More than three-quarters of all pressure reducing support surface claims in the first half of 2007 did not meet Medicare coverage criteria, totaling an estimated $33 million in inappropriate payments, according to an August 2009 Office of Inspector General (OIG) report entitled “Inappropriate Medicare Payments for Pressure Reducing Support Surfaces.”
Pressure reducing support surfaces are used for the care or prevention of pressure ulcers. A pressure ulcer, also known as a bedsore or decubitus ulcer, is an area of skin that breaks down when a person stays in one position for too long.
The Centers for Medicare & Medicaid Services (CMS) categorizes support surfaces into the following three groups:
- Group 1 support surfaces are generally designed to be placed on top of standard hospital or home mattresses and include pressure pads and mattress overlays (foam, air, water, or gel).
- Group 2 support surfaces, which can be special mattresses used alone or placed directly over a bed frame, include powered air flotation beds, powered pressure reducing air mattresses, and nonpowered advanced pressure reducing mattresses.
- Group 3 support surfaces are complete bed systems, known as air-fluidized beds, which simulate the movement of fluid by circulating filtered air through silicone-coated ceramic beads.
The OIG focused its investigation on group 2, which accounted for 80 percent of all support surface payments in 2007.
Support surfaces are covered under Medicare Part B as capped rental Durable Medical Equipment (DME) providing Medicare coverage criteria are met. The OIG, however, found in its review of 363 claims for group 2 support surfaces submitted in the first half of 2007 that:
- 38 percent of claims were undocumented;
- 22 percent of claims were medically unnecessary;
- 17 percent of claims had insufficient documentation; and
- 3 percent of claims had other billing errors.
Many claims did not meeting supplier documentation requirements because:
- the supplier delivered the support surface before obtaining the physician order;
- the supplier did not have a physician order;
- the supplier was missing proof of delivery; or
- the physician order was not dated.
Despite the lack of proper documentation the OIG found in 80 percent of the 363 claims it sampled, all but one included modifier KX Requirements specified in the medical policy have been met.
Remember: Modifier KX should only be used to indicate a DME claim meets Medicare coverage criteria and adequate documention exists. Since the definition of modifier KX differs depending on the Local Coverage Determination (LCD), suppliers should review recently revised LCDs carefully.
To ensure claims for group 2 support surfaces meet Medicare coverage criteria and are paid appropriately, the OIG recommends in its report for CMS to conduct additional prepayment and postpayment medical reviews of group 2 support surface claims; educate suppliers and health care providers about Medicare coverage criteria; review modifier KX usage; and conduct additional statistical analyses to monitor group 2 support surfaces payments. The OIG also recommends in the report that CMS “take appropriate action” regarding claims found to be inappropriate in the review. CMS concurred with these recommendations.
See Appendix A in the OIG report for detailed DME Medicare Administrative Contractor (MAC) LCD coverage and payment rules and supplier documentation requirements.
Monday, November 16th, 2009