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

Last updated on 5/11/2018

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.