Third-Party Liability (TPL) and Medicare
Providers must meet any provider criteria, including accreditation, for third-party insurance or for Medicare to assist members for whom Minnesota Health Care Programs (MHCP) is not the primary payer.

MHCP quantity limits and thresholds apply to all members unless only Medicare coinsurance or deductible is requested. Refer to the Medicare and Other Insurance section of the MHCP Provider Manual for more information.

Eligible Members

Specialized wound treatment technology may be medically necessary for eligible Medical Assistance and MinnesotaCare with wounds that have not responded to standard wound treatment for at least a 30 to 60-day period. Negative pressure wound therapy (NPWT) may be medically necessary for members with wounds of less than 30 days duration if the patient is inpatient and preparing for discharge.

Covered Services

Codes: A4649, A6550, E1399, E2402, K0743-K0746
MHCP covers the following equipment:

· Wound care sets, for negative pressure wound therapy electrical pump, includes all supplies and accessories (A6550)

· Negative pressure wound therapy electrical pumps, stationary or portable (E2402)

· Suction pumps, home model, portable, for use on wounds (K0743)

· Absorptive wound dressings for use with suction pump (K0744 through K0746)

· Miscellaneous durable medical equipment (E1399) and surgical supplies (A4649)

Specialized wound treatment technology is not included in the per diem for members living in a nursing facility or the per diem for members living in an intermediate care facility for people with developmental disabilities (ICF/DD).

Authorization

Authorization is always required for NPWT devices. Coverage may be approved in 3-month intervals. If there is no significant improvement to the wound at the end of the 3-month interval, additional authorization will be denied and other treatments must be tried. If there is improvement to the wound at the end of the 3-month interval, an additional 3 months may be authorized. Authorization is required for platelet rich plasma treatment kits or component kits if the submitted combined charge is over $400.

Submit authorization to the Authorization Medical Review Agent.

Criteria for Specialized Wound Treatment for Chronic Wounds

Authorization for specialized wound therapy for chronic wounds will be considered when a wound does not respond to standard wound treatment for at least a 30-day period. Complete the Specialized Wound Therapy Authorization Form (DHS-4045) (PDF) with the physician order and submit.

Documentation for Authorization Requests

Requests must include a comprehensive treatment plan before requesting authorization for a specialized wound treatment therapy product. Documentation must include:

· Type of wound, including:

· Etiology and stage when appropriate; and

· Date of onset; and

· Evaluation; and

· Previous wound care and assessments done by a licensed medical professional. Every 30 days by a physician, physician assistant, or nurse practitioner is strongly recommended; and

· Weekly wound measurements to assess the appropriateness of current wound treatment. If there is no improvement to the wound, the wound treatment must be changed. This must be done by nursing staff in the skilled facility or by a licensed medical professional in the home setting; and

· Application of dressings to maintain a continuously moist wound environment must have been tried before requesting a specialized wound therapy product (for example, gel dressings); and

· How impregnated dressings have been tried when applicable (for example, sodium, antimicrobial, collagen petroleum); and

· Any debridement of necrotic tissue, if applicable; and

· Evaluation and provision for adequate nutritional status. If the member has nutritional deficits, enteral nutritional support may be covered; and

· How moisture and incontinence have been addressed and appropriately managed; and

· How compliance issues are addressed (that is, missed medical appointments, refusing changes, repositioning, smoking, poor nutritional intake or choices); and

· How medical intervention and correction of underlying conditions that may hinder the healing process of the wound (that is, local or distant infections) are addressed; and

· Assessment of medications that may delay healing (that is, systemic steroids, immunosuppressive drugs); and

· Evaluation of arterial sufficiency when appropriate; and

· Licensed professional (RN, LPN, PT) services in place for treatment in the home; and

· How this request is appropriate for the type of wound being treated.

Pressure ulcers
Documentation for pressure ulcers must establish:

· The member is appropriately turned and positioned; and

· Appropriate pressure management surface is in place while the member is in bed or a wheelchair.

Diabetic neuropathic ulcers
Documentation for diabetic neuropathic ulcers must establish:

· Appropriate offloading is in place. Appropriate offloading may include crutches, walkers, wheelchairs, custom footwear, shoe modifications, or total contact casts; and

· Blood glucose levels are monitored and managed.

Venous ulcers
Documentation for venous ulcers must establish that appropriate compression is in place.

Contraindications
Providers must verify if any of the following contraindications are present for NPWT:

· Cancer present in the wound; or

· Presence in the wound of necrotic tissue with eschar, if debridement has not been attempted; or

· Presence of a fistula to an organ or body cavity near the wound; or

· Untreated osteomyelitis near the wound.

Providers must verify if any of the following contraindications are present for AutoloGel System:

· Active cancer at wound site; or

· Allergy to beef or dairy; or

· Bleeding disorder; or

· Chemotherapy within the past 5 years; or

· Hematological disorder; or

· Perfusion to extremity of wound; or

· Treatment with Methotrexate; or

· Untreated osteomyelitis at wound site.

