Rule 5160-10-18 | DMEPOS: hospital beds, bed accessories, and pressure-reducing support surfaces.
(A) Definitions and explanations.
(1) "Group 1," "group 2," and "group 3" are classes of pressure-reducing support surface.
(a) Group 1 surfaces are generally non-powered pads or overlays that are designed to be placed on top of a hospital bed or standard mattress. They achieve their effect through the application of, for example, a gel layer, air pressure, natural lamb's wool, or synthetic sheepskin. Group 1 may also include some powered systems (alternating pressure or low air loss) that are not classified as group 2.
(b) Group 2 surfaces generally encompass powered air flotation beds, powered air mattresses, and non-powered advanced overlays that are designed to be placed on top of a hospital bed frame or standard bed frame.
(c) Group 3 surfaces are generally air-fluidized beds, which simulate the characteristics of fluid by circulating air through a medium such as silicone-coated ceramic beads. They are used for the treatment of stage III or stage IV pressure sores.
(2) "Stage I," "stage II," "stage III," and "stage IV" are classes of tissue breakdown associated with pressure sores.
(a) Stage I is characterized by erythema (redness lasting at least fifteen minutes after pressure is removed), warmth, tenderness, and sometimes blistering. The affected area is usually located over a bony prominence. Further breakdown may be occurring if erythema fails to dissipate when pressure is removed; however, stage I is usually considered a transient circulatory disturbance, and the affected area generally returns to normal within twenty-four hours.
(b) Stage II involves actual tissue damage and appears as a shallow, open ulcer with a red or pink wound bed without slough or as an intact or ruptured serum-filled blister. It is characterized by a distinct break in epidermal integrity (which may extend into the dermis), erythema, disturbance in skin temperature, tenderness, local swelling or edema, and sometimes drainage. (This stage should not be confused with skin tears, tape burns, perineal dermatitis, maceration, or excoriation.) Stage II tissue damage generally heals quickly and easily.
(c) Stage III is characterized by epidermal and dermal destruction that penetrates subcutaneous tissue, infection, cellulitis, eschar, pain, and drainage. Subcutaneous fat may be visible; however, bone, tendon, and muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. There may be undermining and tunneling of surrounding subcutaneous tissue. With proper attention under optimal conditions, a stage III wound can heal in two to four weeks.
(d) Stage IV is characterized by destruction of the epidermis and dermis, penetration of the deep subcutaneous layers, exposure of subcutaneous structures, destruction of muscle or bone, and possible undermining of surrounding subcutaneous tissue. Slough or eschar may be present.
(B) Coverage of hospital beds.
(1) Payment may be made for a hospital bed on a rental/purchase basis.
(2) The default certificate of medical necessity (CMN) form is the ODM 02910, "Certificate of Medical Necessity: Hospital Beds and Bed Accessories" (rev. 7/2018). The CMN must include an attestation that at least one of the following criteria is met:
(a) The individual's condition (e.g., congestive heart failure, chronic obstructive pulmonary disease, problems with aspiration, disease aggravated by excessive body weight) necessitates elevation of the head or upper body to at least thirty degrees, and such elevation cannot be achieved with pillows or wedges in a standard bed;
(b) The individual uses or will use traction equipment that can be attached only to a hospital bed;
(c) The individual needs additional height or support for safe transfer to a chair, wheelchair, or standing position; or
(d) The elevating functions of a hospital bed will facilitate frequent intervention by an assistant or caregiver to alleviate pain or prevent pressure sores.
(3) Documentation of medical necessity must be submitted for any additional feature that is requested (e.g., powered elevation, powered height adjustment, heavy-duty or extra-heavy-duty construction, extra width).
(a) A heavy-duty hospital bed may be indicated for an individual weighing more than three hundred fifty pounds.
(b) An extra-heavy-duty hospital bed may be indicated for an individual weighing more than six hundred pounds.
(C) Coverage of bed accessories.
(1) Payment for the rental or purchase of a bed accessory (e.g., trapeze, side rail, replacement mattress) does not require PA. The provider, however, must keep on file a completed CMN. The default form is the ODM 02910.
(2) If an accessory is to be used with a hospital bed, then the medical necessity of the hospital bed must also have been established.
(D) Coverage of pressure-reducing support surfaces.
(1) The default CMN form is the ODM 02904, "Certificate of Medical Necessity: Pressure-Reducing Support Surfaces" (rev. 7/2018).
(2) For a group 1 surface, the CMN must include an attestation that at least one of the following criteria is met:
(a) The individual cannot make changes in body position without assistance;
(b) The individual cannot independently make changes in body position sufficient to alleviate pressure;
(c) The individual has a pressure sore (of any stage) on the trunk or pelvis; or
(d) The individual's circulation is compromised.
(3) For a group 2 surface, the CMN must include the following information:
(a) If the individual underwent a surgical procedure involving the closure of a wound with a skin graft or skin flap within the thirty days preceding placement of the surface, an attestation to the surgery;
(b) An attestation that at least one of the following criteria is met:
(i) The individual has a stage III or stage IV pressure sore on the trunk;
(ii) The individual has multiple stage II wounds;
(iii) The individual has third-degree burns (irrespective of whether grafting has been performed); or
(iv) Within the sixty days preceding submission of the PA request or placement of the surface, the individual underwent a surgical procedure involving the closure of a wound with a skin graft or skin flap; and
(c) A description of the treatment protocol.
(4) For a group 3 surface, the following information must be included on the CMN directly or by attachment:
(a) An attestation that the individual is being treated for a stage III or stage IV wound;
(b) A detailed description of the wound, prepared by a qualified health practitioner within the twenty-one days preceding placement of the surface, that specifies location, length, width, depth, and overall appearance and characteristics;
(c) A record of the individual's body weight taken intermittently over a period of at least sixty days preceding placement of the surface;
(d) The results of blood tests (which must have been performed within the twenty-one days preceding placement of the surface), including the following levels:
(i) Serum protein;
(ii) Serum albumin or prealbumin;
(iii) Hemoglobin; and
(iv) Hematocrit; and
(e) A current, comprehensive nutritional assessment of the individual, performed by a registered dietitian or licensed dietitian.
(5) The department may determine the length of an initial rental period and any subsequent rental periods.
(E) Requirements, constraints, and limitations.
(1) A bed does not qualify as a hospital bed if it has no elevating function or if its elevating function is not needed.
(2) PA of payment for a group 3 support surface may be denied if its use is contraindicated by factors such as but not limited to the following examples:
(a) Treatment protocols that involve significant quantities of moisture;
(b) Inability of the individual or an assistant to operate the equipment safely;
(c) Inadequate structure to support the weight of the equipment; or
(d) Insufficient electrical supply.