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Specialized Wound Care Education Benefit to Be Added for Wound Care Management Services

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

Effective for dates of service on or after June 1, 2025, specialized wound care education will become a benefit of Texas Medicaid when provided by a wound care education services provider.

Specialized Wound Care Education

Education of the client or their caregiver during wound care interventions is a standard of care. Clients or their caregivers should be able to explain why each intervention is being performed for their specific type of wound.

Specialized wound care education with prior authorization may be reimbursed when provided by a wound care services provider.

Specialized wound care education will be limited to the following:

  • Four claims with modifier U1 per wound occurrence in an ambulatory surgical center
  • Two claims with a wound care procedure code submitted with modifier U1 per wound occurrence in an office setting or facility

Each wound occurrence is defined as a three-month rolling time period. Additional prior authorization requests for more than the limitation number of claims submitted for wound occurrence will be considered on a case-by-case basis with documentation of medical necessity. These requests will go to a clinical review for consideration.

Documentation

All wound care service requires documentation of the wound, and a comprehensive treatment plan is required to be maintained in the client’s medical record. Providers will document progress with each client encounter and use the measurable signs of healing to determine the degree of improvement as a result of the specialized wound care services education.

The documentation must include:

  • A record of teaching specific to the knowledge and skills necessary for independent care of the client’s wound provided to the client or their caregiver.
  • An affirmative statement that the client or their caregiver has received the education.

Wound care services providers must document the specialized education covered and the client’s progress in the client’s wound care education treatment plan with each billed encounter using the U1 modifier.

Reimbursement

Specialized wound care education will be limited to four wound care education services per 90 days by the same provider for services rendered in the ambulatory surgical center and may be reimbursed with the following procedure codes with modifier U1:

Procedure Codes
11000110421104311044150021500415040
15050152711527315275152771602016025
16030294452958029581   

Specialized wound care education will be limited to two wound care education services per 90 days by the same provider for services rendered in the office, home, or facility setting and may be reimbursed with the following procedure codes with modifier U1:

Procedure Codes
97597975989760297605976069760797608

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