Pressure Reducing Support Surfaces Print

1. Description

This document addresses the use of pressure reducing support surfaces. A pressure reducing support surface is designed to prevent or promote the healing of certain types of pressure ulcers by reducing or eliminating tissue interface pressure. Most of these devices reduce interface pressure by conforming to the contours of the body so that pressure is distributed over a larger surface area rather than concentrated on a more restricted site.

A group 1 pressure reducing support surface includes pressure pads for mattresses, non-powered pressure reducing mattresses and powered pressure reducing mattress overlay systems. A group 2 pressure reducing support surface includes powered pressure reducing mattresses, semi-electric hospital beds with powered pressure reducing mattresses, powered pressure reducing mattress overlays, advanced non-powered pressure reducing mattresses and advanced non-powered pressure reducing mattress overlays. A Group 3 pressure reducing support surface (e.g., air fluidized bed) is a device employing the circulation of warm filtered air through small, silicone coated ceramic beads creating the characteristics of fluid. When the individual is placed in the bed, his/her body weight is evenly distributed over a large surface area, which creates the sensation of "floating."

2. Clinical Indications

2.1.  Group 1 Support Surfaces

Medically Necessary

 

A group 1 mattress overlay or mattress is considered medically necessary if the individual meets:

  • Criterion 1, or

  • Criterion 2 or 3 and at least one of criteria 4-7

    1. Completely immobile – i.e., individual cannot make changes in body position without assistance

    2. Limited mobility – i.e., individual cannot independently make changes in body position significant enough to alleviate pressure

    3. Any stage pressure ulcer on the trunk or pelvis

    4. Impaired nutritional status

    5. Fecal or urinary incontinence

    6. Altered sensory perception

    7. Compromised circulatory status

 

2.2. Group 2 Support Surfaces

Medically Necessary:

A group 2 support surface is considered medically necessary if the individual meets:

  • Criteria 1and 2 and 3, or

  • Criterion 4, or

  • Criteria 5 and 6

    1. Multiple stage II pressure ulcers located on the trunk or pelvis

    2. Individual has been on a comprehensive ulcer treatment program (*see below) for at least the past 30 days that has included the use of an appropriate group 1 support surface

    3. The ulcers have worsened or remained the same over the past month

    4. Large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis

    5. Recent myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis (surgery within the past 60 days)

    6. The individual has been on a group 2 or 3 support surface immediately prior to a recent discharge from a hospital or nursing facility (discharge within the past 30 days)

*The comprehensive ulcer treatment program described above should generally include:

  • Education of the individual and caregiver on the prevention and/or management of pressure ulcers

  • Regular assessment by a nurse, physician or other licensed healthcare practitioner (usually at least weekly for an individual with a stage III or IV ulcer)

  • Appropriate turning and positioning

  • Appropriate wound care (for a stage II, III or IV ulcer)

  • Appropriate management of moisture/incontinence

  • Nutritional assessment and intervention consistent with the overall plan of care

Continued use of a group 2 support surface is considered medically necessary until the ulcer is healed or, if healing does not continue, there is documentation in the medical record to show that:

  1. other aspects of the care plan are being modified to promote healing, or

  2. the use of the group 2 support surface is medically necessary for wound management

When a group 2 pressure reducing support surface is prescribed following a myocutaneous flap or skin graft, continued use is considered medically necessary for up to 60 days from the date of surgery.

 

2.3. Group 3 Support Surfaces

Medically Necessary:

A group 3 support surface (air fluidized bed) is considered medically necessary if the individual meets all of the following:

  1. The individual has a stage III (full thickness tissue loss) or stage IV (deep tissue destruction) pressure sore or is status post muscle/skin flap repair of a stage III or IV pressure sore. An air fluidized bed is typically needed only 6-12 weeks status-post surgery; and

  2. The individual is bedridden or chair bound as a result of severely limited mobility; and

  3. In the absence of an air fluidized bed, the individual would require institutionalization; and

  4. The air fluidized bed is ordered, in writing, by the individual's attending physician based upon a comprehensive assessment and evaluation of the individual after completion of a course of conservative treatment designed to optimize conditions that promote wound healing; and

  5. The course of conservative treatment (*see below) must have been at least one month in duration without progression toward wound healing. This month of prerequisite conservative treatment may include some period in an institution as long as there is documentation available to verify that the necessary conservative treatment was rendered; and

  6. A trained adult caregiver is available to assist the individual with activities of daily living, fluid balance, dry skin care, repositioning, recognition and management of altered mental status, dietary needs, prescribed treatments, and management and support of the air-fluidized bed system and its problems such as leakage; and

  7. A physician directs the home treatment regimen and re-evaluates and re-certifies the need for the air fluidized bed every three months; and

  8. All other alternative equipment has been considered and ruled out.

*Conservative treatment must include:

  • Frequent repositioning of the individual with particular attention to relief of pressure over bony prominences (usually every two hours); and

  • Use of a group 2 support surface to reduce pressure and shear forces on healing ulcers and to prevent new ulcer formation; and

  • Necessary treatment to resolve any wound infection; and

  • Optimization of nutrition status to promote wound healing; and

  • Debridement by any means, including wet-to-dry gauze dressings, to remove devitalized tissue from the wound bed; and

  • Maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings protected by an occlusive covering while the wound heals.