Criteria for Specialized Wound Treatment for Nonchronic Wounds

Authorization for specialized wound therapy for nonchronic wounds will be considered when a member is inpatient and planning for discharge with a wound that is less than 30 days old and is determined to be at risk for delayed healing, infection or other negative outcomes or when there is documentation of medical necessity for accelerated formation of granulation tissue. Complete the Specialized Wound Therapy Authorization Form (DHS-4045) (PDF) with the physician order and submit.

Documentation for Authorization Requests

Requests must include a comprehensive treatment plan before requesting authorization for a specialized wound treatment therapy product. Documentation must include:

· Type of wound, including:

· Etiology and stage when appropriate; and

· Date of onset; and

· Evaluation; and

· Previous wound care and assessments done by a licensed medical professional. Every 30 days by a physician, physician assistant, or nurse practitioner is strongly recommended; and

· Medical intervention and correction of underlying conditions that may hinder the healing process of the wound (that is, local or distant infections are addressed); and

· Assessment of medications that may delay healing (that is, systemic steroids, immunosuppressive drugs); and

· Evaluation of arterial sufficiency when appropriate; and

· Specific medical factors that inform the determination that the member is at risk of delayed healing, infection or other negative outcomes or that there is medical necessity for accelerated formation of granulation tissue; and

· Discharge plan including all of the following:

· Plan for weekly wound measurements to assess the appropriateness of current wound treatment. The wound treatment must be changed if there is no improvement to the wound. This must be done by nursing staff in the skilled facility or by licensed medical professionals in the home setting; and

· Evaluation and provision for adequate nutritional status. Enteral nutritional support may be covered if the member has a nutritional deficit; and

· How moisture and incontinence have been addressed and a plan for appropriate management is in place; and

· How compliance issues are addressed (that is, missed medical appointments, refusing changes, repositioning, smoking, poor nutritional intake or choices); and

· Appropriate medical services (RN, LPN, PT) are arranged for care in a licensed facility or home.

Pressure ulcers
Documentation for pressure ulcers must establish:

· The member is appropriately turned and positioned; and

· Appropriate pressure management surface is in place while the member is in bed or a wheelchair.

Diabetic neuropathic ulcers
Documentation for diabetic neuropathic ulcers must establish:

· Appropriate offloading will be in place. Appropriate offloading may include crutches, walkers, wheelchairs, custom footwear, shoe modifications, or total contact casts; and

· Blood glucose levels are monitored and managed.

Venous ulcers
Documentation for venous ulcers must establish that appropriate compression is in place.

Contraindications
Providers must verify if any of the following contraindications are present for NPWT:

· Cancer present in the wound; or

· Presence in the wound of necrotic tissue with eschar, if debridement has not been attempted; or

· Presence of a fistula to an organ or body cavity within the vicinity of the wound; or

· Untreated osteomyelitis within the vicinity of the wound.

Noncovered Services

MHCP does not cover the following for the treatment of wounds as they are considered investigative due to a lack of evidence demonstrating impact on improved health outcomes:

· Electrical stimulation using low-intensity direct current, high-voltage pulsed current, alternative current, and transcutaneous electrical stimulation

· Electrical stimulation performed by the patient in the home setting

· Electromagnetic therapy

· Noncontact ultrasound

· Topical hyperbaric oxygen

· Electrochemical low-dose tissue oxygenation systems

Documentation when Authorization is not required

Documentation must include:

· Type of wound, including:

· Etiology and stage when appropriate; and

· Date of onset; and

· Evaluation; and

· Previous wound care and assessments done by a licensed medical professional. Every 30 days by a physician, physician assistant, or nurse practitioner is strongly recommended; and

· Weekly wound measurements to assess the appropriateness of current wound treatment. The wound treatment must be changed if there is no improvement to the wound. This must be done by nursing staff in the long-term care facility.

Billing

Providers are responsible to coordinate services. Refer to the Billing Policy Overview section of the MHCP Provider Manual for general billing information.

Bill specialized wound treatment therapy using MN–ITS 837P Professional. Refer to the Billing for Durable Medical Equipment, Medical Supplies, Prosthetics, Orthotics, and Augmentative Devices MN–ITS user manual for general billing requirements and guidance when submitting claims.

· Use modifier NU for purchases.

· Use modifiers KH, KI, or KJ and RR as appropriate for capped rentals.

· Report the ordering provider in the Other Provider Types section of the MN–ITS interactive claim.

· If the member has Medicare, MHCP will pay the deductible or coinsurance on any units for which Medicare has made payment.

· Shipping and delivery costs are included in the MHCP maximum allowable payment. Do not bill either MHCP or the member separately for these costs.

Negative pressure wound therapy devices, suction pumps, and platelet rich plasma centrifuges are capped rental items only.

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