Groups I and II: What Should You Do?

The complicated requirements for Group I and II support surfaces claims involve the “KX” modifier, which must be attached to all such claims. When you attach this modifier, you are stating that all the documentation required by Medicare policy is in the patient’s file.

All decubitus care items require a Written Order Prior to Delivery (WOPD), a signed and dated order from the physician prior to delivering the item to a patient. If you fail to obtain a WOPD, the claim will be denied. Even if you obtain the WOPD at a later time, your claim will not be reimbursable under Medicare guidelines.

As of April 1, 2003, claims for all items requiring a WOPD were deemed “non-appealable claims.” That means if you attach the KX modifier to a claim but did not obtain a WOPD, when you are audited, you will reimburse the DMERC and you cannot appeal the overpayment (CMS 2003 Transmittal R37PI). You will return the money and learn from the experience.

For both Group I and II claims, a Physician’s Order is also required to prove medical necessity. Make sure this document asks the questions provided by the DMERC form (which may not be completed by the provider or anyone financially related to the provider), and that it includes all of the information required to meet the criteria of an approved Medicare Physician’s Order.

To qualify for a Group I mattress per Medicare criteria, the patient is covered if: Question 1 is answered “yes” and that criteria is met alone; or Questions 2 or 3 are answered “yes,” along with at least one of Questions 4 through 7 with supporting documentation.

To quality for a Group II mattress, the following criteria must be met: Questions 1, 2 and 3 must be answered proving criteria has been met; or Question 4 must be answered “yes,” with documentation of Stage III or IV ulcers; or Question 5 must be answered “yes” stating the date of the skin graft, and Question 6 must be answered “yes.” (When a Group II support surface is covered following a skin graft or a myocutaneous flap, coverage is limited to 60 days from the date of surgery.)

Once the ulcer is healed, the mattress will be deemed not medically necessary. If healing does not continue, there must be supporting documentation in the patient’s medical records to show one of the following: The care plan is being modified to promote healing; or, the use of a Group II support surface is medically necessary for wound management. Providers need to verify on a monthly basis that the Group II item is medically necessary prior to attaching the KX modifier.

For both Group I and Group II support surfaces, Medicare also requires a care plan to be documented in the patient’s medical records that includes: a) education of the patient or caregiver on treatment of pressure ulcers; b) assessment of the pressure ulcers by a physician, nurse or other licensed health care practitioner; c) for Stage II, III or IV ulcers, documentation of appropriate wound care; d) turning and positioning of the patient; e) management of incontinence and/or moisture problems (Are bed pads/adult diapers being utilized?); and f) any nutritional needs required for the healing of the pressure ulcers (Is there a dietician involved or is the patient on enteral nutrition?).

Group I and II items are good business. Just be sure to have the required documentation in your patient’s files, and don’t rely on the physician’s records to meet the coverage guidelines. Develop a disease management plan and implement an excellent follow-up program. And remember that good communication is the key to success for your wound care patients and yours as a provider.

Jane Bunch is president of DMEs of America, a Miami-based holding company, and CEO of Kennesaw, Ga.-based JB&CS, a division of DMEA. A reimbursement specialist, Bunch delivers educational seminars worldwide, helps develop corporate compliance plans, and serves as a consultant for fraud and abuse cases. She can be reached at 678/445-1221 or via e-mail at [email protected].