WOUND CARE Medicare Reference Guide Reimbursement Guidelines for Referral Sources
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ots ots marketing ► Surgical Dressings ► Support Surfaces ► Hospital Beds ► Negative Pressure Wound Therapy
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Surgical Dressings Surgical dressings are covered when one of the following are met: (Includes both primary dressings and secondary dressings) 1. Required for treatment of a wound caused by, or treated by, a surgical procedure, OR 2. Required after debridement of a wound • Type of debridement may be surgical, mechanical, chemical, or autolytic Primary: Coverings applied directly to wounds, Secondary: Materials that serve as a protective function to secure primary dressing. Can only deliver 1-month supply at a time, unless documentation supports the need otherwise.
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Evaluation and documentation will include: • Number of wounds • Type of wound • Location of wound • Wound depth • Size • Presence or amount of exudate • Presence or extent of tunneling or undermining • Presence or extent of eschar or granulation tissue • Presence of infection or other complications • Assessment of wound and staging (1-4) Note: All can be performed by a physician, nurse or other qualified health care professional. Quantity and type depend on current wound status changes and recent dressing use.
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Standard Written Order needs to include: • Patient’s name • Date of order • Item to be dispensed: type and size of dressing • Frequency of change • Amount to be used at one time, if more than one • Duration of need • Number of refills • Treating practitioner’s printed name or National Provider Identifier (NPI) • Treating practitioner’s signature Signature and date stamps are not acceptable. Documentation needs to be in the medical record and not on the written order.
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New order required: • At minimum every 3 months, OR • Change in type or frequency of changes, OR • State requirement, OR • Change in supplier
Types of Surgical Dressings TYPE
COVERAGE
USUAL CHANGE
Alginate or Other Fibergelling Dressing A6196-A6199
Moderately to highly exudative full thickness wounds and cavities (stage 3 or 4 ulcers)
Up to 1x/day 1 unit = 6 in.
Collagen Dressing or Wound Filler A6010, A6011, A6021-A6024
Full thickness wounds (stage 3 or 4 ulcers, wounds with light to moderate exudate, or wounds that have stalled or not progressed toward a healing goal)
Can stay in place for up to 7 days
Composite Dressing A6203-A6205
Moderately to highly exudative wounds
Up to 3x/week; 1 wound cover per dressing change
Contact Layer A6206-A6208
Used to line entire wound; not reasonable and necessary when used with any dressing that has a nonadherent or semi-adherent layer as part of the dressing
Up to 1x/week; not intended to be changed with each dressing change
Foam Dressing A6209-A6215
Moderately to highly exudative full thickness wounds (stage 3 or 4 ulcers)
Primary dressing: up to 3x/week; secondary dressing for highly exudative: up to 3x/week; foam fillers: up to 1x/day
Gauze, Non-impregnated A6216-A6221, A6402-A6404, A6407 Gauze, Impregnated with Other than Water, Saline, Hydrogel, or Zinc A6222-A6224, A6266 Gauze, Impregnated with Water or Normal Saline A6228-A6230 Hydrocolloid Dressing A6234-A6241 Hydrogel Dressing A6231-A6233, A6242-A6248 Specialty Absorptive Dressing A6251-A6256
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Transparent Film A6257-A6259
Usually not reasonable and necessary to stack more than 2 gauze pads on top of each other
Up to 3x/day for dressing w/out border; 1 x/day with border
Coverage based on the characteristics of the underlying materials
Up to 1x/day
Not reasonable and necessary compared to non-impregnated gauze Light to moderate exudate
Up to 3x/week
Full thickness wounds with minimal to no exudate
Covers w/out adhesive or fillers: up to 1x/day; covers with adhesive: up to 3x/week
Moderately or highly exudative wounds (stage 3 or 4 ulcers)
W/out adhesive border: up to 1x/day; with adhesive: up to every other day
Open partial thickness wounds with minimal exudate or closed wounds
Up to 3x/week
Wound Filler, Not Elsewhere Classified A6261-A6262
Up to 1x/day
Wound Pouch A6154
Up to 3x/week
ots marketing Source: Revised March 2019, CGS Administrators, LLC.
