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CMS-1590-FC Regulation Effective July 1, 2013
This document is proprietary to Preferred Homecare and for educational purposes only. This information does not guarantee payment from Medicare. January 2014
Written Order Prior to
Delivery (WOPD)
Beneficiary’s name
Detailed description of DME item(s)
Prescribing practitioner’s NPI
Signature & signature date of the
prescribing practitioner (Hand written or
electronic, no stamps)
Date of the order & start date (If start date is
different from the date of the order)
Prescribing practitioner’s printed name
(Must be PECOS enrolled)
The WOPD must be completed on or after the date of the
Face to Face visit & completed by the same practitioner
Qualifying Guidelines
Must meet ALL criteria in one of the below:
SITUATION 1:
Multiple stage II pressure ulcers on trunk or
pelvis (ICD-9 707.02–707.05) and has been on a
comprehensive ulcer treatment program for a
minimum of 30 days which includes:
Patient/caregiver education on prevention
& management of pressure ulcers; and
Regular assessment by a nurse, physician
or other licensed practitioner; and
Appropriate turning and positioning; and
Appropriate wound care (for a stage II, III, or
IV ulcer); and
Appropriate management of moisture
and/or incontinence; and
Nutritional assessment and intervention
consistent with overall plan of care; and
Use of an appropriate group 1 support
surface; and
Ulcers have worsened or remained the
same at minimum for 30 days
SITUATION 2:
Large or multiple stage III or IV pressure
ulcer(s) on trunk or pelvis
SITUATION 3:
Recent (past 60 days) myocutaneous flap or
skin graft for a pressure ulcer on the trunk
or pelvis (ICD-9 707.02 – 707.05); and
Patient has been on a group 2 or 3
support surface immediately prior to a
recent discharge from a hospital or
nursing facility (D/C within the past 30 days)
Face to Face / Chart Notes
Documented in-person visit within 6
months prior to the written order
Must reference the medical necessity of
the Low Air Loss Mattress by addressing
the qualifying guidelines (A diagnosis alone is
not sufficient to meet Medicare coverage criteria)
Conducted by MD, DO, PA, NP or CNS
Must be signed by MD or DO
(Hand written or electronic, no stamps)
Chart Note Examples
EXAMPLE 1:
Patient has a history of Stage III and IV
ulcers on the buttocks. He has been on a
gel mattress and in a wound treatment
prevention program. The wounds are not
properly healing and he will need further
training and education in wound
management, incontinent prevention and
proper nutrition. Home Health has been
ordered 2 times a week to assist with this
and for wound care. Low air loss mattress
ordered.
EXAMPLE 2:
Patient is completely immobile due to the
progression of her Multiple Sclerosis. The
patient currently has Stage III ulcers on
the pelvis and trunk that are not properly
healing. She has been on an alternating
pressure pump and pad for the past year,
but due to her immobility her ulcers have
gotten worse. Ordering Home Health to
treat wounds and provide needed
caregiver education on wound prevention.
Home Health will initially be ordered two
times a week in addition to moving her to
a low air loss mattress.
See CMS National Coverage Determination (NCD) & Local
Coverage Determination (LCD) for complete coverage policy
Chart Note Examples are for illustrative purposes only and not
specific to any patient’s condition or treatment plan.
Low Air Loss Mattress
Medicare Requirements
