Protecting your skin care and positioning claims
Q. Is it true that if a patient does not have a specific diagnosis code for a skin protection and/or positioning cushion, Medicare will not pay for it--even if the patient requires it?
A. Yes, with the original claim, but the denial could be overturned upon appeal. The current policy requires that the patient has a wheelchair and the patient meets Medicare coverage criteria for it; and that the patient has one of the following diagnosis codes:
1) For a skin protection cushion: 707.03, 707.04, 707. 105, 344.00-344.1, 336.0-336.3, 340, 341.0-341.9, 343.0-343.9, 335.0-335.21, 335.23-335.9, 138, 344.09, 741.00-741.93, 330.0-330.9, 331.0, 332.0
2) For a positioning cushion: 344.30-344.32, 438.40-438.42, 342.00-342.92, 438.20-438.22, 359.0, 359.1, 333.4, 333.6, 333.7, 334.0-334.9 If the patient does not have one of the required diagnosis codes for a specific type of cushion, the claim will be initially denied as not medically necessary. After receiving the denial, you should exercise your appeal rights and request a review of the claim.
Before submitting the claim for review, you must ensure you have, or obtain, supporting medical documentation that clearly identifies the patient's condition that requires the properties of the cushion provided. This documentation must explain why this patient requires the cushion, even though he does not meet the coverage criteria based on the diagnosis codes required. This information must come from the patient's medical record. The reviewer will evaluate the documentation. If it is determined that the documentation substantiates the medical need, the reviewer has the authority to approve the claim based on individual consideration.
Dan Fedor is general manager for education and compliance at Pride Mobility Products. Reach him at (800) 800-8586 or email@example.com.