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

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You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

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This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

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CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

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

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

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  1. 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.
  2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association websiteExternal Website.
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  5. CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT-4 should be addressed to the ADA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT-4. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

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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):

  1. 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:
    1. Use of an appropriate group 1 support surface; and
    2. Regular assessment by a nurse, practitioner, or other licensed healthcare practitioner; and
    3. Appropriate turning and positioning; and
    4. Appropriate wound care; and
    5. Appropriate management of moisture/incontinence; and
    6. 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.

  1. 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.

  1. 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 RequirementsPDF to view options for resolving these issues.

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