Ohio Admin. Code 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.
Replaces: 5160-10-18
Notes
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 05/01/1990, 02/17/1991, 12/30/1991, 12/29/1995 (Emer), 03/21/1996, 01/01/2000, 10/01/2004, 04/09/2009
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