Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Negative-Pressure Wound Therapy (NPWT) Systems

Policy #:05.00.38j

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition.


MEDICALLY NECESSARY

A powered or a nonpowered negative-pressure wound therapy (NPWT) system and supplies are considered medically necessary and, therefore, covered when:
  • the basic requirements for all wound types are met, and
  • the subsequent medical necessity criteria for specific wound types listed below are met

BASIC REQUIREMENTS FOR ALL WOUND TYPES PRIOR TO APPLICATION OF AN NPWT SYSTEM

All of the following program measures must apply or be considered and ruled out by the individual's professional provider prior to the application of an NPWT system for all wound types:
  • The individual’s medical record documents the wound assessments, care, and wound measurements, as written by a professional provider, at least weekly.
  • Dressings have been used to maintain a moist wound environment.
  • Necrotic tissue, if present, has been debrided.
  • The individual's nutritional status has been evaluated and appropriately treated.

REQUIREMENTS FOR SPECIFIC WOUND TYPES PRIOR TO APPLICATION OF AN NPWT SYSTEM

In addition to the requirements listed above for all wound types, the following wound-specific therapeutic measures (if applicable) must be applied, or considered and ruled out, by the individual's professional provider, prior to the application of an NPWT system, for the following specific types of ulcers and wounds:
  • Arterial insufficiency ulcers
  • For stage III or IV pressure ulcers, all of the following criteria must be met:
    • The individual is being appropriately turned and positioned.
    • The individual is using a group 2 or 3 support surface for pressure ulcers on the posterior trunk or pelvis. (A group 2 or 3 support surface is not required if the ulcer is not on the trunk or pelvis. For more information on support surfaces, refer to the Company policy addressing this topic.)
    • The individual's moisture and incontinence are being managed appropriately.
  • For neuropathic (diabetic) ulcers, the following criterion must be met:
    • Pressure on the foot ulcer has been reduced using appropriate modalities (such as, but not limited to, the following: total contact casts; removable cast walkers; half shoes; saline wet-to-dry dressings; debridement of all necrotic, callus, and fibrous tissue; crutches).
  • For venous insufficiency ulcers, both of the following criteria must be met:
    • Compression garments and/or bandages have been consistently applied.
    • Leg elevation and ambulation have been encouraged.
  • For individuals who develop complications of a surgically created wound (e.g., dehiscence) or a traumatic wound (e.g., pre-operative flap or graft), both of the following criteria must be met:
    • The wound requires accelerated formation of granulation tissue that cannot be achieved by other available topical wound treatments (e.g., comorbidities exist that prevent healing).
    • Results of previous wound treatments are documented.

REQUIREMENTS FOR ALL WOUND TYPES DURING TREATMENT WITH AN NPWT SYSTEM

In addition to the criteria above, the professional provider must demonstrate all of the following for coverage of NPWT:
  • The wounds being treated with a NPWT system are directly assessed and the findings are documented.
  • The NPWT dressing changes are supervised or directly performed and the findings are documented.
  • Changes in the wound's dimensions and characteristics (e.g., size [length, depth, and width], color, exudate type and amount, odor, and evidence of healing) are documented at least weekly.

LENGTH OF COVERAGE

NPWT systems may be applied in the hospital setting. All requests for continued use must meet all applicable medical necessity criteria upon review by the company.

When the above criteria are met, coverage for the NPWT system may be eligible for up to a maximum of four months (including the time NPWT was applied, regardless of the place of application [e.g., home, inpatient facility, skilled nursing facility]).

If it is determined during the course of treatment for an initial wound that the NPWT system will be applied to additional wounds, all additional wounds must meet the criteria listed in this policy to determine medical necessity. In the case of additional wound occurrence(s) after the initial NPWT is started, the four months maximum will apply to each wound.

SUPPLIES

HCPCS code A6550 describes an allowance for a dressing set that is used in conjunction with a stationary or portable NPWT pump (HCPCS code E2402). A single code A6550 is used for each single, complete dressing change, and contains all necessary components, including but not limited to any separate, non-adherent porous dressing(s), drainage tubing, and an occlusive dressing(s) that creates a seal around the wound site for maintaining a controlled negative pressure at the wound. An individual using a powered NPWT system is eligible for a maximum of 15 wound care sets (A6550) per wound per month, unless there is documentation that the wound size requires more than one wound care set for each dressing change. An individual is eligible for a maximum of 10 canisters (HCPCS code A7000) per month, unless there is documentation evidencing a large volume of drainage (ie, greater than or equal to 90 mL of exudate/day).

