Note: For the purposes of this article, “advanced practice registered nurse (APRN)” includes nurse practitioner (NP) clinical nurse specialist (CNS) providers only.
Effective for dates of service on or after March 1, 2021, benefits for wound care management services will change for the Children with Special Health Care Needs (CSHCN) Services Program.
Overview of Benefit Changes
Major changes to this medical benefit include the following:
- Definitions for first- and second-line therapies
- Updates for wound debridement services
- Expanded benefit information for skin substitutes
- Updated documentation requirements
- Expanded list of services that are not a benefit of the CSHCN Services Program
Wound Care Therapy
Wound care management includes the care of acute and chronic wounds, including, but not limited to, open ulcers (venous pressure or diabetic ulcers), fistulas, or erosion of skin related to cancer.
Prior authorization is not required for wound care management services.
First-Line Wound Care Therapy
First-line wound care therapy includes the following:
- Cleaning, antibiotics, and pressure off-loading
- Dressings, which may include wet and dry dressings; dressings applied to the wound are considered part of the service for wound debridement
- Whirlpool for burns
Second-Line Wound Care Therapy
Second-line wound care therapy is limited to chronic Stage 3 or 4 wounds and is a benefit only after first-line therapy has been tried for at least 30 days without measurable signs of improved healing. First-line wound care therapy may continue as appropriate, with the addition of second-line wound care measures as indicated by the client’s medical condition. Second-line wound care therapy includes the following:
- Application of metabolically active skin equivalents/skin substitutes
- Pulsatile jet system
Wound debridement procedure codes 11045, 11046, and 11047 will be a benefit in the office, inpatient hospital, and outpatient hospital settings when services are provided by APRN, physician assistant, physician, and dentist providers. Procedure codes 11045, 11046, and 11047 are not appropriate and will not be reimbursed for the following:
- Washing bacteria or fungal debris from the feet
- Paring or cutting of corns or calluses
- Incision and drainage of an abscess
- Trimming or debridement of nails, or avulsion of nail plates
- Acne surgery
- Destruction of warts
- Burn debridement
Procedure code 97602 will be a benefit as follows:
In Place of Service
When Services are Provided by
APRN, physician assistant, physician, podiatrist, physical therapist, and occupational therapist providers
APRN, physician assistant, physician, podiatrist, physical therapist, occupational therapist, and home health agency providers
Outpatient hospital setting
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 CSHCN Services Program-enrolled supervising physician or qualified non-physician provider.
Skin Substitute Grafts
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.
Wound care services that include the use of skin substitutes must be provided in accordance with the FDA-approved package label and applied according to the manufacturer’s instructions for use. 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:
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.
Only the application of FDA-approved products may be considered for reimbursement. The approved skin substitute product(s) must have a published average sales price and be in compliance with FDA assessments. 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
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.
Additional Documentation Requirements
All wound care services require documentation of the wound. A comprehensive treatment plan is also required to be maintained in the client’s medical record.
For all wound care management services, the client’s medical history related to the current wound must also include the wound location.
Documentation maintained in the client’s medical record must support the need for skin substitute applications and the product used.
All wound treatments involving the application of skin substitutes must include, but are not limited to, documentation of 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.
- All wounds must be free of infection, necrotic tissue, or exudate and any underlying conditions that compromise wound healing. The documentation in the client’s record must reflect the conditions have been treated and
- Clients who use tobacco 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.
- 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 the CSHCN Services Program:
- More than 10 applications of skin substitute grafts per episode of wound care in a 12-week period of care per rolling year, which will begin on the first day of the first skin substitute application.
- 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, as epithelium will repopulate the deficit from the appendages, negating the benefit of over grafting.
- Skin substitute products not billed concurrently with procedure code 15271, 15272, 15273, 15274, 15275, 15276, 15277, or 15278 will not be separately reimbursed.
For more information, call the TMHP-CSHCN Services Program Contact Center at 800-568-2413.