Support Surface documentation needs

The following qualification criteria need to be documented in the patient’s medical record notes to qualify for the prescribed equipment. Note: Justification notes are valid for six months.

One of the following needs to be sufficiently documented to support the need for the prescribed equipment.

  • Explain why the patient is completely immobile (patient cannot make changes in body position without assistance)


  • Explain why the patient has limited mobility (Patient cannot independently make changes to body position significant enough to alleviate pressure and at least one of conditions A-D


  • Explain the patient’s stage ulcer on the truck or pelvis and at least one of conditions A-D
  • 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 pressure reducing support surface)

A. Describe the patient nutritional


B. Describe the patient’s Fecal or urinary incontinence


C. Describe the patient altered sensory perception


D. Describe the patients compromised circulatory status

 Diagnosis: See LCD (Local coverage determination) at for any additional qualifying information questions, diagnosis codes and descriptions

 Medicare approved detailed equipment description for support surface

Powered pressure-reducing mattress with pump, alternating, overlay/pad, (HCPC-E0181)


Patient notes/justification – Must be documented using your normal dictation process. Letter of medical necessity, notes wrote on letter head or prescriptions are not valid.

Prescription/order requirements– Must contain Patient’s name, date of the order and Start date, detailed equipment description (See above), signature of the ordering physician and a signature date.