Gel Overlays

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Physician Documentation Requirements

Gel Overlays

  • Detailed written order that contains:
    • Pt.’s name
    • Detailed description of the item(s) to be ordered
    • Length of Need the Pt. will require the item(s)
    • Physician’s printed name
    • Physician’s NPI
    • Physician’s signature
    • Physician’s date of signature
  • Face to face evaluation* dated within 6 months of the detailed written order documenting:
    • Pt.’s diagnoses or conditions that warrant the medical necessity of the item
    • Pt. is completely immobile – ie., Pt. cannot independently make changes in body position significant enough to alleviate pressure
      (OR)
    • Pt. has limited mobility – ie., Pt. cannot independently make changes in body position significant enough to alleviate pressure AND has one or more of the following conditions:
      • Impaired nutritional status
      • Fecal or urinary incontinence
      • Altered sensory perception
      • Compromised circulatory status
        (OR)
    • Pt. has one or more pressure ulcers (any Stage) on the trunk or pelvis AND one or more of the following conditions:
      • Impaired nutritional status
      • Fecal or urinary incontinence
      • Altered sensory perception
      • Compromised circulatory status

*Additionally, the Pt.’s medical records dated within the last 30 days should document a Care Plan by the physician or home care nurse that should include the following:

  • Education of the Pt. or Caregiver on prevention and/or management of pressure ulcers
  • Regular assessment by a nurse, physician, or other licensed healthcare practitioner
  • Appropriate turning and positioning
  • Appropriate wound care (for a Stage II, III, or IV ulcer)
  • Appropriate management of moisture/incontinence
  • Nutritional assessment and intervention consistent with overall Plan of Care

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