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 March 1, 2021, benefits for wound care management services will change for Texas Medicaid.
Overview of Benefit Changes
Major changes to this medical benefit include the following:
- Definitions for different stages of pressure injuries
- Updates for wound debridement services
- Expanded benefit information for skin substitutes
- Updated documentation requirements
- Expanded list of services that are not a benefit of Texas Medicaid
Pressure Injuries
The National Pressure Ulcer Advisory Panel defines a pressure injury as follows:
A pressure injury is a localized damage to the skin and/or underlying tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, comorbid conditions, and condition of the soft tissue.
Stage 1 Pressure Injury
A Stage 1 pressure injury has intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Its color may differ from the surrounding area. The extent of skin pigmentation may affect the appearance and ease of detection of erythematous of otherwise colored lesions, placing some populations at risk.
Stage 2 Pressure Injury
A Stage 2 pressure injury has partial thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis, and shear in the heel. This stage should be used to describe moisture associated skin damage (MASD), including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).
Stage 3 Pressure Injury
A Stage 3 pressure injury has full thickness loss of skin. Adipose is visible in the ulcer, and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable pressure injury.
Stage 4 Pressure Injury
A Stage 4 pressure injury has full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, or cartilage of bone in the ulcer. Slough and/or eschar may be visible. Epibole, undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an Unstageable pressure injury.
Unstageable Pressure Injury
An Unstageable pressure injury has obscured full-thickness skin and tissue loss, in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.
Deep Tissue Pressure Injury
A Deep Tissue pressure injury (DTPI) has persistent, non-blanchable deep red, maroon, or purple discoloration. Skin is intact or nonintact with localized area of persistent non-blanchable deep red, maroon, or purple discoloration, or with epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full-thickness pressure injury (Unstageable, Stage 3, or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.
Wound Debridement
Procedure code 97602 will be a benefit as follows:
|
In Place of Service |
When Services are Provided by |
|
Office, home settings |
Physician assistant, nurse practitioner, clinical nurse specialist, physician, podiatrist, physical therapist, occupational therapist, home health agency, hospital, rehabilitation center, and CCP providers |
|
Outpatient setting |
Home health agency, hospital, and rehabilitation center providers |
Professional services for selective wound debridement (procedure codes 97597 and 97598) may be reimbursed to a licensed physical therapist, when it is determined to be within the provider’s scope of practice, and the service is prescribed by a Medicaid-enrolled supervising physician or qualified non-physician provider.
Prior Authorization
Prior authorization requests for procedure codes 11042, 11043, and 11044 will be considered for 7 calendar days, beginning on the requested procedure date.
Prior authorization requests must be submitted by the provider within 30 calendar days prior to, or on the date the procedure is performed. If the prior authorization request is not submitted within 30 calendar days prior to, or on the date the procedure is performed, the request will be denied.
The physician’s signature on the Special Medical Prior Authorization (SMPA) Request Form is considered current when signed and dated within 30 calendar days prior to, or on the date the procedure is performed. If the physician’s signature is not signed and dated within the 30-calendar-day period prior to or on the date the procedure is performed, the request will be denied.
When submitting an initial prior authorization request, the treating provider (registered nurse, physician, physical therapist) must submit a signed and dated wound care treatment plan or letter of medical necessity that includes all the following documentation:
- Planned interventions for the problem identified
- Treatment goals
- Expected outcomes
The treatment plan or letter of medical necessity is considered current when it is signed and dated within 30 calendar days prior to or on the date the procedure is performed. Otherwise, a new treatment plan must be submitted.
Retroactive authorization requests for wound debridement performed on an urgent or emergent basis (procedure code 11042, 11043, or 11044) will be denied if not submitted within 14 calendar days, beginning the day after the procedure is performed.
For retroactive authorization requests, the physician’s signature on the Special Medical Prior Authorization (SMPA) Request Form is considered current when signed and dated within 14 calendar days, beginning the day after the procedure is performed. Requests with the physician’s signature not signed and dated within the 14-calendar-day period will be denied.
For retroactive authorization to be considered, the treatment plan or letter of medical necessity must be signed and dated within 14 calendar days beginning the day after the procedure is performed. If the treatment plan is not signed and dated within the 14-calendar-day period, the request will be denied.
Prior authorization requests for subsequent debridement will be considered on a case-by-case basis with documentation of medical necessity. These requests will be reviewed by the Medical Director.
Skin Substitutes
Second-line wound care therapy includes the application of metabolically active skin equivalents/skin substitutes.
The application of skin substitutes may be a benefit for the treatment of chronic Stage 3 or 4 wounds that have failed to respond to standard wound care treatment after 30 days. A failed response is defined as a wound that has increased in size or depth, or has not changed in baseline size or depth, and shows no measurable signs of healing improvements after 30 days of appropriate wound-care measures.
Use of the appropriate specific skin substitute product(s) for the episode of each documented wound is expected. Compliance with the Food and Drug Administration (FDA) assessments and submitted guidelines for the specific skin substitute product(s) used is expected. Skin substitute products not used within the scope of the FDA’s intended use and indications are considered experimental and/or investigational.