An individual using a nonpowered NPWT system is eligible for a maximum of 10 wound care sets (A6550) and 10 wound care cartridges (HCPCS code A9999) per month. Additionally, the individual is eligible to receive 1 strap (A9999) for the length of the therapy.

NOT MEDICALLY NECESSARY

Treatment with an NPWT system and supplies is considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support its use in the treatment of illness or injury in any of the following circumstances:
  • More than four months have elapsed using an NPWT system (including the time NPWT was applied, regardless of the place of application [e.g., home, inpatient facility, skilled nursing facility]).
  • There are surgical or traumatic wounds without complications.
  • Adequate wound healing has occurred.
  • Any measurable degree of wound healing has failed to occur during the prior month.
  • Cancer is present in the wound.
  • The NPWT equipment or supplies are no longer being used for the individual, regardless of the professional provider's orders to continue or discontinue use.
  • The professional provider fails to perform and document all of the following on a weekly basis:
    • Direct assessment of the wound(s) being treated with the NPWT system
    • Supervision of, or directly performing, the wound dressing changes
    • Changes in the wound’s dimensions and characteristics (e.g., size [length, depth, and width], color, exudate type and amount, odor, and evidence of healing)
  • Necrotic tissue with eschar is present if debridement has not been attempted.
  • There is a fistula to an organ or body cavity within the vicinity of the wound.
  • There are exposed vital organs (treatment may proceed after the organ has been covered by vicryl absorbable mesh).
  • The wound has been inadequately debrided (granulation tissue will not form over necrotic tissue).
  • Osteomyelitis that is present within the vicinity of the wound that is not concurrently being treated with intent to cure.
  • Coagulopathy has not been treated.
  • There are non-enteric and unexplored fistulas.
  • The individual has an allergy to any component required for the procedure.
  • A nonpowered NPWT system is being used to treat a wound greater than 13 cm at it widest diameter, or when wound exudate production exceeds 60 cc in 24 hours.

A powered NPWT system (HCPCS code E2402) must be capable of accommodating more than one wound care set for multiple wounds on an individual. Therefore, more than one E2402 billed per individual for the same time period will be denied as not medically necessary.

EXPERIMENTAL/INVESTIGATIONAL

Although the US Food and Drug Administration (FDA) has approved devices for NPWT or portable wound suction pumps, the Company has determined that the safety and/or effectiveness of the following systems cannot be established by review of the available published peer-reviewed literature. Therefore, they are considered experimental/investigational by the Company and not covered:
  • Kalypto System
  • PICO Single Use Negative Pressure Wound Therapy System

REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

If required documentation is not available on file to support a claim at the time of an audit or record request, the durable medical equipment (DME) supplier may be required to reimburse the Company for overpayments.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, a negative-pressure wound therapy (NPWT) system and supplies are covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as not medically necessary are not eligible for coverage or reimbursement by the Company.

Subject to the terms and conditions of the applicable benefit contract, Kalypto System and PICO Single Use Negative Pressure Wound Therapy System are not eligible for payment under the medical benefits of the Company’s products because the service is considered experimental/investigational and, therefore, not covered.

Services that are experimental/investigational are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

Codes that are a daily rental (E2402) are not subject to purchase maximum.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

There are numerous devices approved by the FDA for powered NPWT systems.

Spiracur SNaP® Wound Care System (Sunnyvale, CA) was classified by the FDA on October 28, 2008, as a Class II device, and is permitted to be marketed as "a nonpowered suction apparatus device intended for wound management via application of negative pressure to the wound for removal of fluids, including wound exudate, irrigation fluids, and infectious materials. It is further indicated for management of wounds, burns, flaps and grafts."

Description

Negative-pressure wound therapy (NPWT), also known as vacuum-assisted closure, is the application of controlled negative pressure (vacuum pressure) to a wound to remove exudate and debris from wounds. NPWT is delivered through an integrated system of a suction pump, separate exudate collection chamber, and/or dressing sets to a qualified wound.

