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CGS Administrators, LLC

Serving the states of AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, SC, TN, TX, VA, WV and the U.S. territories Puerto Rico and the Virgin Islands

Note: This is a revision to a previous version published September 4, 2014. It corrects an error in the “Prescriptions” requirement section that incorrectly referenced the Affordable Care Act (ACA) §6407 requirement for HCPCS code E2402. The ACA requirements do not apply to code E2402; however, code E2402 does require a written order prior to delivery.

October 2, 2014

Negative Pressure Wound Therapy Devices (NPWT) - Coverage Reminder - Revised – October 2, 2014

Joint DME MAC Publication

A recent examination of CERT reviews for NPWT claims has identified common errors in the information submitted in support of claims payment. This article will review the findings and related policy requirements.

Reasons for Denial

Payment Rules

Prescriptions:

All items billed to Medicare require a prescription. NPWT base code E2402 (NEGATIVE PRESSURE WOUND THERAPY ELECTRICAL PUMP, STATIONARY OR PORTABLE) requires that the prescription must meet the Written Order Prior to Delivery requirements.

Reasonable and Necessary (R&N) Criteria:

NPWT is only covered for certain types of wounds when other treatments have failed. The LCD specifies the following:

A Negative Pressure Wound Therapy pump (E2402) and supplies (A6550, A7000) are covered when either criterion A or B is met:

  1. Ulcers and Wounds in the Home Setting:

    The beneficiary has a chronic Stage III or IV pressure ulcer (see Appendices Section), neuropathic (for example, diabetic) ulcer, venous or arterial insufficiency ulcer, or a chronic (being present for at least 30 days) ulcer of mixed etiology. A complete wound therapy program described by criterion 1 and criteria 2, 3, or 4, as applicable depending on the type of wound, must have been tried or considered and ruled out prior to application of NPWT.

    1. For all ulcers or wounds, the following components of a wound therapy program must include a minimum of all of the following general measures, which should either be addressed, applied, or considered and ruled out prior to application of NPWT:
      1. Documentation in the beneficiary's medical record of evaluation, care, and wound measurements by a licensed medical professional, and
      2. Application of dressings to maintain a moist wound environment, and
      3. Debridement of necrotic tissue if present, and.
      4. Evaluation of and provision for adequate nutritional status
    2. For Stage III or IV pressure ulcers:
      1. The beneficiary has been appropriately turned and positioned, and
      2. The beneficiary has used a group 2 or 3 support surface for pressure ulcers on the posterior trunk or pelvis (see LCD on support surfaces), and
      3. The beneficiary's moisture and incontinence have been appropriately managed
    3. For neuropathic (for example, diabetic) ulcers:
      1. The beneficiary has been on a comprehensive diabetic management program, and
      2. Reduction in pressure on a foot ulcer has been accomplished with appropriate modalities
    4. For venous insufficiency ulcers:
      1. Compression bandages and/or garments have been consistently applied, and
      2. Leg elevation and ambulation have been encouraged
  2. Ulcers and Wounds Encountered in an Inpatient Setting:
    1. An ulcer or wound (described under A above) is encountered in the inpatient setting and, after wound treatments described under A-1 through A-4 have been tried or considered and ruled out, NPWT is initiated because it is considered in the judgment of the treating physician, the best available treatment option.
    2. The beneficiary has complications of a surgically created wound (for example, dehiscence) or a traumatic wound (for example, pre-operative flap or graft) where there is documentation of the medical necessity for accelerated formation of granulation tissue which cannot be achieved by other available topical wound treatments (for example, other conditions of the beneficiary that will not allow for healing times achievable with other topical wound treatments).

    Coverage of NPWT ends when certain conditions occur. The LCD specifies:

  3. For wounds and ulcers described under A or B above, once placed on an NPWT pump and supplies, in order for coverage to continue, a licensed medical professional must do the following:
    1. On a regular basis,
      1. Directly assess the wound(s) being treated with the NPWT pump, and
      2. Supervise or directly perform the NPWT dressing changes, and
    2. On at least a monthly basis, document changes in the ulcer's dimensions and characteristics.

Documentation

In the event of a claim review,

Durable Medical Equipment Provided During a Part A Stay:

Durable Medical Equipment (DME) is only covered when provided for use in the beneficiary's home. DME provided during a covered Part A stay is not eligible for separate reimbursement by the DME MACs.

This article presents a summary of the policy requirements related to the errors identified in the CERT reviews. There are additional requirements necessary for coverage that are not discussed. Refer to the LCD and related Policy article for complete information. Further education regarding this policy is available on your DME MAC contractor website.

Referenced Information

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