Medicare Support Mattresses Group 1 Coverage

A Group 1 mattress overlay or mattress (E0181, E0182, E0184, E0185, E0186, E0187, E0188, E0189, E0196, E0197, E0198, E0199 and A4640) is covered if one of the following three criteria are met:

  1. The beneficiary is completely immobile - i.e., beneficiary cannot make changes in body position without assistance, or
  2. The beneficiary has limited mobility - i.e., beneficiary cannot independently make changes in body position significant enough to alleviate pressure and at least one of conditions A-D below, or
  3. The beneficiary has any stage pressure ulcer on the trunk or pelvis and at least one of conditions A-D below.

Conditions for criteria 2 and 3 (in each case the medical record must document the severity of the condition sufficiently to demonstrate the medical necessity for a pressure reducing support surface):

  1. Impaired nutritional status
  2. Fecal or urinary incontinence
  3. Altered sensory perception
  4. Compromised circulatory status

When the coverage criteria for a Group 1 mattress overlay or mattress are not met, the claim will be denied as not reasonable and necessary.

 

The support surface provided for the beneficiary should be one in which the beneficiary does not "bottom out". Bottoming out is the finding that an outstretched hand, placed palm up between the undersurface of the mattress overlay or mattress and the beneficiary's bony prominence (coccyx or lateral trochanter), can readily palpate the bony prominence. This bottoming out criterion should be tested with the beneficiary in the supine position with their head flat, in the supine position with their head slightly elevated (no more than 30 degrees), and in the side-lying position.

 

A support surface which does not meet the characteristics specified in the Coding Guidelines section of the Policy Article will be denied as not reasonable and necessary.


HCPCS CODES:

Group 1 Codes

Code

Description

A4640

REPLACEMENT PAD FOR USE WITH MEDICALLY NECESSARY ALTERNATING PRESSURE PAD OWNED BY PATIENT

A9270

NON-COVERED ITEM OR SERVICE

E0181

POWERED PRESSURE REDUCING MATTRESS OVERLAY/PAD, ALTERNATING, WITH PUMP, INCLUDES HEAVY DUTY

E0182

PUMP FOR ALTERNATING PRESSURE PAD, FOR REPLACEMENT ONLY

E0184

DRY PRESSURE MATTRESS

E0185

GEL OR GEL-LIKE PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

E0186

AIR PRESSURE MATTRESS

E0187

WATER PRESSURE MATTRESS

E0188

SYNTHETIC SHEEPSKIN PAD

E0189

LAMBSWOOL SHEEPSKIN PAD, ANY SIZE

E0196

GEL PRESSURE MATTRESS

E0197

AIR PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

E0198

WATER PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

E0199

DRY PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

E1399

DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS


The CMS.gov website is an excellent resource for finding out about all of your options.