CMS makes concessions for support surfaces

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Friday, June 7, 2019

WASHINGTON – CMS has implemented a shorter, five-day turnaround time for prior authorizations for support surfaces, but there are no changes to the coverage criteria, CMS officials said during a Special Open Door Forum on June 4.

The agency will turn around expedited PA requests for support surfaces in two days, it says.

“We realize that the support surfaces process is a lot different than with power mobility,” a CMS official said during the call.

CMS announced in April that it planned to add five codes for Group 2 support surfaces—E0193, E0277, E0371, E0372 and E0373—to its prior auth program. The requirement goes into effect July 22 for providers in California, Indiana, New Jersey and North Carolina, and Oct. 21 for all states.

CMS officials reminded listeners that the coverage criteria for support surfaces falls into three buckets and that it’s for patients in the “third bucket” that they expect to receive expedited PA requests. Those patients have a diagnosis of a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days and have been on a Group 2 or 3 support surface prior to discharge within the past 30 days.

For all PA requests, there needs to be a care plan by the treating practitioner that addresses other factors required for wound healing, including nutrition, moisture and incontinence, and turning and positioning, CMS officials said.

If an initial PA request is denied, providers may resubmit as many times as necessary. Most (80%) are affirmed on the first request, with 96% affirmed by the second request, officials said.

On the call, industry consultant Andrea Stark noted that the local coverage determination for support surfaces requires a 30-day trial period for a Group 1 support surface and asked if the PA process could start before those 30 days were up.

“If we have to wait until we get to the end of the trial and then add a five-day delay for normal channels, that could delay the patient from getting treatment and allowing those ulcers to deteriorate,” said Stark, a reimbursement consultant with MiraVista.

While the reviewer should be able to see that it is coming toward the end of that 30-day timeframe, the PA request should be done closer to the end of the period, officials said.

Providers will also have to submit PA requests for seven codes for complex rehab power mobility devices starting July 22.