MEDICAL POLICY Dressings and Wound Care Supplies

POLICY . . . . . . . . PG-0241 EFFECTIVE . . . . . .07/01/09 LAST REVIEW . . . 05/12/15 MEDICAL POLICY Dressings and Wound Care Supplies GUIDELINES ...
Author: Iris Harmon
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POLICY . . . . . . . . PG-0241 EFFECTIVE . . . . . .07/01/09 LAST REVIEW . . . 05/12/15

MEDICAL POLICY Dressings and Wound Care Supplies

GUIDELINES This policy does not certify benefits or authorization of benefits, which is designated by each individual policyholder contract. Paramount applies coding edits to all medical claims through coding logic software to evaluate the accuracy and adherence to accepted national standards. This guideline is solely for explaining correct procedure reporting and does not imply coverage and reimbursement.

DESCRIPTION A dressing is used to assist in the healing of a wound and has the challenge of protecting the site from additional infection, drainage of exudate, encouragement of new tissue growth, and to prevent further tissue damage. The dressing is often chosen by a wound care specialist/medical provider after an examination and evaluation of the wound. It must be determined how often a dressing must be changed and the correct type of dressing to be applied for optimal healing. First the wound is staged, measured, and documented by color and drainage. The documentation must be maintained throughout the entire care of the wound. Size, drainage, color, healing, new tissue growth, smell, dressing type and size, and other related wound information must all be noted with each dressing change. The staging of pressure ulcers is as follows: Stage I Non-blanchable erythema of intact skin Stage II Partial thickness skin loss involving epidermis and/or dermis Stage III Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia Stage IV Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures A dressing type is determined based on the wound evaluation by the wound care specialist/medical provider. A single wound may have one type of dressing applied, and during the healing process it will be determined if a different type will be required. It is not medically necessary to apply two different types of dressings to the same wound. Dressing needs may change frequently (e.g.,weekly) in the early phases of wound treatment and/or with heavily draining wounds. Providers are expected to have a mechanism for determining the quantity of dressings that the consumer is actually using and to adjust their provision of dressings accordingly. No more than one month's supply of dressings may be provided at one time. The stockpiling of surgical dressings and related supplies by a consumer is not allowed. Tape Tape is covered when needed to hold on a wound cover, elastic roll gauze or non-elastic roll gauze. Additional tape is usually not required when a wound cover with an adhesive border is used. The medical necessity for tape in these situations must be documented. Tape change is determined by the frequency of change of the wound cover. Quantities of tape submitted must reasonably reflect the size of the wound cover being secured. Typical use for wound covering;  16sq in or less, up to 2 units per dressing change  16 to 48sq in, up to 3 units per dressing change  Greater than 48sq in, up to 4 units per dressing change Wound pouch Usual dressing change is up to three times per week. Alginate or other fiber gelling dressing Alginate or other fiber gelling dressing covers are covered for moderately to highly exudative full thickness wounds (e.g., stage III or IV ulcers), and alginate or other fiber gelling dressing fillers for moderately to highly exudative full thickness wound cavities (e.g., stage III or IV ulcers). They are not medically necessary on dry wounds or wounds covered with eschar. Usual dressing change is up to once per day. One wound cover sheet of the approximate size