Non-covered situations 1. Drainage from a cutaneous fistula which has not been caused by or treated by a surgical procedure, OR 2. Stage 1 pressure injury, OR 3. First degree burn, OR 4. Wounds caused by trauma which do not require surgical closure or debridement, OR 5. Venipuncture or arterial puncture site other than the indwelling catheter or needle
SURGICAL DRESSINGS
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Support Surfaces Group 1 (Overlays) Group 2 (Pressure Reducing) Group 4 (Air-Fluidized Bed) Group 1 (mostly overlays)-Patient must meet criteria 1, 2, or 3: 1. Completely immobile – Patient cannot make changes in body position without assistance, OR 2. Limited mobility – Patient cannot independently make changes in body position significant enough to alleviate pressure, OR 3. Any stage pressure ulcer on the trunk or pelvis. • If the patient meets criteria 2 or 3 above, they must also have at least one of the following conditions: A. Impaired nutritional status B. Fecal or urinary incontinence C. Altered sensory perception D. Compromised circulatory status
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Examples of Group 1 support surfaces: • E0181 – Powered alternating pressure pad with pump – needs a written order prior to delivery • E0182 – Pump for alternating pressure pad – for replacement only • E0184 – Dry foam pressure mattress – needs a written order prior to delivery • E0185 – Gel pressure pad for mattress – would not be a good choice for an obese patient or a patient with an incontinence issue • E0197 – Air pressure pad for mattress • E0199 – Dry foam pressure pad for mattress Group 2 (powered pressure-reducing mattresses)-Patient must meet criteria 1 AND 2, OR 3, OR 4 below:
1. Multiple stage 2 pressure ulcers located on the trunk or pelvis that have failed to improve over the last month, AND 2. Patient has been on a comprehensive ulcer treatment program for at least the past month, which has included: the use of an appropriate Group 1 support surface; regular assessment; appropriate turning, positioning, and wound care; moisture and incontinence management; and nutritional assessment and intervention, OR 3. Large or multiple stage 3 or 4 pressure ulcer(s) on the trunk or pelvis, OR 4. Recent myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis (surgery within the past 60 days) and patient has been on a Group 2 or 3 support surface immediately prior to discharge from the hospital or nursing facility (discharge within the past 30 days).
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Examples of Group 2 support surfaces are: • E0371 – Nonpowered, advanced pressure-reducing overlay for mattress • E0372 – Powered air overlay for mattress • E0373 – Nonpowered, advanced pressure-reducing mattress • E0277 – Powered, pressure-reducing air mattress • E0193 – Low air loss therapy – this therapy is appropriate for patients that are incontinent or have heavily draining wounds *Prior authorization is required before delivery for ALL Group 2 codes and takes a minimum of 5 days for a decision.
Foam overlays or mattresses MUST have a waterproof cover to be reimbursed by Medicare. With all overlays in Group 2, the physician order must be written PRIOR to delivery and must be signed and dated by the treating physician. Group 3 (air-fluidized bed)-Patient must meet ALL of the following: 1. Stage 3 (full-thickness tissue loss) or stage 4 (deep tissue destruction pressure sore). 2. Bedridden or chair bound as a result of severely limited mobility. 3. In absence of an air-fluidized bed, the patient would require institutionalization. 4. The air-fluidized bed is ordered in writing by the patient’s attending physician based upon a comprehensive assessment and evaluation of the patient after conservative treatment has been tried without success. Conservative treatment should generally include: frequent repositioning; use of Group 2 wound management; nutritional optimization; education of patient and caregiver on the prevention and/or management of pressure ulcers; and assessment by physician, nurse, or other licensed health care practitioner at least weekly. • The treating practitioner must re-evaluate for the need on a monthly basis. • All other alternative equipment must have been considered and ruled out.
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Beds
Coverage is considered for a fixed-height hospital bed when at least 1 of the following are met: • Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed, OR • Patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain, OR • Requires the head of the bed to be elevated more than 30 degrees most of the time because of CHF, COPD, or problems with aspiration, OR • Requires traction equipment that can only be attached to a hospital bed. • Semi-electric beds are considered for coverage if 1 of the above criteria is met AND • If the patient requires frequent changes in body position such as to alleviate pain, prevent aspiration, or a respiratory issue. • If a heavy duty-type bed is medically necessary, the weight must be at least 350 pounds and must be documented. • Medicare does not cover full electric beds.
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Standard Written Order requirements: • Beneficiary’s name • Date of order • Detailed description of the item being ordered (be specific to the type of bed, for example: fixed height, semi-electric, high/low semi-electric bed, etc.) • Any other items being billed • Length of need • Treating practitioner’s printed name or NPI • Treating practitioner’s signature
Signature and date stamps are not acceptable. Documentation needs to be in medical record and not on the written order.
