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 independently make changes in body position without assistance)

Or

  • 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

Or

  • 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 status

OR

B. Describe the patient’s Fecal or urinary incontinence

OR

C. Describe the patient altered sensory perception

OR

D. Describe the patients compromised circulatory status

Diagnosis: See LCD (Local coverage determination) at CGSMedicare.com 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 letterhead 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.

10/17

Support Surface, stage 2 documentation needs

The following qualification criteria need to be documented in the patients’ 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 the patient’s multiple stage II pressure ulcers located on the trunk or pelvis which has failed to improve over the past month, and explain the patient’s comprehensive ulcer treatment program including each of the following.
  1. Explain the use of an appropriate group 1 support surface. And
  2. Explain the regular assessment done by a nurse, physician, or other related healthcare practitioner. And
  3. Explain the turning and positioning needs and schedule. And
  4. Explain the wound care. And
  5. Explain the management of moisture/incontinence. And
  6. Explain the nutritional assessment and intervention consistent with the overall plan of care.

Or

  • Explain the patient’s large or multiple stage III or IV pressure ulcer on the trunk or pelvis, including the stage, location and size.

Or       

  • Describe the patient’s myocutaneous flap or skin graft and location for a pressure ulcer on the trunk or pelvis within the past 60 days. Explain the support surface previously used and when the treatment began.

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

Medicare approved detailed equipment descriptions for Group 2 support surfaces

Powered pressure-reducing mattress (low air loss), (HCPC-E0277)

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.

10/17