License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

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Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
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October 28, 2020

Prior Authorization of Pressure Reducing Support Surfaces – Tips for Suppliers and Providers

The CGS Medical Review clinicians have been closely observing the trends in requests for prior authorization for pressure reducing support surfaces (PRSS). For 2020, to date, CGS has noted from January 1, 2020 through September 30, 2020:

Jurisdiction B
PRSS PA Requests received total: 2204
% cases affirmed: 49.1%
% cases non-affirmed: 50.9%

Jurisdiction C
PRSS PA Requests received total: 4687
% cases affirmed: 45.2%
% cases non-affirmed: 54.8%

For both jurisdictions, the top 5 reasons for non-affirmation are:

Reason
The medical record documentation does not demonstrate the beneficiary has large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis. Refer to Local Coverage Determination L33642 and Policy Article A52490.
The medical record documentation contains an error not otherwise specified.
The medical record documentation does not indicate the beneficiary has multiple stage II pressure ulcers located on the trunk or pelvis. Refer to Local Coverage Determination L33642 and Policy Article A52490.
The medical record documentation is not authenticated (handwritten or electronic) by the author. Refer to Medicare Program Integrity Manual 3.3.2.4
The medical record does not demonstrate the beneficiary was on a comprehensive ulcer treatment program for at least a month prior to being placed on a group 2 surface. Refer to Local Coverage Determination L33642 and Policy Article A52490.

Based on these denial reasons, suppliers are reminded of the following PRSS Group 2 local coverage determination (LCD) coverage criteria and the associated review tips to avoid future denials:

A group 2 support surface is covered if the beneficiary meets at least one of the following three Criteria (1, 2 or 3):

The beneficiary has multiple stage II pressure ulcers located on the trunk or pelvis (refer to the ICD-10 code list section in the LCD-related Policy Article for applicable diagnoses) which have failed to improve over the past month, during which time the beneficiary has been on a comprehensive ulcer treatment program including each of the following:

Use of an appropriate group 1 support surface; and
Regular assessment by a nurse, practitioner, or other licensed healthcare practitioner; and
Appropriate turning and positioning; and
Appropriate wound care; and
Appropriate management of moisture/incontinence; and
Nutritional assessment and intervention consistent with the overall plan of care.

Medical Review Tip: A comprehensive care plan is a critical component of pressure ulcer healing, in addition to the use of a support surface, regardless of the group. Frequent turning of the beneficiary, and addressing their skin moisture, incontinence and nutrition all play a key role and must be documented in the medical record.

The beneficiary has large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis (refer to the ICD-10 code list section in the LCD-related Policy Article for applicable diagnoses).

Medical Review Tip: Suppliers should work with the treating practitioner to thoroughly describe the characteristics of the pressure ulcers for which the PRSS is being prescribed. Note the criterion includes multiple stage III or IV pressure ulcers as an option for coverage. This means documenting more than one (1) pressure ulcer. In addition, coverage is also considered for a single, large pressure ulcers, with "large" traditionally defined as >8 cm² in size. Medical review clinicians, when considering coverage of large ulcers, take into account whether undermining and/or tunneling are present, the anatomic location on the body and the size of the beneficiary.

The beneficiary had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days (refer to the ICD-10 code list section in the LCD-related Policy Article for applicable diagnoses), and has been on a group 2 or 3 support surface immediately prior to discharge from a hospital or nursing facility within the past 30 days.

Medical Review Tip: For beneficiaries qualifying for a PRSS under this skin graft or myocutaneous flap requirement, ensure that the flap or graft surgery information is included in the medical records sent for review. In addition, it is critical to document prior use of a group 2 or group 3 PRSS.

Signature Requirements

Services that are ordered or provided to Medicare beneficiaries require that those services be authenticated by the author. Suppliers are often faced with the difficult task of determining if the signature is valid or what to do if the signature is missing. The Centers for Medicare and Medicaid Services (CMS) has requirements related to signatures on medical documentation and orders/prescriptions. CGS has created a document on its website that summarizes the CMS signature requirements. The CMS Signature Requirements document provides guidance for handwritten and electronic signatures. It gives the supplier instructions on how to fix illegible signatures and what can be accepted if the signature is missing from certain documents. A signature attestation statement is an option, in limited situations, and a suggested example is included in the CMS Signature Requirements document.

If you are having trouble with missing or invalid signatures, simply click on this link for CMS Signature Requirements to view options for resolving these issues.