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Wound Care Equipment and Supply Benefits to Change for Texas Medicaid July 1, 2018

Last updated on 9/11/2020

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective for dates of service on or after July 1, 2018, wound care equipment and supply benefits will change for Texas Medicaid.

Overview of Benefit Changes

Major changes to this medical benefit policy include the following:

Updated benefit language
Revised quantity limitations
New prior authorization criteria
Updated documentation requirements
New prior authorization form
Place of service and provider type updates

Updated Benefit Language

Wounds are defined as acute or chronic, as follows:

Acute wounds progress through the normal stages of wound healing and show definite signs of healing within four weeks.
Chronic wounds do not progress normally through the stages of healing (often getting ‘stalled’ in one phase) and do not show evidence of healing within four weeks.

Providers are to consider the clinical efficacy of the wound care product, the client’s functional status, as well as the measurable signs of effective wound management when ordering products to treat wounds. Measureable signs of wound management include, but are not limited to, the following:

A decrease in wound size, either in surface area or volume
A decrease in amount of exudate
A decrease in amount of necrotic tissue
Improved infection status

Cleansers

Wound cleansing helps create an optimal healing environment and decreases the potential for infection. Cleansing agents and methods vary based on effectiveness and individual client needs. Wound cleansing agents may include, but are not limited to, the following:

Normal saline
Commercial wound cleansers
Povidone iodine
Hydrogen peroxide
Sodium hypochlorite

Compression

Compression dressings, wraps or stockings apply pressure to body parts to control edema and aid circulation by redirecting blood centrally. Below the knee and above the knee compression stockings may be benefits for Texas Medicaid clients. Compression dressings or stockings may be used for, but not limited to, the following indications:

Edema in pregnancy
Postural hypotension
Lymphedema
Treatment of any of the following complications of chronic venous insufficiency:
- Venous edema
- Stasis ulcers
- Varicose veins (not including spider veins)
- Lipodermatosclerosis

Custom burn compression garments may be a benefit with prior authorization and documentation supporting medical necessity.

Dressings

A dressing is a wet or dry, sterile or non-sterile, pad or compress that is designed to be in direct contact with the wound. A dressing is applied to promote healing and protect the wound from further harm. Dressings and related supplies may include, but are not limited to, the following:

Wound packing and fillers
Gauze, impregnated or non-impregnated, sterile or non-sterile
Dry dressings
Collagen dressings
Alginate or other fiber gelling dressings
Composite dressings
Antimicrobials
Foam dressings
Contact layers and transparent films
Hydrocolloid, Hydrofiber, and Hydrogel dressings
Specialty absorptive dressings
Compression dressings and wraps
Tape to secure dressings

Additional Exclusions

The following services are not a benefit of Texas Medicaid:

Contact or non-contact ultrasound treatment for wounds
Electrochemical low-dose tissue oxygenation systems

Quantity Limitations

The following quantity limitations will be effective for dates of service on or after July 1, 2018:

Table A: Procedure Codes	Limitation Effective July 1, 2018
A4213	30 per month
A4216	60 per month
A4217	10 per month
A4244	4 per month
A4246	4 per month
A4247	6 per month
A4320	15 per month
A4322	30 per month
A4364	8 per month
A4450	100 per month
A4452	100 per month
A4455	4 per month
A4456	60 per month
A4461	30 per month
A4465	4 per month
A4490	4 per year
A4495	4 per year
A4500	4 per year
A4510	4 per year
A4927	1 per month
A5120	50 per month
A5121	30 per month
A5122	15 per month
A5126	40 per month
A6010	10 per month
A6011	30 per month
A6021	10 per month
A6022	10 per month
A6023	2 per month
A6024	4 per month
A6025	15 per month
A6196	30 per month
A6197	15 per month
A6198	4 per month
A6199	15 per month
A6203	30 per month
A6204	30 per month
A6205	10 per month
A6206	60 per month
A6207	30 per month
A6208	4 per month
A6209	30 per month
A6210	15 per month
A6211	4 per month
A6212	30 per month
A6213	30 per month
A6214	10 per month
A6216	200 per month
A6217	200 per month
A6218	15 per month
A6219	120 per month
A6220	30 per month
A6221	15 per month
A6222	60 per month
A6223	60 per month
A6224	60 per month
A6228	120 per month
A6229	30 per month
A6230	15 per month
A6231	60 per month
A6232	30 per month
A6233	10 per month
A6234	30 per month
A6235	15 per month
A6236	10 per month
A6237	30 per month
A6238	10 per month
A6239	15 per month
A6240	8 per month
A6241	15 per month
A6242	30 per month
A6243	15 per month
A6244	4 per month
A6245	30 per month
A6246	30 per month
A6247	10 per month
A6248	8 per month
A6250	2 per month
A6251	60 per month
A6252	30 per month
A6253	15 per month
A6254	60 per month
A6255	30 per month
A6256	15 per month
A6257	30 per month
A6258	30 per month
A6259	15 per month
A6261	8 per month
A6262	8 per month
A6266	120 per month
A6402	200 per month
A6403	100 per month
A6404	15 per month
A6407	60 per month
A6410	30 per month
A6411	30 per month
A6412	30 per month
A6441	60 per month
A6442	120 per month
A6443	120 per month
A6444	120 per month
A6445	120 per month
A6446	120 per month
A6447	120 per month
A6448	30 per month
A6449	60 per month
A6450	30 per month
A6451	30 per month
A6452	60 per month
A6453	30 per month
A6454	60 per month
A6455	30 per month
A6456	60 per month
A6457	60 per month
A6530	16 per year
A6531	16 per year
A6532	16 per year
A6533	16 per year
A6534	16 per year
A6535	16 per year
A6536	16 per year
A6537	16 per year
A6538	16 per year
A6539	16 per year
A6540	16 per year
A6541	16 per year
A6544	4 per year
A6545 with modifier AW	8 per year
A6550	15 per month
A7000	10 per month
E2402*	1 per month for up to 3 months
*Note: The initial 90 days of treatment with negative pressure wound therapy does not require prior authorization. Prior authorization is required for continued therapy after the initial 90 days of treatment.

