By Kim Turner, RN
Effective for dates of delivery on or after July 22, 2019, Medicare requires prior authorization for Group 2 Pressure Reducing Support Surfaces (PRSS) for the states of California, Indiana, New Jersey, and North Carolina for HCPCS E0193, E0277,E0371,E0372, and E0373.
Prior Authorization for these HCPCS will expand to the remaining states and territories effective October 21, 2019. Medicare will begin accepting requests for the affected codes on October 07, 2019.
After these dates, claims submitted to Medicare for PRSS must be associated with a prior authorization request as a condition of payment. Lack of an affirmed prior authorization request will result in a claim denial.
What does this mean for you? Planning for discharge begins at the time of admission! Work with referral sources to establish the necessity of an item prior to an immediate need.
Planning for discharge will be critical for patients that you believe may need a PRSS that requires prior authorization. When these items are ordered, the DME supplier must submit a prior authorization request which includes all required documentation prior to providing the item to the Medicare beneficiary. Medicare contractors have five (5) business days to respond to prior authorization requests and two (2) business days for expedited requests (e.g., in a few instances following a hospital discharge after a myocutaneous flap or graft).
For Medicare to provide a provisionally affirmed prior authorization request and reimbursement for the PRSS, there are several requirements that must be met:
1. Signed and dated *written order from the ordering practitioner;
2. Documentation that 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 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:
a. Use of an appropriate group 1 support surface; and,
b. Regular assessment by a nurse, physician, or other licensed healthcare practitioner; and,
c. Appropriate turning and positioning; and,
d. Appropriate wound care; and,
e. Appropriate management of moisture/incontinence; and,
f. Nutritional assessment and intervention consistent with the plan of care.
2. The beneficiary has large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis; or,
3. The beneficiary had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days 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.
* Written Order required Prior To Delivery (WOPD)
Proper completion of the PA coversheet and a thorough intake process aids in minimizing most rejections.