SUPPORT SURFACES/ BEDS
The code for all Group 3 support surfaces is E0194.
Negative Pressure Wound Therapy (NPWT) Covered when either criteria A or B are met: A. Ulcers and Wounds in the Home Setting 1. Chronic stage 3 or 4 pressure ulcer, OR 2. Neuropathic ulcer–diabetic, OR 3. Venous or arterial insufficiency ulcer, OR 4. Chronic ulcer mixed etiology–present for at least 30 days
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Complete wound therapy program that meets 1 AND 2, 3, OR 4 (below) and alternative treatment must have been tried or considered and ruled out prior to NPWT: 1. For ALL ulcers or wounds, the following elements include a minimum of all listed measures that should either be addressed and applied or considered and ruled out prior to application: • Documentation in medical record of evaluation, care, and wound measurements by a licensed medical practitioner, AND • Application of dressings to maintain a moist wound environment, AND • Debridement of necrotic tissue if present, AND • Evaluation of and provision for adequate nutritional status. 2. For stage 3 or 4 pressure ulcers: • Patient has been turned and positioned appropriately, AND • Used Group 2 or 3 support surface for pressure ulcers on posterior trunk or pelvis, AND • Moisture and incontinence have been managed appropriately. 3. Neuropathic ulcers – diabetic: • Been on a comprehensive diabetic management program, AND • Reduction in pressure on a foot ulcer accomplished with appropriate modalities. 4. Venous insufficiency ulcers: • Compression bandages and/or garments consistently applied, AND • Leg elevation and ambulation has been encouraged.
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B. Ulcers and Wounds from Inpatient Setting 1. An ulcer or wound encountered during an inpatient setting and after wound treatments have been tried or considered and ruled out, then NPWT is considered best treatment by physician, OR 2. Complications of a surgically created wound or traumatic wound (i.e. pre-op flap or granuloma) with documentation of medical necessity for accelerated formation of granulation tissue which cannot be achieved by other available topical wound treatments.
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In either situation above, treatment will be covered beyond discharge. Make sure to have the initial date of service for the inpatient stay. This helps with determining duration of treatment.
General information to consider: • A licensed health care provider (LHCP) can be a physician, physician assistant (PA), registered nurse (RN), licensed practical nurse (LPN), or physical therapist (PT), and should be licensed to assess wounds and/or administer care within same state as patient receiving treatment. • General, vague, or non-specific statements are insufficient information. Medical records must have detailed information justifying medical necessity. • The following are exclusions and are not considered for coverage: • The presence in the wound of necrotic tissue with eschar, if debridement is not attempted. • Osteomyelitis within the vicinity of the wound that isn’t concurrently being treated with intent to cure. • Cancer present in the wound. • The presence of an open fistula to an organ or body cavity within the vicinity of the wound. Medical record includes: • History and previous treatment, and current wound management • Current wound management for use of the NPWT pump: • Length of use • Dressing types • Frequency of use • Changes in wound condition • Precise measurements • Quantity of exudate • Presence of granulation and necrotic tissue • Concurrent measures being addressed related to wound therapy such as nutrition, debridement, support surfaces, positioning, and incontinence control • Initial assessment must include statement from treating physician with: • Condition of wound – including measurements • Efforts to address all aspects of wound care
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Standard Written Order requirements: • Beneficiary’s name • Date of order • Detailed description of the items being ordered • Treating practitioner’s printed name or NPI • Treating practitioner’s signature
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Disclaimer: For the National Pressure Injury Advisory Panel’s new terminology, go to npiap.com.
NEGATIVE PRESSURE WOUND THERAPY
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NOTE ABOUT MEDICARE For any item to be considered for coverage by Medicare, the patient must meet the guidelines as outlined in the medical policies and associated articles as described on the Medicare websites, and the clinical records must prove the medical necessity.
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The information in this guide was compiled by VGM Group, Inc., a member service organization. The information provided herein is our judgment about interpretation of applicable policies and regulations and is believed to be current and substantially accurate as of the time of publication. Policies and regulations are subject to amendment or repeal, and the governing agency may issue official or informal interpretations, rulings or opinions at any time. The opinions and information expressed herein are subject to change based on such factors and should not be taken as legal advice or as binding on the authors. Contents updated October 2020.
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