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Specialized Wound Treatment Technology

Revised: 07-26-2013

  • Overview
  • Eligible Providers
  • Covered Services
  • Noncovered Services
  • Eligible Recipients
  • Authorization
  • Billing
  • Overview

    Specialized wound treatment technology is used to treat non-healing wounds.

    Eligible Providers

    The following providers may provide specialized wound treatment technology and related supplies:

  • • Federally Qualified Health Center
  • • Home health agencies
  • • Hospitals
  • • Indian Health Services
  • • Medical suppliers
  • • Pharmacies
  • • Rural Health Clinic
  • TPL and Medicare

    Providers must meet any provider criteria, including accreditation, for third party insurance (TPL) or for Medicare in order to assist recipients for whom MHCP is not the primary payer.

    MHCP quantity limits and thresholds apply to all recipients unless only Medicare co-insurance or deductible is requested.

    Eligible Recipients

    Specialized wound treatment technology may be medically necessary for eligible MHCP recipients with wounds that have not responded to standard wound treatment for at least a 30 – 60 day period. Negative Pressure Wound Therapy (NPWT) may be medically necessary for eligible MHCP recipients with wounds of less than 30 days duration if the patient is inpatient and preparing for discharge.

    Covered Services

    Codes: These are not all-inclusive codes:
    E2402, A6550, A6551, K0743, K0744, K0745:
    Negative Pressure Wound Therapy
    E1399, A4649:
    Platelet rich plasma systems (i.e., AutoloGel, Magellan)

    The platelet rich plasma centrifuge is not covered in long term care facilities. Device-specific supplies (i.e., applicators, reagents) may be covered in long term care facilities.

    Authorization

    Authorization is always required for Negative Pressure Wound Therapy devices and coverage may be approved in 3 month intervals. If there is no significant improvement to the wound at the 3-month interval, additional authorization will be denied; and other treatments must be tried. If there is improvement to the wound at the 3-month interval, an additional 3 months may be authorized. Authorization is required for platelet rich plasma treatment kits / component kits if the submitted charge is over $400.

    Submit authorization request and required documentation 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) with a physician's order and submit.

    Documentation for Authorization Requests

    For all wounds, document and include the following in a comprehensive treatment plan before requesting authorization for a specialized wound therapy product:

  • • Wound type, including:
  • • Etiology and stage when appropriate
  • • Date of onset
  • • Evaluation
  • • Previous wound care and assessments done by a licensed medical professional (every 30 days by MD, PA, DO, NP is strongly recommended)
  • • Weekly wound measurements to assess the appropriateness of current wound treatment. If 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
  • • Application of dressings to maintain a continuously moist wound environment must have been tried prior to requesting a specialized wound therapy product (gel dressings)
  • • Impregnated dressings have been tried when applicable (e.g., sodium, antimicrobial, collagen petroleum)
  • • Debridement of necrotic tissue - mechanical, surgical/chemical
  • • Evaluation and provision for adequate nutritional status. If the recipient has nutritional deficits, enteral nutritional support may be covered. Refer to Enteral Nutritional Products policy.
  • • Moisture and incontinence have been addressed and appropriately managed
  • • Compliance issues are addressed (i.e., missed medical appointments, refusing dressing changes, repositioning, smoking, poor nutritional intake or choices)
  • • Medical intervention/correction of underlying conditions that may hinder the healing process of the wound (i.e., local or distant infections are addressed)
  • • Assessment of medications that may delay healing (i.e. systemic steroids, immunosuppressive drugs)
  • • Evaluation of arterial sufficiency when appropriate
  • • Licensed professional (RN, LPN, PT) services in place for treatment in the home
  • • Document how this request is appropriate for the type of wound being treated
  • For pressure ulcers, also document the following:

  • • Recipient is appropriately turned and positioned
  • • Appropriate pressure management surface is in place while in bed/wheelchair
  • For diabetic neuropathic ulcers, also document the following:

  • • Appropriate offloading is in place. Appropriate offloading may include crutches, walkers, wheelchairs, custom shoes, depth shoes, shoe modifications, custom inserts, custom relief orthotic walkers, diabetic boots, forefoot and heel relief shoes, or total contact casts
  • • Blood glucose levels are monitored and managed
  • For venous ulcers: also document that appropriate compression is in place

    Respond to the following:
    Are any of the following contraindications present for the negative pressure wound therapy:

  • • Untreated osteomyelitis within the vicinity of the wound
  • • Presence in the wound of necrotic tissue with eschar, if debridement has not been attempted
  • • Cancer present in the wound
  • • Presence of a fistula to an organ or body cavity within the vicinity of the wound
  • Are any of the following contraindications present for AutoloGel System:

  • • Active cancer at wound site
  • • Chemotherapy within the past 5 years
  • • Hematological disorder
  • • Bleeding disorder
  • • Perfusion to extremity of wound
  • • Untreated osteomyelitis at wound site
  • • Recipient being treated with Methotrexate
  • • Allergy to beef or dairy
  • Included with AutoloGel Therapy System: Each authorized unit includes the AutoloGel MultiPack Component Kit and the necessary reagents for one treatment. A maximum of 8 units will be approved per month. The centrifuge is not separately authorized in home care; it must be billed on a separate claim, with the PA number in the notes field.