In chronic nonhealing wounds (of at least 30 days duration), the presence of fluid inhibits the healing process because it impedes granulation and provides a medium for the growth of micro-organisms. An NPWT system uses negative pressure to drain wound exudates and excess interstitial fluid from the wound bed. The healing process is accelerated by the relief of fluid pressure in the area, which allows granulation, blood vessel formation, and healthy tissue growth to occur. Additionally, the negative pressure from the pump can draw the wound edges together. This, along with granulation and tissue growth, can promote wound closure. Even after receiving NPWT, an individual may still require skin grafts or additional therapies.

Once activated, the NPWT system begins drawing out the fluid that would normally hinder the wound healing process. The duration of treatment with an NPWT system varies with the type and size of the wound being treated. A treatment period lasts an average of eight weeks.

A general wound therapy program includes the measures listed below. All of the following should be applied prior to initiating treatment with an NPWT system:
  • Documentation in the individual's medical record of the evaluation, care, and wound measurements, written by a professional provider
  • Wound assessments (e.g., size [length, depth, and width], color, exudate type and amount, odor, evidence of healing, sinus tracking or tunneling, pain, type of dressing used) performed weekly by a professional provider
  • Application of dressings to maintain a moist wound environment
  • Debridement of necrotic tissue if present
  • Evaluation of and provision for adequate nutritional status

Types of wounds considered appropriate for NPWT systems are:
  • Stage III: Full-thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining and tunneling of adjacent tissue.
  • Stage IV: Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracks may also be present.
  • Neuropathic (diabetic) ulcer
  • Chronic (present for at least 30 days) ulcer of mixed etiology
  • Venous or arterial insufficiency ulcer
  • Complications of a surgically created wound
  • Traumatic wound

NEGATIVE PRESSURE WOUND THERAPY SYSTEMS

A powered NPWT vacuum pressure system (e.g., VAC Therapy®, Kinetic Concepts Inc., San Antonio, TX; Renasys™Systems, Smith and Nephew, St. Petersburg, FL; Avance® NPWT Pump, Baar, Switzerland) can apply between -25 and -200 mmHg of pressure to a wound, either continuously or intermittently. A powered NPWT system generally requires the use of a porous sponge dressing (e.g., Avance® Foam Dressing Kit, Baar, Switzerland) that is attached by an evacuation tube to a collection container and a negative-pressure pump. The sponge dressing is placed directly on the wound and away from other areas of the skin (for large wounds, several dressings may be necessary). Transparent adhesive tape is applied to form an airtight seal around the sponge, and then the NPWT pump can be attached and treatment initiated.

PICO Single Use NPWT System (Smith and Nephew, St. Petersburg, FL) is considered a powered NPWT vacuum pressure system; however, currently, there is no available published peer-reviewed clinical evidence to show that the PICO Single Use NPWT System is as safe and effective as other wound care systems.

A nonpowered NPWT vacuum system delivers from -75 to -125 mmHg of pressure to a wound, using continuous suction. This system uses an adhesive hydrocolloid dressing layer with integrated nozzle and tubing and antimicrobial gauze wound interface layer. The saline-moistened gauze dressing is applied directly to the wound, and the hydrocolloid dressing is placed on top of the gauze. Together, these form an air-tight seal around the wound. The tubing is cut to a desired length and attached to a coupling, which then attaches to the cartridge, which doubles as the negative-pressure pump and collection canister with a capacity of approximately 60 mL of wound exudate. After use, the system is discarded.

A nonpowered NPWT system (e.g., SNaP® Wound Care System, Spiracur, Sunnyvale, CA) is designed to accommodate wounds that are generally less than 13 cm x 13 cm and that produce only small amounts of exudate (ie, less than 60 cc per 24 hours). The system is very portable, usually weighing less than half a pound, and is secured to the body by means of a strap. This system can be used for more than one wound, if the wounds are close together, are less than 13 cm in diameter, and produce less than 60 cc of exudate per 24 hours.

PORTABLE WOUND SUCTION PUMP

Kalypto System (Smith and Nephew, St. Petersburg, FL) with proprietary wound dressings that absorb and "lock-in" any exudate so a collection container is not required, has been reclassified by the Centers for Medicare & Medicaid Services (CMS) as a portable wound suction pump. Currently, there is no available published peer-reviewed clinical evidence to show that the Kalypto System is as safe and effective as other wound care systems or standard therapy.
References


Armstrong DG, Lavery LA, Boulton AJ. Negative pressure wound therapy via vacuum-assisted closure following partial foot amputation: what is the role of wound chronicity? Int Wound J. 2007;4(1):79-86.