of the wound, or up to two units of wound filler (1 unit = 6in of alginate or other fiber gelling dressing rope), is usually used at each dressing change. It is inappropriate to use alginates or other fiber gelling dressings in combination with hydrogels. Composite dressing Usual composite dressing change is up to three times per week, one wound cover per dressing change. Contact layer Contact layer dressings are used to line the entire wound. They are not intended to be changed with each dressing change. Usual dressing change is up to once per week. Foam dressing Foam dressings are covered when used on full thickness wounds (e.g., stage III or IV ulcers) with moderate to heavy exudate. Usual dressing change for a foam wound cover used as a primary dressing, is up to three times per week. When a foam wound cover is used as a secondary dressing for wounds with very heavy exudate, dressing change may be up to three times per week. Usual dressing change for foam wound fillers is up to once per day. Gauze, non-impregnated Usual non-impregnated gauze dressing change is up to three times per day for a dressing without a border, and once per day for a dressing with a border. It is usually not necessary to stack more than two gauze pads on top of each other in any one area. Gauze, impregnated with other than water, normal saline, hydrogel, zinc paste Usual dressing change for gauze dressings impregnated with other than water, normal saline, or hydrogel is up to once per day. Hydrocolloid dressings Hydrocolloid dressings are covered for use on wounds with light to moderate exudate. Usual dressing change for hydrocolloid wound covers or hydrocolloid wound fillers is up to three times per week. Hydrogel dressing Hydrogel dressings are covered when used on full thickness wounds with minimal or no exudate (e.g., stage III or IV ulcers). Hydrogel dressings are not usually medically necessary for stage II ulcers. Documentation must substantiate the medical necessity for use of hydrogel dressings for stage II ulcers (e.g., location of ulcer is sacrococcygeal area). Usual dressing change for hydrogel wound covers without adhesive border or hydrogel wound fillers is up to once per day. Usual dressing change for hydrogel wound covers with adhesive border is up to three times per week. The quantity of hydrogel filler used for each wound must not exceed the amount needed to line the surface of the wound. Additional amounts used to fill a cavity are not medically necessary. Documentation must substantiate the medical necessity for code A6248 billed in excess of three units (fluid ounces) per wound in 30 days. Use of more than one type of hydrogel dressing (filler, cover, or impregnated gauze) on the same wound, at the same time, is not medically necessary. Specialty absorptive dressings Specialty absorptive dressings are covered when used for moderately or highly exudative wounds (e.g., stage III or IV ulcers). Usual specialty absorptive dressing change is up to once per day for a dressing without an adhesive border, and up to every other day for a dressing with a border. Transparent film dressing Transparent film dressings are covered when used on open partial thickness wounds with minimal exudate or closed wounds. Usual dressing change is up to three times per week. Wound filler, not elsewhere classified Wound fillers are dressing materials that are placed into open wounds to eliminate dead space, absorb exudate, or maintain a moist wound surface. A usual dressing change is up to once per day; however, it depends on the type of wound and the other dressings applied.

Non-covered Dressings Supplies used for these types of medical indications should not be submitted for coverage of supplies. Examples of situations in which dressings are non-covered are;  Drainage from a cutaneous fistula which has not been caused by or treated by a surgical procedure  A stage I pressure ulcer  A first degree burn  Wounds caused by trauma which do not require surgical closure or debridement (e.g., skin tear or abrasion)  A venipuncture or arterial puncture site (e.g., blood sample) other than the site of an indwelling catheter or needle Gauze, impregnated, water or normal saline There is no medical necessity for these dressings compared to non-impregnated gauze which is moistened with bulk saline, or sterile water. When these dressings are billed, payment will be based on the least costly medically appropriate alternative, sterile non-impregnated gauze. These types of dressing are denied as a convenience item. Assorted non-covered A non-elastic binder for an extremity is non-covered for all indications because it does not meet the definition of a surgical dressing. The following are examples of wound care items which are non-covered under surgical dressings benefit:  Skin sealants or barriers  Wound cleansers or irrigating solutions  Solutions used to moisten gauze (e.g., saline)  Silicone gel sheets, topical antiseptics  Topical antibiotics  Enzymatic debriding agents  Gauze or other dressings used to cleanse or debride a wound but not left on the wound Small adhesive bandages (e.g., Band-Aid or similar product) are not primarily used for the treatment of wounds addressed in the surgical dressing policy, and will therefore be denied as non-covered. A collagen dressing (per 6in) is non-covered as wounds this size are often treated through other wound care mechanisms, as this wound not be the medical treatment plan. A silicone gel sheet used for the treatment of keloids or other scars, does not meet the definition of the surgical dressing because it is used for cosmetic indications. This will be denied as noncovered. A first-aid type adhesive bandage does not meet the definition of the surgical dressing benefit, and will also be denied as non-covered. When surgical dressing kits are used for the provision of surgical dressings, all components of the kit will be considered not medically necessary. Eye pads These products are expected to be used for conditions such as strabismus. If used in a physician’s office or for a surgical service, these will be denied as part of the surgical service. Gradient compression stockings/wraps See Reimbursement/Coverage Guidelines Policy PG-0081 Compression burn garments Compression burn garments are used to reduce hypertrophic scarring and joint contractures following a burn injury. These items are always custom made and will always require an invoice to assist in pricing and review of the product supplied. These items are not able to be priced for any product line.

