Here’s help sorting out Medicare reimbursement

Medicare has mapped out rigorous guidelines for home health care. In acute care settings, Medicare reimbursement is based on a diagnosis category, not on actual services and supplies provided. But for home health care, reimbursement for individual services and products are scrutinized individually. For support surfaces, reimbursement is divided in to three categories: 

Group I: This includes static surfaces (overlays or mattresses). To qualify for a Group I surface, patients must be immobile or have a pressure ulcer somewhere on the trunk or pelvis. If no skin breakdown is evident, patients must have limited mobility and at least one of the broadly recognized risk factors for pressure ulcers, such as malnutrition, incontinence, altered perception, or poor circulation, according to Ben Peirce, RN, CWCN, clinical manager of the Wound Care Program for Columbia Home Care–Southeast Florida in Ft. Lauderdale. 

Group II: These surfaces are significantly more expensive and complex. All are dynamic surfaces, meaning they operate with a power source, usually a motor. Low air-loss surfaces are the most common Group II surfaces. Most are air permeable so water vapor can escape, therefore reducing moisture retention near the skin. The range of quality is extreme within this group, Peirce says, with both extremely reliable and well-designed equipment as well as substandard merchandise on the market. 

"These beds are simple enough so that lots of manufacturers want to get into the game, but they’re complex enough so that it’s easy to produce shoddy equipment," Peirce says. "It’s important to select a Group II device from a reputable firm." 

To qualify for a Group II surface, patients must meet one of three requirements: 

1. multiple Stage II pressure ulcers on the pelvis or trunk that haven’t improved for 30 days or longer while on a Group I device; 

2. multiple Stage III or IV ulcers on the trunk or pelvis; 

3. ulcers present during an immediately prior hospitalization as a result of a graft or flap procedure. 

Group III: These surfaces generally comprise air-fluidized beds, which are the mainstay of high air-loss therapy. These are highly specialized devices that circulate high volumes of air through a bed of granulated material consisting of tiny ceramic balls. They are stand-alone beds, not mattresses that can be placed on another frame, making them expensive and cumbersome – a major obstacle for moving into a home. Because of their size, these beds are rarely used for home health care. However, modular units are now available. 

To qualify for a Group III bed, patients must have Stage III or IV pressure ulcers and be severely immobile or bedridden. Medicare requires monthly re-certification by a physician, and patients must have been on a Group II surface before becoming eligible for Group III. Also, a trained adult caregiver must be present to help patients get into and out of bed.