    Criteria for Specialized Wound Treatment for Non-chronic Wounds

    Authorization for specialized wound therapy for non-chronic wounds will be considered when a recipient 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) with a physician's order and submit.

    Documentation for Authorization Requests

    For all wounds, document and include the following in a comprehensive treatment plan before requesting authorization for a specialized wound therapy product:

  • • Wound type, including:
  • • Etiology and stage when appropriate
  • • Date of onset
  • • Evaluation
  • • Previous wound care and assessments done by a licensed medical professional (every 30 days by MD, PA, DO, NP is strongly recommended)
  • • Medical intervention/correction of underlying conditions that may hinder the healing process of the wound (i.e., local or distant infections are addressed)
  • • Assessment of medications that may delay healing (i.e. systemic steroids, immunosuppressive drugs)
  • • Evaluation of arterial sufficiency when appropriate
  • • Specific medical factors that inform the determination that the recipient is at risk of delayed healing, infection or other negative outcomes or that there is medical necessity for accelerated formation of granulation tissue.
  • • Discharge plan including all of the following:
  • • Plan for weekly wound measurements to assess the appropriateness of current wound treatment. If no improvement to the wound, the wound treatment must be changed. This must be done by nursing staff in the skilled facility or by licensed medical professionals in the home setting
  • • Evaluation and provision for adequate nutritional status. If the recipient has a nutritional deficit, enteral nutritional support may be covered. Refer to Enteral Nutritional Products policy.
  • • Moisture and incontinence have been addressed and a plan for appropriate management is in place
  • • Compliance issues are addressed (i.e., missed medical appointments, refusing dressing changes, repositioning, smoking, poor nutritional intake or choices)
  • • Appropriate medical services (RN, LPN, PT) are arranged for care in a licensed facility or home
  • For pressure ulcers, also document the discharge plan for the following:

  • • Recipient will be appropriately turned and positioned
  • • Appropriate pressure management surface will be in place while in bed/wheelchair
  • For diabetic neuropathic ulcers, also document discharge plan for the following:

  • • Appropriate offloading will be in place. Appropriate offloading may include crutches, walkers, wheelchairs, custom shoes, depth shoes, shoe modifications, custom inserts, custom relief orthotic walkers, diabetic boots, forefoot and heel relief shoes, or total contact casts
  • • Blood glucose levels will be monitored and managed
  • For venous ulcers: also document the discharge plan for appropriate compression

    Respond to the following:
    Are any of the following contraindications present for the negative pressure wound therapy:

  • • Untreated osteomyelitis within the vicinity of the wound
  • • Presence in the wound of necrotic tissue with eschar, if debridement has not been attempted
  • • Cancer present in the wound
  • • Presence of a fistula to an organ or body cavity within the vicinity of the wound
  • Noncovered Services

  • • Electrical stimulation using low-intensity direct current, high voltage pulsed current, alternative current, and transcutaneous electrical stimulation for the treatment of wounds is considered investigative due to a lack of evidence demonstrating its impact on improved health outcomes
  • • Electrical stimulation for the treatment of wounds performed by the patient in the home setting is considered investigative due to a lack of evidence demonstrating its impact on improved health outcomes
  • • Electromagnetic therapy for the treatment of wounds is considered investigative due to a lack of evidence demonstrating its impact on improved health outcomes
  • • Non-contact ultrasound treatment for wounds is considered investigative due to a lack of evidence demonstrating its impact on improved health outcomes
  • • Topical hyperbaric oxygen for the treatment of wounds is considered investigative due to a lack of evidence demonstrating its impact on improved health outcomes
  • • Electrochemical low-dose tissue oxygenation systems are considered investigative due to a lack of evidence demonstrating impact on improved health outcomes
  • Documentation when Authorization is not Required

    Providers must maintain documentation

  • • Wound type, including:
  • • Etiology and stage when appropriate
  • • Date of onset
  • • Evaluation
  • • Previous wound care and assessments done by a licensed medical professional (every 30 days by MD, PA, DO, NP is strongly recommended)
  • • Weekly wound measurements to assess the appropriateness of current wound treatment. If no improvement to the wound, the wound treatment must be changed. This must be done by nursing staff in the long term care facility
  • Billing

  • • Use MN–ITS 837P Professional
  • • Report the ordering provider in the Other Provider Types section of MN–ITS Direct Data Entry (DDE) claims or X12 Batch billing refer to the Minnesota Uniform Companion Guides
  • • For rental, one unit = one month rental
  • • Negative Pressure Wound Care Devices, suction pumps and platelet rich plasma centrifuges are capped rental items. After 13 months rental, the equipment is considered purchased and no further rental payments will be made.
  • • If the recipient has Medicare, MHCP will pay the deductible/co-insurance on any units for which Medicare made payment. Any units for which Medicare denies payment must meet MHCP authorization, quantity and coverage limits
  • • Shipping costs are included in the MHCP maximum allowable payment and may not be separately billed to MHCP or the recipient
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