POLICY Dressings and wound care supplies do not require prior authorization but are subject to limits and coverage as listed below. For any item to be covered it must: 1. Be eligible for benefit coverage 2. Be medically indicated for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member

3. Have a written signed and dated order by the treating physician. Limits are placed as a guideline; however, adjustments may need to be made based on a medical review of the number of wounds a member has, the types of wounds, and drainage. This guideline only addresses the dressings applied to wounds, and not the additional services which may be provided (e.g., debridement and wound vac therapy). There are some products classified as dressings which do not fit the standard definition of a dressing. They are unique and have limited and specialized applications. HMO, PPO, Individual Marketplace, Elite Non-covered A4461, A4463, A4465, A6000, A6024, A6025, A6228 - A6230, A6250, A6260, A6412, and A6413 Advantage Non-covered A4461, A4463, A4465, A6000, A6024, A6025, A6228-A6230, A6250, A6260, A6412, and A6413

CODING/BILLING INFORMATION The appearance of a code in this section does not necessarily indicate coverage. Codes that are covered may have selection criteria that must be met. Payment for supplies may be included in payment for other services rendered.

HCPCS CODES A4450 Tape, non-waterproof, per 18sq in A4452 Tape, waterproof, per 18sq in A4461 Surgical dressing holder, non-reusable, each A4463 Surgical dressing holder, reusable, each A4465 Non-elastic binder for extremity A6000 Noncontact wound-warming wound cover for use with the noncontact wound-warming device and warming card A6010 Collagen based wound filler, dry form, per gram of collagen A6011 Collagen based wound filler, gel/paste, per gram of collagen A6021 A6022 A6023 A6024 A6025 A6154 A6196 A6197 A6198 A6199 A6203 A6204 A6205 A6206 A6207 A6208 A6209 A6210 A6211 A6212 A6213 A6214 A6215

Collagen dressing, pad size 16sq in or less, each Collagen dressing, pad size more than 16sq in but less than or equal to 48sq in, each Collagen dressing, pad size more than 48sq in, each Collagen dressing wound filler, per 6in Gel sheet for dermal or epidermal application, (e.g., silicone, hydrogel, other), each wound pouch, each Wound pouch, each Alginate or other fiber gelling dressing, wound cover, pad size 16sq in or less, each dressing Alginate or other fiber gelling dressing, wound cover, pad size more than 16sq in but less than or equal to 48sq in, each dressing Alginate or other fiber gelling dressing, wound cover, pad size more than 48sq in, each dressing Alginate or other fiber gelling dressing, wound filler, per 6in Composite dressing, pad size 16sq in or less, with any size adhesive border, each dressing Composite dressing, pad size more than 16sq in but less than or equal to 48 q in, with any size adhesive border, each dressing Composite dressing, pad size more than 48sq in, with any size adhesive border, each dressing Contact layer, 16sq in or less, each dressing Contact layer, more than 16sq in but less than or equal to 48sq in, each dressing Contact layer, more than 48sq in, each dressing Foam dressing, wound cover, pad size 16sq in or less, without adhesive border, each dressing Foam dressing, wound cover, pad size more than 16sq in but less than or equal to 48sq in, without adhesive border, each dressing Foam dressing, wound cover, pad size more than 48sq in, without adhesive border, each dressing Foam dressing, wound cover, pad size 16sq in or less, with any size adhesive border, each dressing Foam dressing, wound cover, pad size more than 16sq in but less than or equal to 48sq in, with any size adhesive border, each dressing Foam dressing, wound cover, pad size more than 48sq in, with any size adhesive border, each dressing Foam dressing, wound filler, per gram

A6216 A6217

Gauze, non-impregnated, non-sterile, pad size 16sq in or less, without adhesive border, each dressing Gauze, non-impregnated, non-sterile, pad size more than 16sq in but less than or equal to 48sq in, without adhesive border, each dressing

