Catheters – Medicare Billing Document Requirements
Reducing Support Group I – LCD Coverage
For an item to be covered by Medicare, the supplier must receive a detailed written order (DWO) before submitting a claim. If the supplier bills for an item addressed in this policy without first obtaining the completed DWO, the thing would be denied as not reasonable and necessary.
For some items in this policy to be covered by Medicare, a written order before delivery (WOPD) is required. Refer to the DOCUMENTATION REQUIREMENTS section of this LCD and the NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section of the related Policy Article for information about WOPD prescription requirements.
A Group 1 mattress overlay or mattress (E0181-E0189, E0196-E0199, and A4640) is covered if one of the following three criteria are met:
- The beneficiary is completely immobile – i.e., the beneficiary cannot make changes in body position without assistance, or
- The beneficiary has limited mobility – i.e., the beneficiary cannot independently make changes in body position significant enough to alleviate pressure and at least one of conditions A-D below, or
- The beneficiary has any stage pressure ulcer on the trunk or pelvis and at least one of the conditions A-D below.
Conditions for criteria 2 and 3 (in each case, the medical record must document the severity of the condition sufficiently to demonstrate the medical necessity for a pressure reducing support surface):
A) Impaired nutritional status
B) Fecal or urinary incontinence
C) Altered sensory perception
D) Compromised circulatory status
When the coverage criteria for a Group 1 mattress overlay or mattress are not met, the claim will be denied as not reasonable and necessary.
The support surface supplied for the beneficiary should be one in which the beneficiary does not “bottom out.” Bottoming out is when an outstretched hand, placed palm up between the undersurface of the mattress or cushion and the beneficiary’s bony prominence (coccyx or lateral trochanter), can readily palpate the bony prominence.