Despite medicare reimbursement cuts in 1996 and more stringent documentation requirements, the demand for products in the support surfaces market continues to grow. A report by the research firm Frost & Sullivan, San Antonio, Tex, anticipates that support surface sales will reach $1.1 billion this year, and this forecast may prove to be a conservative estimate.

As more manufacturers scramble for market share and introduce products and technology, HME providers can negotiate better pricing and find quality products at lower prices to conform more easily to reimbursement requirements. But negotiating better prices from the manufacturer is of minimal importance if you do not receive reimbursement for the products you provide. To succeed in the support surfaces market, you must couple cost-effective purchasing with a thorough understanding of reimbursement issues.

Code Crackers
The vast selection of support surfaces available makes reimbursement coding confusing. To reduce the risk of payment delays and/or denials, first verify that the item you intend to purchase is on the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC) product classification list. Then check that the Centers for Medicare and Medicaid Services (CMS) approved the product for billing under a specific Health Care Financing Administration Common Procedure Coding System (HCPCS) code.

There are more than 200 manufacturer-specific products approved for Group I Support Surfaces (A4640, E0180-E0187, E0196-E0199), more than 170 products for Group II Support Surfaces (E0193, E0277), and five products listed for Group III Support Surfaces (E0194). It is your responsibility to determine that Medicare or Medicaid covers the product, and that your reimbursement requests use the correct HCPCS by contacting the SADMERC through its Web site at www.pgba.com or by phone at (877) 735-1326.

The documentation requirements for support surfaces are comprehensive. First you must obtain a written order prior to delivery (WOPD) for all items classified as support surfaces, including wheelchair cushions (E0192, E0962-E0965).

To qualify for a Group I support surface, the patient must either be completely immobile or have limited mobility or a pressure ulcer (any stage) on the pelvis or trunk. In addition, the patient must have either impaired nutritional status, fecal or urinary incontinence, altered sensory perception, or compromised circulatory function.

Along with the WOPD, you must obtain a completed “Statement of Ordering Physician Group I Support Surfaces” and maintain it in the patient file, even though you never send it to the DMERC with the claim. For Group I support surfaces, a physician, nurse, or licensed clinician may complete the statement. Add a “ZX” modifier to the HCPCS code to verify that you met the documentation guidelines for Group I support surfaces.

To qualify for a Group II support surface, the patient must have multiple Stage II pressure ulcers on the trunk or pelvis. The patient also must have been on a comprehensive ulcer treatment program—which included the use of an appropriate Group I support surface—for at least a month and the patient’s ulcers must have worsened or shown no improvement from this treatment. A patient will also qualify for a Group II Support Surface if the patient has either one of two scenarios:

1. The patient has large or multiple Stage III or IV pressure ulcer(s) on the trunk or pelvis.

2. The patient has undergone surgery for a pressure ulcer on the trunk or pelvis within the last 60 days and used a Group II or Group III support surface prior to being discharged from a hospital or nursing home within the last 30 days.

Ensure that the patient file documents the location, size, and stage of the ulcer. You may wish to take pictures of the ulcers for further verification. Also keep a copy of the patient’s plan of care in the patient file. Monitor the patient closely to ensure that you meet both his or her needs and medical policy guidelines. Depending on the progress of the patient, you may need to upgrade the patient to a Group III support surface.

As with Group I surfaces, to bill for Group II surfaces you must obtain a WOPD and a “Statement of Ordering Physician Group II Support Surfaces” completed by a physician, nurse, or licensed clinician. The “ZX” modifier to the HCPCS code also works the same way for Group II.

Group III Challenges
Medical policy and physician documentation requirements for a Group III support surface (air-fluidized bed) are tedious and complex. Prior to initiating therapy on a Group III support surface, you should thoroughly educate the patient’s physician about the stringent documentation requirements for Group III. This helps ensure the physician will comply with these requirements.

To qualify for a Group III surface, a patient must have a Stage III or Stage IV pressure ulcer and be bedridden or wheelchair-bound due to severely limited mobility. You must obtain the WOPD from the patient’s attending physician and he or she must base the WOPD upon a comprehensive assessment and evaluation of the patient after more conservative treatment proved ineffective.

Medical policy guidelines also require documentation to support that without the use of a Group III support surface, the patient would require institutionalization. A health care provider must evaluate the patient within a week prior to beginning therapy with an air-fluidized bed. Documentation of prior treatment should include:

• Duration of prior treatment.
• Wound care products used and frequency of changes.
• Pressure reducing surfaces used within 30 days that the physician considered or ruled out, and why it would be ineffective.
• A comprehensive assessment, including the stage, size, and location of ulcers; the patient’s nutritional status; incontinence assessment; and other pressure risk factors. For ulcers greater than 8 sq cm in surface area and/or located someplace besides the posterior trunk or pelvis, detailed documentation must support why alternative treatment/equipment would be ineffective. Also make sure the assessment is dated and identifies the people performing the assessment and their qualifications.

Remember the CMN
Finally, in addition to the WOPD, you need to obtain a completed DMERC Certificate of Medical Necessity (CMN) 01.02B signed and dated by the physician. A revised CMN must be obtained in the sixth month of therapy to verify continuing medical need. If the revised CMN indicates the condition of the patient has worsened or shown no improvement (question No. 22), you will need additional documentation that establishes any changes made, or planned, to the patient’s plan of care. Submit the revised CMN with the claim in the seventh month.

For a patient on a Group III support surface, you must obtain and keep in the patient file monthly statements from the patient’s physician that include:

• The size of the ulcer.
• The healing progress. (If healing did not progress, the statement must detail changes to the plan of care.)
• Verification that the continued use of the support surface is medically necessary for wound management.

Also, remember to study the patient plan of care. The plan should include:

• Patient/caregiver education on the prevention and/or management of pressure ulcers.
• Regular assessment by a physician, nurse, or other licensed health care practitioner. Patients with Stage III or Stage IV ulcers should receive weekly assessments. Request a copy of the assessment form for the patient’s file.
• A schedule for performing appropriate turning and positioning.
• Wound care management followed with use of appropriate products for Stage II, III, or IV ulcers.
• Moisture/incontinence management.
• Nutritional assessment and intervention consistent with the overall plan of care.

Once you thoroughly understand the medical and documentation coverage guidelines required for reimbursement for support surfaces, you can be confident that entering this rapidly growing market can be profitable.

Jane W. Bunch is CEO of Jane’s Billing and Consulting Inc, Marietta, Ga. Contact JB&C at (678) 445-1221.