Armstrong DG, Lavery LA; Diabetic Foot Study Consortium. Negative pressure wound therapy after partial diabetic foot amputation: a multicentre, randomised controlled trial. Lancet. 2005;366(9498):1704-10.

Armstrong DG, Marston WA, Reyzelmen A, et al. Comparison of Negative Pressure Wound Therapy with the SNaP™ Wound Care System vs. V.A.C.® Therapy System for the Treatment of Chronic Lower Extremity Ulcers: A Multicenter Randomized Controlled Trial. Wound Repair and Regeneration. Accepted for Publication.

Blakeley EK. Vacuum therapy approved for Medicare reimbursement. [Wounds1 Web site]. 10/31/2000. Available at: http://www.wounds1.com/news/mainstory.cfm/1. Accessed April 29, 2019.

Bloemen MC, van der Wal MB, Verhaegen PD, et al. Clinical effectiveness of dermal substitution in burns by topical negative pressure: a multicenter randomized controlled trial. Wound Repair Regen. 2012; 20(6):797-805.

Braakenburg A, Obdeijn MC, Feitz R, et al. The clinical efficacy and cost effectiveness of the vacuum-assisted closure technique in the management of acute and chronic wounds: a randomized control trial. Plast Reconstr Surg. 2006;118(2):390-7.

Dumville JC, Hinchliffe RJ, Cullum N, et al. Negative pressure wound therapy for treating foot wounds in people with diabetes mellitus. Cochrane Database Syst Rev. 2013; 10:CD010318.

Dumville JC, Munson C. Negative pressure wound therapy for partial-thickness burns. Cochrane Database Syst Rev. 2012; 12:CD006215.

ECRI Institute. Managing acute and chronic wounds using negative pressure wound therapy stytems from Smith & Nephew, Inc. Plymouth Meeting (PA): ECRI Institute; 2013 April 01. (ECRI hotline response). Also available at: http://www.ecri.org. Accessed April 29, 2019.

ECRI Institute. Negative-pressure wound therapy for treating complicated wounds. Plymouth Meeting (PA): ECRI Institute; 2013 Jan 23. (ECRI hotline response). Also available at: http://www.ecri.org. Accessed April 29, 2019.

ECRI Institute. PICO Single-use System (Smith & Nephew, Inc.) for Delivering Negative Pressure Wound Therapy. Plymouth Meeting (PA): ECRI Institute; 2012 June 6. (ECRI hotline response). Also available at: http://www.ecri.org. Accessed April 29, 2019.

Fong KD, Hu D, et al. Initial clinical experience using a novel ultraportable negative pressure wound therapy device. Wounds. 2010;22(9):230-6.

Fong KD, Hu D, et al. The SNaP system: biomechanical and animal model testing of a novel ultraportable negative-pressure wound therapy system. Plast Reconstr Surg. 2010;125(5):1362-71.

Hutton D, Sheehan P. Cost Savings with the SNaP wound Care System. International Wound Journal. Accepted for publication.

Landsman A. Analysis of the SNaP Wound Care System, a negative pressure wound device for treatment of diabetic lower extremity wounds. J Diabetes Sci Technol. 2010;4(4):831-2.

Lerman B, Oldenbrook L, Eichstadt SL, et al. Evaluation of chronic wound treatment with the SNaP wound care system vs. modern dressing protocols. Plast Reconstr Surg. 2010;126:1153-61.

Lerman B, Oldenbrook L, Ryu J, et al. Thhe SNaP Wound Care System: a case series using a novel ultraportable negative pressure wound therapy device for the treatment of diabetic lower extremity wounds. J Diabetes Sci Technol. 2010;4(4):825-30.

Noridian. Local Coverage Determination (LCD).Negative pressure wound therapy pumps (L33821): [Noridian Web site]. Original: 10/01/2015. (Revised 05/25/2017). Available at: https://med.noridianmedicare.com/documents/2230703/7218263/Negative+Pressure+Wound+Therapy+Pumps+LCD+and+PA/21a6cc9a-7d71-4b36-9445-6d7585c4eac9.
Accessed April 29, 2019.

Noridian. Local Coverage Determination (LCD).Suction Pumps (L33612): [Noridian Web site]. Original: 10/01/2015. (Revised 01/01/2019). Available at: https://med.noridianmedicare.com/documents/2230703/7218263/Suction+Pumps+LCD+and+PA/4608abe8-05e6-4cd8-9378-c2e0c9faaf5a
Accessed April 29, 2019.