The following procedure codes are a benefit for the application of skin substitute grafts:
| Procedure Codes | ||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 15271 | 15272 | 15273 | 15274 | 15275 | 15276 | 15277 | ||||||||||||||||||||||||||||||||||||||||||
| 15278 | ||||||||||||||||||||||||||||||||||||||||||||||||
Approved skin substitute products used in wound care services that are provided in an office-based setting will be considered for separate reimbursement when submitted with an appropriate application procedure code from the table above.
The approved skin substitute product(s) must have a published average sales price, must be FDA cleared/approved or be designated as 361 HCT/P exempt, and should be used in accordance with each product's individualized labeling and application guidelines. The approved list of skin substitute products will be reviewed and updated biannually. Providers should refer to the Center for Medicare & Medicaid Services (CMS) Medicare Part B Drug Average Sales Price web page at www.cms.gov for updates to the list of approved skin substitute products.
All skin substitute products used in wound care services that are provided in a facility setting are considered part of the application services and are not separately reimbursed.
Procedure code C9250 will be considered part of the application services and will not be separately reimbursed, regardless of the setting.
Surgical Wound Preparation
Appropriate surgical wound preparation may be expected at least once at the initiation of care, prior to placement of the skin substitute graft. Repeated use of surgical preparation services in conjunction with skin substitute application codes will be considered not reasonable or necessary and will not be reimbursed.
Procedure codes 15002, 15003, 15004, 15005, 15040, and 15050 are a benefit for surgical wound preparation.
Note: Procedure code 15005 will no longer be a benefit for ambulatory surgical center providers.
Limitations
The treatment of any chronic skin wound will typically last no more than 12 weeks.
Skin substitute applications and grafts will be limited to 10 per episode of care in a 12-week period, per rolling year beginning on the first day of the first skin substitute application. If more than one specific product is used or a product change occurs during the 12-week period of care, the expectation remains that the cumulative number of applications will not exceed 10.
More than 10 skin substitute applications in a 12-week period will be considered on a case-by-case basis with documentation of medical necessity. These requests will be reviewed by the Medical Director.
Re-Treatment of Healed, Stage 3, or Stage 4 Chronic Wounds
Retreating healed skin wounds showing greater than 75 percent in size reduction and smaller than 0.5 square cm is not considered medically reasonable or necessary and will not be reimbursed.
Retreating a venous stasis ulcer or diabetic neuropathic foot ulcer with any skin substitute product(s) within one year of previous treatment is considered treatment failure. This unsuccessful treatment does not meet reasonable and necessary criteria for re-treatment and will not be reimbursed.
Unsuccessful treatment is defined as an increase in size or depth of an ulcer, or no change in baseline size or depth and no sign of improvement or indication that improvement is likely (such as granulation, epithelialization, or progress towards closing) for a period of 4 weeks past the start of therapy.
Contraindications
Skin substitute grafts are contraindicated for the following:
- Clients with known hypersensitivity to any component of the specific skin substitute graft (e.g., allergy to avian, bovine, porcine, or equine products).
- Skin substitute grafts will not be considered reasonable and necessary for clients with inadequate control of underlying conditions or exacerbating factors, such as the following:
- Clients with uncontrolled diabetes
- Clients with active infection
- Clients with active Charcot arthropathy of the ulcer extremity
- Clients with vasculitis
- Clients who continue smoking tobacco and have not received smoking cessation guidance from their physician
Additional Documentation Requirements
For all wound care management services, the client’s medical history related to the current wound must also include the wound location.
Skin Substitutes
Documentation maintained in the client’s medical record must support the need for skin substitute applications and the product used.
Documentation for all wound care treatments involving the application of skin substitute products must include, but is not limited to, the following:
- Wound treatments are accompanied by the appropriate adjunctive measures, and identify the specific adjunctive therapies being provided to the client as part of the wound treatment regimen.
- Clients who use tobacco must satisfy one of the following documentation requirements:
- The client will have ceased smoking or have refrained from systemic tobacco intake for at least 4 weeks prior to beginning skin substitute applications and during the conservative wound care.
- Smoking history, cessation counseling on the effects of smoking on surgical outcomes, treatment for smoking cessation (if applicable), and the outcome of counseling must be recorded in the client’s medical record.
- Adequate circulation/oxygenation to support tissue growth/wound healing must be present as evidenced by physical examination (e.g., Ankle-Brachial Index [ABI] of no less than 0.60, toe pressure greater than 30 millimeters of mercury [mmHg]).
- The wound has a skin deficit at least 1.0 square centimeter in size.
- For diabetic foot ulcers, the client’s medical record reflects a diagnosis of Type 1 or Type 2 diabetes.
- Partial or full thickness ulcers must have a clean granular base without tendon and or muscle involvement, bone exposure, or sinus tracts.
- Documentation of the wound’s response to the treatment is required at least every 30 days for each treatment episode. The documentation requirements must include measurements of the initial wound, measurements at the completion of appropriate wound care every 30 days, and measurements immediately prior to placement and with each subsequent placement of the skin substitute.
Services That are Not a Benefit
The following services will not be a benefit of Texas Medicaid:
- Separately billed, repeated use of a skin substitute product after 12 weeks for a single wound or episode
- Skin substitute grafting for partial thickness loss with the retention of epithelial appendages is not covered, as epithelium will repopulate the deficit from the appendages, negating the benefit of over grafting
For more information, call the TMHP Contact Center at 800-925-9126.