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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.77 Wound Care Management : 9.2.77.1 First-Line Wound Care Therapy

9.2.77.1
First-line wound care therapy includes the following:
9.2.77.1.1
Wound cleansing helps to create an optimal healing environment and decreases the potential for infection by loosening and removing cellular debris and residual topical agents from previous dressings.
Wound cleansing agents may include normal saline, commercial wound cleansers, providone iodine, hydrogen peroxide, or sodium hydrochlorite. Cleansing solutions and methods vary based on effectiveness and individual client needs.
Systemic or topical antibiotics may be used to prevent or treat wound infections and to aid in the healing of wounds.
Pressure off-loading devices, such as pillows, boots, mattresses, and protectors, may also be used as part of first-line wound care therapy to prevent or relieve pressure on the wound.
9.2.77.1.2
Compression performed as a part of wound care management is a benefit and may be reimbursed when billed with procedure code 29580.
9.2.77.1.3
Wound debridement includes the pre-debridement wound assessment, the debridement, and the post-procedure instructions provided to the client on the date of service.
Selective debridement consists of the following:
Non-selective debridement consists of the following:
The following procedure codes are a benefit for wound debridement:
 
The procedure code submitted on the claim (and authorization request, if applicable) must reflect the level of debrided tissue, e.g., partial-thickness skin, full-thickness skin, subcutaneous tissue, muscle, and/or bone, and not the extent, depth, or grade of the ulcer or wound.
Prior authorization is required for non-emergent wound debridement procedure codes 11042, 11043, and 11044. A request for prior authorization must be submitted to TMHP with the Special Medical Prior Authorization (SMPA) Request Form before the procedure is performed. Providers must retain a copy of the signed and dated form in the client’s medical record at the provider’s place of business. The requesting provider may be asked for additional information to clarify or complete a request for the equipment/supply requested.
Requests for prior authorization for wound debridement procedure codes 11042, 11043, and 11044 must include the following documentation:
For procedure codes 11043 and 11044, at least one of the following conditions must be present and documented:
Complications of surgically created or traumatic wound where accelerated granulation therapy is necessary but cannot be achieved by other available topical wound treatment
Wound debridement procedure codes 11042, 11043, and 11044 are not appropriate and will not be approved for the following:
Retroactive authorization is required for wound debridement procedure codes 11042, 11043, and 11044 that are performed on an urgent or emergent basis. The provider must submit a request for retroactive authorization within 14 calendar days, beginning the day after the procedure is performed.
9.2.77.1.4
Wound dressings may include wet and dry dressings.
Dressings applied to the wound are considered part of the service for wound debridement. Metabolically active skin equivalents used in wound care may be considered separate benefits, in addition to the wound debridement procedure. The following procedure codes are a benefit for metabolically active skin equivalents provided in the office setting:
 
The client’s medical record must include documentation that wound treatments with metabolically active skin equivalents or skins substitutes are accompanied by appropriate adjunctive measures, and must identify the adjunctive therapies being provided to the client as part of the wound treatment regimen.
Prior authorization is required for unspecified skin substitute procedure code Q4100. When requesting prior authorization for procedure code Q4100, providers must submit the Special Medical Prior Authorization (SMPA) Request Form and the following information with the request:
9.2.77.1.5
Whirlpool may be a benefit when used as first-line wound care therapy for the treatment of burn wounds.

Texas Medicaid & Healthcare Partnership
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