Negative Pressure Wound Therapy Devices (NPWT)
Attention all users of NPWT. The Noridian Healthcare Services has issued a joint DME-MAC publication about CERT reviews for NPWT claims. They have identified common errors in the information submitted in support of claims payment. See Below their findings posted 9-4-2014.
COVERAGE REMINDER – NEGATIVE PRESSURE WOUND THERAPY DEVICES (NPWT)
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
Referring physician’s detailed written order missing – 9.09%
Payment Rules- Prescriptions
All items billed to Medicare require a prescription. NPWT base code E2402 (NEGATIVE PRESSURE WOUND THERAPY ELECTRICAL PUMP, STATIONARY OR PORTABLE) is listed as one of the specified items that must meet the Affordable Care Act (ACA) §6407 requirements. ACA §6407 requires that there must be an in-person visit sometime in the 6 months prior to the prescription date and the prescription must meet the Written Order Prior to Delivery requirements.
Reasonable & Necessary (R&N) Related:
- Coverage criteria A not met – 63.64%
- Coverage criteria B not met – 9.09%
- Coverage criteria C not met – 9.09%
Payment Rules – 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:
Criteria A: Ulcers and Wounds in the Home Setting: The beneficiary has a chronic Stage III or IV pressure ulcer, 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.
– 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:
- Documentation in the beneficiary’s medical record of evaluation, care, and wound measurements by a licensed medical professional, 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
– For Stage III or IV pressure ulcers:
- The beneficiary has been appropriately turned and positioned, and
- 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
- The beneficiary’s moisture and incontinence have been appropriately managed
– For neuropathic (for example, diabetic) ulcers:
- The beneficiary has been on a comprehensive diabetic management program, and
- Reduction in pressure on a foot ulcer has been accomplished with appropriate modalities
– For venous insufficiency ulcers:
- Compression bandages and/or garments have been consistently applied, and
- Leg elevation and ambulation have been encouraged
Criteria B: Ulcers and Wounds Encountered in an Inpatient Setting:
- 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.
- 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).
Criteria C: Coverage of NPWT ends when certain conditions occur. The LCD specifies:
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:
- On a regular basis,
- Directly assess the wound(s) being treated with the NPWT pump, and
- Supervise or directly perform the NPWT dressing changes, and
- On at least a monthly basis, document changes in the ulcer’s dimensions and characteristics.
In the event of a claim review, Medicare requires that:
- there is a prescription (order) for every separately billable item.
- there be sufficient detailed information contained in the beneficiary’s medical record to demonstrate that the relevant policy requirements are met.
- Beneficiary was in a Part A stay on date of service (DOS) – 9.09%
Payment Rules – 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.