Wet-to-dry dressings, when used for debridement, do not require an occlusive dressing. Use of wet-to-dry dressings for wound debridement, begun during the period of conservative treatment and which continue beyond 30 days, does not in and of itself affect the medical necessity of an air fluidized bed. Should additional debridement again become necessary while the individual is using an air fluidized bed (after the first 30-day course of conservative treatment) that will not in and of itself affect the medical necessity of an air fluidized bed.

In addition, conservative treatment should generally include:

    • Education of the individual and caregiver on the prevention and management of pressure ulcers

    • Assessment by a physician, nurse or other licensed healthcare practitioner at least weekly

    • Appropriate management of moisture or incontinence

Continued use of an air fluidized bed is considered medically necessary until the ulcer is healed or, if healing does not continue, there is documentation in the medical record to show that:

  1. other aspects of the care plan are being modified to promote healing; or

  2. the use of the air fluidized bed is medically necessary for wound management

Not Medically Necessary

A group 1 or group 2 overlay, mattress, or bed is considered not medically necessary when the criteria above are not met.

A group 3 support surface (air fluidized bed) is considered not medically necessary under any of the following circumstances:

  1. The individual has coexisting pulmonary disease (the lack of firm back support makes coughing ineffective and dry air inhalation thickens pulmonary secretions)

  2. The individual requires treatment with wet soaks or moist wound dressings that are not protected with an impervious covering such as plastic wrap or other occlusive material

  3. The caregiver is unwilling or unable to provide the type of care required by the individual on an air fluidized bed

  4. Structural support is inadequate to support the weight of the air fluidized bed system (it generally weighs 1600 pounds or more)

  5. Electrical system is insufficient for the anticipated increase in energy consumption

  6. Other known contraindications exist

A support surface (group 1 or group 2) that does not meet the characteristics specified in the Definition section of this document is considered not medically necessary.

3. Discussion/General Information

Pressure reducing support surfaces are designed to prevent or promote the healing of pressure ulcers by reducing or eliminating tissue interface pressure. Most of these devices reduce interface pressure by conforming to the contours of the body so that pressure is distributed over a larger surface area rather than concentrated on a more restricted site. Pressure reducing support surfaces that contain multiple components are categorized according to the clinically predominant component, which is usually the topmost layer of a multi-layer product.

For all types of support surfaces, the support surface provided should be one in which the individual does not "bottom out." Bottoming out is the finding that an outstretched hand, placed palm up between the undersurface of the overlay or mattress and the individual's bony prominence (coccyx or lateral trochanter), can readily palpate the bony prominence. This bottoming out criterion should be tested with the individual in the supine position with their head flat, in the supine position with their head slightly elevated (no more than 30 degrees), and in the sidelying position.

In a meta-analysis by Nicosia and colleagues (2007) the authors concluded data support the use of foam mattresses, air mattresses or overlays versus a standard hospital mattress to reduce the risk of developing heel pressure ulcers. However, the authors noted the results are limited based on the small number and poor quality of controlled clinical trial data included in the meta-analysis.

4. Definitions

Pressure Ulcer (National Pressure Ulcer Advisory Panel, 2007)
A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated.

Pressure Ulcer Stages

Suspected Deep Tissue Injury:
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
Further description:
Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.

Stage I:
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.
Further description:

The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate "at risk" persons (a heralding sign of risk).

Stage II:
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.
Further description:
Presents as a shiny or dry shallow ulcer without slough or bruising.*This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.
*Bruising indicates suspected deep tissue injury

Stage III:
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Further description:
The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

Stage IV:
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.
Further description:
The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.

Unstageable:
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.
Further description:
Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed.

Support Surface Descriptions/Definitions

Group 1

Group 1 pressure reducing support surfaces include: pressure pads for mattresses, non-powered pressure reducing mattresses and powered pressure reducing mattress overlay systems.

Pressure pads for mattresses describe non-powered pressure reducing mattress overlays. These devices are designed to be placed on top of a standard hospital or home mattress. This includes:

  • A gel or gel-like mattress overlay, which is characterized by a gel or gel-like layer with a height of 2 inches or greater

  • An air mattress overlay, which is characterized by interconnected air cells having a cell height of 3 inches or greater that are inflated with an air pump

  • A water mattress overlay, which is characterized by a filled height of 3 inches or greater

  • A foam mattress overlay, which is characterized by all of the following:

    1. Base thickness of 2" or greater and peak height of 3" or greater if it is a convoluted overlay (e.g., eggcrate) or an overall height of at least 3 inches if it is a non-convoluted overlay

    2. Foam with a density and other qualities that provide adequate pressure reduction

    3. Durable, waterproof cover

Non-powered pressure reducing mattresses include:

  • A foam mattress, which is characterized by all of the following:

    1. Foam height of 5 inches or greater

    2. Foam with a density and other qualities that provide adequate pressure reduction

    3. Durable, waterproof cover

    4. Can be placed directly on a hospital bed frame

  • An air, water or gel mattress, which is characterized by all of the following:

    1. Height of 5 inches or greater of the air, water or gel layer

    2. Durable, waterproof cover

    3. Can be placed directly on a hospital bed frame

Powered pressure reducing mattress overlay systems (alternating pressure or low air loss) are characterized by all of the following:

  1. An air pump or blower that provides either sequential inflation and deflation of air cells or a low interface pressure throughout the overlay

  2. Inflated cell height of the air cells through which air is being circulated is 2.5 inches or greater

  3. Height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure overlays), and air pressure provide adequate patient lift, reduce pressure, and prevent bottoming out

Group 2

Group 2 pressure reducing support surfaces include: powered pressure reducing mattresses, semi-electric hospital beds with powered pressure reducing mattresses, powered pressure reducing mattress overlays, advanced non-powered pressure reducing mattresses and advanced non-powered pressure reducing mattress overlays.

A powered pressure reducing mattress (alternating pressure, low air loss, or powered flotation without low air loss) is characterized by all of the following:

  1. An air pump or blower that provides either sequential inflation and deflation of the air cells or a low interface pressure throughout the mattress

  2. Inflated cell height of the air cells through which air is being circulated is 5 inches or greater

  3. Height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure mattresses), and air pressure provide adequate patient lift, reduce pressure, and prevent bottoming out

  4. A surface designed to reduce friction and shear

  5. Can be place directly on a hospital bed frame

A semi-electric hospital bed with a fully integrated powered pressure reducing mattress that has all the characteristics defined above is considered a group 2 pressure reducing support surface.

An advanced non-powered pressure reducing mattress overlay is characterized by all of the following:

  1. Height and design of individual cells provide significantly more pressure reduction than a group 1 overlay and prevent bottoming out

  2. Total height of 3 inches or greater

  3. A surface designed to reduce friction and shear

  4. Documented evidence to substantiate that the product is effective for the treatment of condition described by the coverage criteria for group 2 support surfaces

A powered pressure reducing mattress overlay (low air loss, powered flotation without low air loss, or alternating pressure) is characterized by all of the following:

  1. An air pump or blower that provides either sequential inflation and deflation of the air cells or a low interface pressure throughout the overlay

  2. Inflated cell height of the air cells through which air is being circulated is 3.5 inches or greater

  3. Height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure overlays), and air pressure to provide adequate patient lift, reduce pressure, and prevent bottoming out

  4. A surface designed to reduce friction and shear

An advanced non-powered pressure reducing mattress is characterized by all of the following:

  1. Height and design of individual cells provide significantly more pressure reduction than a group 1 mattress and prevent bottoming out

  2. Total height of 5 inches or greater

  3. A surface designed to reduce friction and shear

  4. Documented evidence to substantiate that the product is effective for the treatment of conditions described by the coverage criteria for group 2 support surfaces

  5. Can be placed directly on a hospital bed frame

Pressure reducing support surfaces that contain multiple components are categorized according to the clinically predominant component, which is usually the topmost layer of a multi-layer product. For example, a product with 3-inch powered air cells on top of a 3-inch foam base would be categorized as a powered overlay not as a powered mattress.

Group 3

Group 3 pressure reducing support surfaces include air fluidized beds. An air fluidized bed uses the circulation of warm filtered air through small, silicone coated ceramic beads creating the characteristics of fluid. When the individual is placed in the bed, his/her body weight is evenly distributed over a large surface area, which creates the sensation of "floating."

5. Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

If you need information regarding DME Billing Code Click Here. Diagnosis Code Click Here

HCPCS
Group 1 support surfaces:
A4640 Replacement pad for use with medically necessary alternating pressure pad owned by patient
E0181 Powered pressure reducing mattress overlay/pad, alternating, with pump, includes heavy duty
E0182 Pump for alternating pressure pad, for replacement only
E0184 Dry pressure mattress
E0185 Gel or gel-like pressure pad for mattress, standard mattress length and width
E0186 Air pressure mattress
E0187 Water pressure mattress
E0188 Synthetic sheepskin pad
E0189 Lambswool sheepskin pad, any size
E0196 Gel pressure mattress
E0197 Air pressure pad for mattress, standard mattress length and width
E0198 Water pressure pad for mattress, standard mattress length and width
E0199 Dry pressure pad for mattress, standard mattress length and width
E0272 Mattress, foam rubber
Group 2 support surfaces:
E0193 Powered air flotation bed (low air loss therapy)
E0277 Powered pressure-reducing air mattress
E0371 Nonpowered advanced pressure reducing overlay for mattress, standard mattress length and width
E0372 Powered air overlay for mattress, standard mattress length and width
E0373 Nonpowered advanced pressure reducing mattress
Group 3 support surfaces:
E0194 Air fluidized bed
ICD-9 Diagnosis
All diagnoses, including, but not limited to, the following:
707.00-707.09 Pressure ulcer
707.20-707.25 Pressure ulcer stages

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