the patient meets in a signed and dated statement from the treating physician.

Other Comments

The staging of pressure ulcers used in this policy is as follows:

Stage I - Observable pressure related alteration of intact skin whose indicators as compared to the adjacent or opposite area on the body may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel) and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.

Stage II - Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.

Stage III - Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.

Stage IV - Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers.

Bottoming out is the finding that an outstretched hand, placed palm up between the undersurface of the overlay or mattress and the patient's bony prominence (coccyx or lateral trochanter), can readily palpate the bony prominence. This bottoming out criterion should be tested with the patient in the supine position with their head flat, in the supine position with their head slightly elevated (no more than 30 degrees), and in the sidelying position.

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