Prior authorization: New rule in effect for pressure reducing support surfaces

prior authorization

Clinicians caring for Medicare beneficiaries who need pressure reducing support surfaces when discharged home are adapting to a new rule.

Those clinicians now need to submit a Prior Authorization Request for Pressure-Reducing Support Surfaces, said Cynthia Broadus, BSHA, RN, CHCRM, LNHA, CLNC, WCC, DWC, OMS, executive director at the National Alliance of Wound Care and Ostomy (NAWCO) in Somonauk, Ill.

The Prior Authorization Request for Pressure Reducing Support Surfaces is a rule established by the Centers for Medicare and Medicaid Services (CMS) that took effect Oct. 21, 2019.

Submitting the preauthorization documentation will identify the need for the pressure reducing support surface and provide the supporting documentation, according to Broadus.

“The authorization must be submitted before the support surface is supplied to the patient and before a claim can be submitted for payment,” she said.

The durable medical equipment’s medical administrative contractor will notify the requesting party of CMS’s decision.

“If the request is denied or non-affirmed, the requesting party can provide additional information to resolve the non-affirmation along with resubmitting the prior request for preauthorization,” Broadus said. “If a preauthorization is not submitted and approval is not received, claims for payment will be denied.”

The pressure reducing surfaces that are now subject to prior authorization are Group 2 codes, Broadus said. They include:

  • E0193: Powered air flotation bed (low air loss therapy)
  • E0277: Powered pressure reducing air mattress
  • E0371: Non-powered advanced pressure reducing overlay for mattress, standard mattress length and width
  • E0372: Powered air overlay for mattress, standard mattress length and width
  • E0373: Non-powered advanced pressure reducing mattress 

Key takeaways for wound care clinicians

The first important consideration is to initiate discharge planning upon admission.

The second is to conduct initial patient admission assessments accurately to identify which patients with pressure injuries will need Group 2 support surfaces when discharged, Broadus said.

These patients include those with:

  • Multiple Stage 2 pressure injuries on the trunk or pelvis and proof that a Group 1 support surface and a comprehensive treatment plan had been in place for at least one month before the request.
  • Patients who have large or multiple Stage 3 or 4 pressure injuries on the trunk or pelvis.
  • Patients who have had a surgical procedure for a myocutaneous flap or skin graft for pressure injury on the trunk or pelvis within the past 60 days, and has been on a Group 2 or 3 support surface immediately before discharge from a hospital or nursing facility.

Equipment suppliers and hospitals must work collaboratively to collect the necessary information and forward it to the contractor for approval, according to Broadus.

“The authorization process takes time,” she said. “Early submission will prevent unnecessary delays at discharge. Decision letters are generally postmarked by the fifth business day after receipt of preauthorization requests and resubmitted preauthorization requests. Expedited decisions are sometimes received as quickly as two business days from the date of the expedited request.”

Understanding support surface therapy

While accurate and timely prior authorization requests for support surfaces are essential for homebound patients, another important factor is choosing the best support surface for each patient.

There are hundreds of support surfaces on the market to treat or prevent pressure injuries, said Roz Jordan, MSc, BSN, RN, CWCN, WCC, OMS, vice president of NAWCO.

Clinicians usually have to work with what their organization has already bought, according to Jordan.

“There is not one be-all and end-all support surface that works for every patient,” she said. “A wound care clinician will want to assess all the different support surface therapies available to them, then decide which one is best for each patient in order to provide individualized care.”

The goal of all support surfaces is to redistribute pressure.

“There are two ways to do that — using either an active support surface or a reactive support surface,” Jordan said.

Features of an active support surface

“With an active support surface, there is movement within the surface, regardless of the patient’s weight (also known as the load),” Jordan said. “This type of surface provides alternating pressure.”

Features of a reactive support surface

This surface reacts in response to the patient’s body (load). “The patient sinks into the product, and the product immerses and envelops the patient to relieve pressure,” Jordan said.

Ensure staff understand prior authorization

Regardless of the practice environment, staff involved in collecting the documentation needed to obtain prior authorization approval need to ensure all required criteria have been met before submitting requests to prevent adverse decisions, Broadus said.

Jordan recommends staff reach out to product reps as another resource if they have additional questions about support surfaces.

“Patients benefit from clinicians who have a solid understanding of product options and their features,” she said. “This results in improved clinical decisions for patients.”

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Carole Jakucs

Carole Jakucs, MSN, RN, PHN, is a full-time freelance writer. Her background in nursing includes tenures in healthcare management and as a care provider. She has worked in med/surg/telemetry, pediatric emergency department and college health. 

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