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Negative Pressure Wound Therapy to Become a Benefit Effective September 1, 2022

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, precertification, 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 September 1, 2022, negative pressure wound therapy (NPWT) procedure codes 97605, 97606, 97607, and 97608 will become benefits of Texas Medicaid.

NPWT may be provided utilizing durable medical equipment (DME) or nondurable medical equipment to treat acute and chronic wounds that include diabetic foot ulcers, venous leg ulcers, pressure ulcer wounds, nonhealing surgical wounds, or nonadhering skin grafts.

NPWT may consist of using a traditional computerized electric vacuum pump or a disposable single-use mechanical device that includes a collection canister and a hydrocolloid dressing with the integrated nozzle and tubing.

NPWT may promote tissue granulation and wound healing by providing a warm, moist wound bed while removing excessive secretions or bacterial material from the wound. NPWT should be considered only when other treatments are not effective.

Reimbursement

The following provider types and places of service may be reimbursed for clients who are 18 years of age or older for procedure codes 97605 and 97606:

Provider Type

Place of Service

Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Physician, Clinic/Group Practice, Podiatrist, Physical Therapist, Occupational Therapist, Comprehensive Care Program, Podiatry Group, and Physical and Occupational Therapy Group

Office

Home Health Agency

Home

Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Physician, Clinic/Group Practice, Podiatrist, Physical Therapist, Occupational Therapist, Podiatry Group, and Physical and Occupational Therapy Group

Outpatient Hospital

Procedure codes 97605 and 97606 include management of the exudate collection system, topical application, wound assessment, and instructions for ongoing care services.

DME and supplies are not included for procedure codes 97605 and 97606 and may be reimbursed separately.

The following provider types and places of service may be reimbursed for clients who are 18 years of age or older for procedure codes 96707 and 96708:

Provider Type

Place of Service

Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Physician, Clinic/Group Practice, Podiatrist, Physical Therapist, Occupational Therapist, Comprehensive Care Program, Podiatry Group, and Physical and Occupational Therapy Group

Office

Home Health Agency

Home

Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Physician, Clinic/Group Practice, Podiatrist, Physical Therapist, Occupational Therapist, Hospital, Rehabilitation Center, Podiatry Group, and Physical and Occupational Therapy Group

Outpatient Hospital

Procedure codes 97607 and 97608 include management of the exudate collection system, topical application, wound assessment, instructions for ongoing care services, and the disposable device.

The disposable device is included with procedure codes 97607 and 97608 and is not separately reimbursed.

Contraindications for NPWT

NWPT is contraindicated for any of the following wound types and conditions:

  • Necrotic tissue with eschar present
  • Untreated osteomyelitis
  • Fistulas
  • Wounds containing malignancy
  • Exposed vasculature, nerves, anastomotic site, or organs
  • Actively bleeding wounds

Initial Prior Authorization

Prior authorization is not required for the initial 90 days of NPWT. A maximum of 36 NPWT treatments will be allowed in any 90-day period per rolling year, which will begin on the first day of the first NPWT treatment.

Prior authorization is required for more than 36 NPWT treatments within or after the initial 90 days and will be considered on a case-by-case basis with documentation of medical necessity. A request submitted to TMHP may be considered for services beyond the initial 90 days for an additional 30-day treatment period. These requests will be reviewed by the medical director.

Claims for procedure codes 97605, 97606, 97607, and 97608 must include the authorization number on the claim at the time of claim submission.

For more information, call the TMHP Contact Center at 800-925-9126.