Samson D, Lefevre F, Aronson N. Wound-healing technologies: low-level laser and vacuum-assisted closure. Evid Rep Tech Assess (Summ).2004;(111):1-6.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Product classification. Negative pressure wound therapy powered suction pump. [FDA Web site] 03/10/2014. Available at: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPCD/classification.cfm?ID=OMP. Accessed April 29, 2019.

US Food and Drug Administration 510(k) Premarket Notification Database. Medela® INVIA Wound Therapy. No K080357. Rockville, MD: FDA. July 24, 2008. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf8/K080357.pdf. Accessed April 29, 2019.

US Food and Drug Administration 510(k) Premarket Notification Database. NPD 1 000 Negative Pressure Wound Therapy System. No. K080275.Rockville, MD: FDA. October 09, 2008. Available at:
http://www.accessdata.fda.gov/cdrh_docs/pdf8/K080275.pdf. Accessed April 29, 2019.

US Food and Drug Administration 510(k) Premarket Notification Database. PICO Single Use Negative Pressure Wound Therapy System. No. K111170. Rockville, MD: FDA. December 15, 2011. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf11/K111170.pdf. Accessed April 29, 2019.

US Food and Drug Administration 510(k) Premarket Notification Database. PICO Single Use Negative Pressure Wound Therapy System. No. K112127. Rockville, MD: FDA. May 16, 2012. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf11/K112127.pdf. Accessed April 29, 2019.

US Food and Drug Administration 510(k) Premarket Notification Database. SNaP® Wound Care System. No. K111393. Rockville, MD: FDA. July 28, 2011. Available at:
http://www.accessdata.fda.gov/cdrh_docs/pdf11/K111393.pdf. Accessed April 29, 2019.

Vuerstaek JD, Vainas T, Wuite J, et al. State-of-the-art treatment of chronic leg ulcers: A randomized controlled trial comparing vacuum-assisted closure (V.A.C.) with modern wound dressings. J Vasc Surg. 2006;44(5):1029-38.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

97607, 97608


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)



THE FOLLOWING CODES ARE USED TO REPRESENT NEGATIVE PRESSURE WOUND SYSTEMS:

A6550 Wound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories

A7000 Canister, disposable, used with suction pump, each

A7048 Vacuum drainage collection unit and tubing kit, including all supplies needed for collection unit change, for use with implanted catheter, each

E2402 Negative pressure wound therapy electrical pump, stationary or portable

THE FOLLOWING CODES ARE USED TO REPRESENT NEGATIVE PRESSURE WOUND SUCTION SUPPLIES:

HYDROCOLLOID DRESSING WITH INTEGRATED NOZZLE AND TUBING:
A4649 Surgical supply; miscellaneous

CARTRIDGE:
A9999 Miscellaneous DME supply or accessory, not otherwise specified

STRAP:
A9999 Miscellaneous DME supply or accessory, not otherwise specified


EXPERIMENTAL/INVESTIGATIONAL

THE FOLLOWING CODES ARE USED TO REPRESENT THE KALYPTO SYSTEM:
K0743 Suction pump, home model, portable, for use on wounds

K0744 Absorptive wound dressing for use with suction pump, home model, portable, pad size 16 sq in or less

K0745 Absorptive wound dressing for use with suction pump, home model, portable, pad size more than 16 sq in but less than or equal to 48 sq in

K0746 Absorptive wound dressing for use with suction pump, home model, portable, pad size greater than 48 sq in

THE FOLLOWING CODE IS USED TO REPRESENT THE PICO SINGLE-USE NEGATIVE PRESSURE WOUND THERAPY SYSTEM:
A9272 Wound suction, disposable, includes dressing, all accessories and components, any type, each


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

Revisions from 05.00.38j
05/22/2019This policy has been reviewed and reissued to communicate the Company's continuing coverage on Negative Pressure Wound Therapy (NPWT) Systems.
06/20/2018Effective 6/20/18, this policy has been reviewed and reissued to communicate the Company’s continuing position on Negative-Pressure Wound Therapy (NPWT) Systems.
12/13/2017This version of the policy will become effective 12/13/2017.

This policy was updated to communicate the company's continuing position on Negative-Pressure Wound Therapy (NPWT) Systems.


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 12/13/2017
Version Issued Date: 12/13/2017
Version Reissued Date: 05/22/2019

Connect with Us        


© 2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.