New Prior Authorization Criteria

Quantities that exceed the limitations identified in the tables above will require prior authorization with documentation supporting medical necessity.

Prior authorization with documentation supporting medical necessity and the quantity requested, will be required for the following procedure codes:

Table B: Procedure Codes
A6215	A6260	A6501	A6502	A6503	A6504	A6505
A6506	A6507	A6508	A6509	A6510	A6511	A6512
A6513	A6549	A9272	T1999

Information from the section below, “Updated Documentation Requirements,” must be submitted anytime that prior authorization is required.

Compression Burn Garments

The following procedure codes for compression burn garments will require documentation of an appropriate diagnosis and evidence of medical necessity:

Table C: Procedure Codes
A6501	A6502	A6503	A6504	A6505	A6506	A6507
A6508	A6509	A6510	A6511	A6512	A6513

Prior authorization requests for compression burn garments will be reviewed by the medical director.

Disposable Wound Suction

Documentation for procedure code A9272 must include justification addressing why no other wound care equipment and supplies will meet the client’s need.

Negative Pressure Wound Therapy (NPWT)

Prior authorization for NPWT may be considered for additional 30-day treatment periods beyond the initial 90-day treatment period. For each prior authorization request, providers must submit documentation to support continued use of NPWT, including the measurements at the initiation of NPWT and the current measurements (length, width, depth and any undermining or tunneling.)

Providers must also document if any of the following contraindications are present:

No measurable improvement of wound status occurring over the prior 90-day period
The wound care equipment or supplies are no longer being used by the client as prescribed

Updated Documentation Requirements

The requesting durable medical equipment (DME) provider may be asked for additional information to clarify or complete a request for the wound care equipment or supplies including, but not limited to, the following:

Overall health status of clients whose wounds are not progressing through the normal stages of healing, including, but not limited to, the following:
- Albumin or pre-albumin (within 30 days)
- Hemoglobin A1C (within 30 days)
- Use of pressure-reducing surfaces, repositioning, and encouraged ambulation

Reauthorization will be considered based on medical necessity, with a new prior authorization request.

All of the following information must be submitted with every prior authorization request. If prior authorization is not required, this documentation must be maintained in the client’s medical record and is subject to retrospective review.

Category 1: Medical History and Compliance

A comprehensive treatment plan, including the prescribed wound care and management planned for the client. This may include, but is not limited to, documentation of the following:
- Any medical diagnosis or chronic condition that affects wound healing
- History of previous wound care treatments and outcomes with dates (including therapies initiated in a hospital or skilled nursing facility)
- Continued management of unresolved compliance issues (e.g., missed medical appointments, refusing dressing changes, repositioning, smoking, poor nutritional intake or choices)
- Whether a family member, friend or caregiver agrees to be available to assist the client

Category 2: Wound Care Interventions

Relevant information related to the current wound, including the following:
- Any mechanical, surgical, enzymatic or autolytic tissue debridement (if performed)
- Treatment for infection (if present)

Category 3: Wound Description & Details

Detailed description of the wound, including the following:
- Dates of previous and current assessments
- The measurements at the initiation of wound care and the current measurements, including length, width, depth and any undermining or tunneling
- Wound color
- Amount, quality, quantity and odor of drainage (if present)
- Presence of granulation or eschar (if appropriate)
The currently prescribed wound care regimen, to include types of dressings, frequency of dressing changes and supplies needed for each dressing change
Frequency client will be seen by a licensed medical professional to assess wound healing and current wound treatment regimen

Category 4: Contraindications

Absence of the following contraindications:
- Untreated osteomyelitis within the vicinity of the wound
- Wound ischemia
- Gangrene
- Presence in the wound of necrotic tissue with eschar (if debridement has not been attempted)
- Cancer present in the wound or around the margins
- Presence of a fistula to an organ or body cavity within the vicinity of the wound
Documentation explaining the appropriateness of wound care is required if any of the above contraindications are present

New Prior Authorization Form

The new prior authorization form, titled “Wound Care Equipment and Supplies Order Form,” is to be used when submitting prior authorization requests for the following services:

Wound care supplies that exceed quantity limitations
All wound care supplies that require prior authorization, as identified in Table B above

The following forms will be discontinued on June 30, 2018, and will no longer be accepted after July 31, 2018:

Statement for Initial Wound Therapy System In-Home Use (Form #F00100)
Statement for Recertification of Wound Therapy System In-Home Use (Form #F00099)

Providers may refer to the article titled, "New Prior Authorization Form for Wound Care Equipment and Supplies to be Effective July 1, 2018 ," which was published on this website May 11, 2018, for additional information about the new form.

Place of Service and Provider Type Updates

The following procedure codes will only be a benefit when services are provided by home health DME and medical supplier (DME) providers in the home setting:

Table D: Procedure Codes
A4490	A4495	A4500	A4510	A6544

The following procedure codes will only be a benefit when services are provided by home health DME and medical supplier (DME) providers in the home setting, and hospital providers in the outpatient hospital setting:

Table E: Procedure Codes
A6501	A6502	A6503	A6504	A6505	A6506	A6507
A6508	A6509	A6510	A6511	A6512	A6513

For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.