A6218 A6219 A6220

Gauze, non-impregnated, non-sterile, pad size more than 48sq in, without adhesive border, each dressing Gauze, non-impregnated, pad size 16sq in. or less, with any size adhesive border, each dressing Gauze, non-impregnated, pad size more than 16sq in but less than or equal to 48sq in, with any size adhesive border, each dressing Gauze, non-impregnated, pad size more than 48sq in, with any size adhesive border, each dressing Gauze, impregnated with other than water, normal saline, or hydrogel, pad size 16sq in or less, without adhesive border, each dressing Gauze, impregnated with other than water, normal saline, or hydrogel, pad size more than 16sq in, but less than or equal to 48sq in, without adhesive border, each dressing Gauze, impregnated with other than water, normal saline, or hydrogel, pad size more than 48sq in, without adhesive border, each dressing

A6221 A6222 A6223 A6224 A6228 A6229

Gauze, impregnated, water or normal saline, pad size 16sq in or less, without adhesive border, each dressing Gauze, impregnated, water or normal saline, pad size more that 16sq in but less than or equal to 48sq in, without adhesive border, each dressing

A6230 A6231 A6232

Gauze, impregnated, water or normal saline, pad size more than 48sq in, without adhesive border, each dressing Gauze, impregnated, hydrogel, for direct wound contact, pad size 16sq in or less, each dressing Gauze, impregnated, hydrogel, for direct wound contact, pad size greater than 16sq in, but less than or equal to 48sq in, each dressing Gauze, impregnated, hydrogel for direct wound contact, pad size more than 48sq in, each dressing Hydrocolloid dressing, wound cover, pad size 16sq in or less, without adhesive border, each dressing Hydrocolloid dressing, wound cover, pad size more than 16sq in but less than or equal to 48sq in, without adhesive border, each dressing Hydrocolloid dressing, wound cover, pad size more than 48sq in, without adhesive border, each dressing Hydrocolloid dressing, wound cover, pad size 16sq in or less, with any size adhesive border, each dressing Hydrocolloid dressing, wound cover, pad size more than 16sq in but less than or equal to 48sq in, with any size adhesive border, each dressing Hydrocolloid dressing, wound cover, pad size more than 48sq in, with any size adhesive border, each dressing Hydrocolloid dressing, wound filler, paste, per fluid ounce Hydrocolloid dressing, wound filler, dry form, per gram Hydrogel dressing, wound cover, pad size 16sq in or less, without adhesive border, each dressing Hydrogel dressing, wound cover, pad size more than 16sq in but less than or equal to 48sq in, without adhesive border, each dressing Hydrogel dressing, wound cover, pad size more than 48sq in, without adhesive border, each dressing Hydrogel dressing, wound cover, pad size 16sq in or less, wtih any size adhesive border, each dressing Hydrogel dressing, wound cover, pad size more than 16sq in but less than or equal to 48sq in, with any size adhesive border, each dressing Hydrogel dressing, wound cover, pad size more than 48sq in, with any size adhesive border, each dressing Hydrogel dressing, wound filler, gel, per fluid ounce Skin sealants, protectants, moisturizers, ointments, any type, any size Specialty absorptive dressing, wound cover, pad size 16sq in or less, without adhesive border, each dressing Specialty absorptive dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48sq in, without adhesive border, each dressing Specialty absorptive dressing, wound cover, pad size more than 48sq in, without adhesive border, each dressing Specialty absorptive dressing, wound cover, pad size 16sq in or less, with any size adhesive border, each dressing Specialty absorptive dressing, wound cover, pad size more than 16sq in but less than or equal to 48sq in, with any size adhesive border, each dressing Specialty absorptive dressing, wound cover, pad size more than 48sq in, with any size adhesive border, each dressing Transparent film, 16sq in or less, each dressing Transparent film, more than 16sq in but less than or equal to 48sq in, each dressing Transparent film, more than 48sq in, each dressing Wound cleansers, any type, any size Wound filler, gel/paste, per fluid ounce, not elsewhere classified Wound filler, dry form, per gram, not elsewhere classified Gauze, impregnated, other than water, normal saline, or zinc paste, any width, per linear yard

A6233 A6234 A6235 A6236 A6237 A6238 A6239 A6240 A6241 A6242 A6243 A6244 A6245 A6246 A6247 A6248 A6250 A6251 A6252 A6253 A6254 A6255 A6256 A6257 A6258 A6259 A6260 A6261 A6262 A6266

