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Billing Clarification on Support Surfaces and Hospital Beds

National Government Services, the Jurisdiction B DME MAC has developed this article to clarify issues related to the billing of hospital beds with mattresses, hospital beds without mattresses and support surfaces.   

Hospital Beds, Air-Fluidized Beds, and Powered Air Flotation Beds

If a patient requires a hospital bed (E0250–E0266, E0290–E0297, E0301–E0304, or E0328–E0329) and a change in their condition results in them needing either a powered air flotation bed (E0193) or an air-fluidized bed (E0194), Medicare will begin a new 13-month rental cap for either the powered air flotation bed or air-fluidized bed. However, if the patient’s condition improves and they switch back to a hospital bed (E0250–E0266, E0290–E0297, E0301–E0304, or E0328–E0329) the capped rental period for the hospital bed will resume where it left off, because there was not an interruption in a period of continuous use due to medical need.

If the patient’s condition worsens and they again require an air flotation bed (E0193) or air-fluidized bed (E0194), a new capped rental period will not begin unless there is definitive documentation that the patient’s pressure ulcers healed completely and stayed healed for 60+ days. However, the 60+ days relates to the period of time when the wound is healed, not to the period of time that the patient is not using the air flotation bed or air-fluidized bed.

Example

Patient began renting a medically necessary E0194 on 02/01/2010, the wound completely healed on 04/20/2010, no new wounds were present and E0194 was discontinued. A new capped rental period for E0194 would begin only if:

  • There was documentation in the patient’s medical records that the wound remained healed on 07/01/2010 and that no new wounds were present at that time; and
  • There was documentation of a recurrence of the wound or a new wound after 07/01/2010. 

A new capped rental period would not begin if documentation does not show that the wound was completely healed between 04/20/2010 and 07/01/2010 and that no new wounds were present. If the wound recurred on 06/15/2010, but the patient did not begin using the E0194 until 08/01/2010, a new capped rental period would not begin.

Hospital Beds with Mattresses, Group I Support Mattresses, and Group II Support Mattresses

When claims are submitted to Medicare, the beneficiary’s payment history is scanned to ensure that the item being billed is not the same or similar to an item that has previously been billed and according to Medicare records is still in use. This includes claims for hospital bed HCPCS codes E0250, E0255, E0260, E0265, E0290, E0292, E0294, E0296, E0303, E0304, E0328, and E0290, with a narrative description indicating a mattress is included and the patient is also renting or owns a medically necessary group I (E0184, E0186, E0187, E0196) or group II support mattress (E0277, E0373).

Effective December 6, 2010, the Jurisdiction B DME MAC will begin issuing ANSI 151 same/similar claim denial on claims for hospital beds with mattresses when the patient is currently renting or owns a medically necessary group I or II support mattress. If the beneficiary’s condition changes and resulting in their need for a different item (i.e., a hospital bed and a group II support surface), Medicare would consider payment. However, at no time will Medicare allow for a hospital bed with mattress and a support surface classified as a mattress (i.e., group I support mattress [E0184, E0186] or group II support mattress [E0277, E0373]).  

Helpful Tips

When submitting claims for hospital beds, suppliers should ensure that the correct HCPCS codes are being utilized prior to claim submission to the DME MAC.

  • Suppliers should verify during the intake process whether or not the patient is currently renting or owns a medically necessary group I or II support surface mattress. If the supplier determines the patient is renting or owns a medically necessary group I or II support surface mattress, they should deliver the appropriate hospital bed without mattress and bill the appropriate corresponding HCPCS code to the DME MAC. 

Suppliers should inform patients during the intake process that Medicare considers a group I or II support mattress same or similar to a hospital bed with mattress. Therefore, if their condition changes and they subsequently require and receive a “special” support mattress to contact them immediately so that billing can be modified for the hospital bed. At that time, suppliers may pick up the hospital bed mattress that the patient is no longer using or can opt to leave the hospital bed mattress in the patient’s home. 

If the hospital bed mattress is picked up, suppliers should bill using hospital bed HCPCS codes where the narrative indicates that a mattress is not included (E0251, E0256, E0261, E0266, E0291, E0293, E0295, E0297, E0301, E0302).

If the beneficiary chooses to keep the hospital bed mattress suppliers may execute an Advance Beneficiary Notice of Noncoverage (ABN) in order to hold the beneficiary liable for the difference between the hospital bed with mattress and hospital bed without mattress. In that situation the supplier should bill using the upgrade modifiers.

Line 1: Bill the appropriate HCPCS code for the upgraded item the supplier actually provided to the beneficiary (hospital bed with mattress) with the dollar amount of the upgraded item. If the supplier has a properly obtained ABN on file signed by the beneficiary, report modifier GA; if the supplier did not properly obtain an ABN signed by the beneficiary, report modifier GZ.

Line2:  Bill the appropriate HCPCS code for the reasonable and necessary item (hospital bed without mattress) with the actual charge for the item; report modifier GK.

The following examples explain how to file claims with an ABN and without an ABN.

Example 1

Upgraded with an ABN E0260RRKHGA $100
Medically necessary item E0261RRKXKHGK $50

Example 2

Upgrade without an ABN E0260RRKHGZ $100
Medically necessary item E0261RRKXKHGK $50

We have developed the following charts to assist suppliers in the correct coding of hospital beds and support surfaces.

Hospital Beds to Support Surface Beds

Beneficiary Currently Renting Beneficiary Requires Any of the Listed Mattresses Coding for Bed Should Be Changed to
E0193 E0194 Yes
E0193 E0250-E0265, E0290-E0297, E0301-E0304, E0328-E0329 No
E0194 E0250-E0265, E0290-E0297, E0301-E0304, E0328-E0329 No
E0250-E0265, E0290-E0297, E0301-E0304, E0328-E0329 E0250-E0265, E0290-E0297, E0301-E0304, E0328-E0329 No

*Wounds healed for 60+ days may result in a new capped rental period

Hospital Beds and Support Surface Mattresses

Beneficiary Currently Renting Beneficiary Requires Any of the Listed Mattresses Coding for Bed Should Be Changed to
E0250 E0184, E0186, E0187, E0196, E0277, E0373 E0251
E0290 E0184, E0186, E0187, E0196, E0277, E0373 E0291
E0255 E0184, E0186, E0187, E0196, E0277, E0373 E0256
E0292 E0184, E0186, E0187, E0196, E0277, E0373 E0293
E0260 E0184, E0186, E0187, E0196, E0277, E0373 E0261
E0294 E0184, E0186, E0187, E0196, E0277, E0373 E0295
E0265 E0184, E0186, E0187, E0196, E0277, E0373 E0266
E0296 E0184, E0186, E0187, E0196, E0277, E0373 E0297
E0303 E0184, E0186, E0187, E0196, E0277, E0373 E0301
E0304 E0184, E0186, E0187, E0196, E0277, E0373 E0302

National Government Services LCDs, additional information regarding coverage requirements and coding can be accessed from the Medical Policy Center section on the NGSMedicare.com Web site.

Billing Clarification on Support Surfaces and Hospital Beds
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