A6402 A6403 A6404 A6407 A6410 A6411 A6412 A6413 A6441 A6442 A6443 A6444 A6445 A6446 A6447 A6448 A6449 A6450 A6451 A6452 A6453 A6454 A6455 A6456 A6457 A6501 A6502 A6503 A6504 A6505 A6506 A6507 A6508 A6509 A6510 A6511 A6512 A6513

Gauze, non-impregnated, sterile, pad size 16sq in or less, without adhesive border, each dressing Gauze, non-impregnated, sterile, pad size more than 16sq in less than or equal to 48sq in, without adhesive border, each dressing Gauze, non-impregnated, sterile, pad size more than 48sq in, without adhesive border, each dressing Packing strips, non-impregnated, up to 2in in width, per linear yard Eye pad, sterile, each Eye pad, non-sterile, each Eye patch, occlusive, each Adhesive bandage, first-aid type, any size, each Padding bandage, non-elastic, non-woven/non-knitted, width greater than or equal to three inches and less than 5in per yard Conforming bandage, non-elastic, knitted/woven, non-sterile, width less than 3in, per yard Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than or equal to 3in and less than 5in, per yard Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than or equal to 5in, per yard Conforming bandage, non-elastic, knitted/woven, sterile, width less than 3in, per yard Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to 3in and less than 5in, per yard Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to 5in, per yard Light compression bandage, elastic, knitted/woven, width less than 3in, per yard Light compression bandage, elastic, knitted/woven, width greater than or equal to 3in and less than 5in, per yard Light compression bandage, elastic, knitted/woven, width greater than or equal to 5in, per yard Moderate compression bandage, elastic, knitted/woven, load resistance of 1.25 to 1.34ft pounds at 50% maximum stretch, width greater than or equal to 3in and less than 4in, per yard High compression bandage, elastic, knitted/woven, load resistance greater than or equal to 1.35ft pounds at 50% maximum stretch, width greater than or equal to 3in and less than 5in, per yard Self-adherent bandage, elastic, non-knitted/non-woven, width less than 3in, per yard Self-adherent bandage, elastic, non-knitted/non-woven, width greater than or equal to 3in and less than 5in, per yard Self-adherent bandage, elastic, non-knitted/non-woven, width greater than or equal to 5in, per yard Zinc paste impregnated bandage, nonelastic, knitted/woven, width greater than or equal to 3in and less than 5in, per yard Tubular dressing with or without elastic, any width, per linear yard Compression burn garment, bodysuit (head to foot), custom fabricated Compression burn garment, chin strap, custom fabricated Compression burn garment, facial hood, custom fabricated Compression burn garment, glove to wrist, custom fabricated Compression burn garment, glove to elbow, custom fabricated Compression burn garment, glove to axilla, custom fabricated Compression burn garment, foot to knee length, custom fabricated Compression burn garment, foot to thigh length, custom fabricated Compression burn garment, upper trunk to waist including arm openings (vest), custom fabric Compression burn garment, trunk, including arms down to leg openings (leotard), custom fabric Compression burn garment, lower trunk including leg openings (panty), custom fabric Compression burn garment, not otherwise classified Compression burn mask, face and/or neck, plastic or equal, custom fabricated

HCPCS Modifiers Modifier -A1 Dressing for one wound Modifier -A2 Dressing for two wounds Modifier -A3 Dressing for three wounds Modifier -A4 Dressing for four wounds Modifier -A5 Dressing for five wounds Modifier -A6 Dressing for six wounds Modifier -A7 Dressing for seven wounds Modifier -A8 Dressing for eight wounds Modifier -A9 Dressing for nine or more wounds

REVISION HISTORY EXPLANATION 10/08/13: HCPCS Codes deleted A6200-A6202 (terminated 12/31/09), A6514 (never an active code). Eye pad diagnosis reference deleted as not found to be necessary. Added HCPCS Modifiers A1-A9. Policy reviewed and updated to reflect most current clinical evidence. Approved by Medical Policy Steering Committee as revised. 05/12/15: Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee. REFERENCES Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services Ohio Department of Medicaid http://jfs.ohio.gov/ Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets Industry Standard Review