One goal of the AHRQ report was to characterize the state of the evidence on skin substitutes as wound care products for chronic wounds. In rare cases, the goal of wound care provided in the outpatient setting may only be to prevent the progression of a wound which, due to severe underlying weakness or other factors such as inoperability, is not expected to improve.
WOUND AND BURN CARE HS-216
Electrical Stimulation and Electromagnetic Therapy for Wound Healing
Signs of improvement include decreases in wound size (surface area or volume), the amount of exudates, or the amount of necrotic tissue.
Hyperbaric and Topical Oxygen Wound Therapies
Continuation of HBO therapy is not covered if no measurable signs of healing and a significant reduction in wound size (at least 50% reduction from the original pretreatment size) have been demonstrated during any 30-day period.
Negative Pressure Wound Therapy
Documentation in the member's medical record for evaluation, care and wound measurements by a licensed physician; AND,. The presence of a fistula to an organ or body cavity near the wound; OR. NOTE: If the criteria are NOT met, continued coverage of the NPWT pump and supplies will be denied as NOT medically necessary.
At the discretion of the treating physician, adequate wound healing occurred to the extent that NPWT treatment could be discontinued; OR,. Wound healing is defined as improvement in either surface (length times width) or depth of the wound; OR,. Four months (including the time spent using NPWT in the hospital setting before discharge home) were spent using the NPWT pump in the treatment of the posterior wound; OR,.
Ultrasound Therapy for Wound Healing (Mist Therapy™) 38
There is no documentation of the continued need for debridement, or current wound infection, or complex wounds or dressings. Debridement of the wound(s) if no necrotic, devitalized, fibrotic, or other tissue or foreign body is present that would interfere with wound healing. The timing, frequency, and number of reapplications of CTPs should be appropriate for the material used and the member's clinical condition.
Skin substitutes are contraindicated in members with a known hypersensitivity to any component of the specific skin substitute (e.g., bovine allergy). In diabetic foot ulcers, if satisfactory healing progress is not noted after 9 weeks of treatment and 3 applications of the CTP, reapplication of the CTP is not recommended and other treatment modalities should be considered. Otherwise, re-application of the CTP is not recommended and will not be reimbursed and other treatment modalities should be considered.
Covered Products
The patient must be trained and/or have the support system necessary to participate in the follow-up care associated with wound treatment with Apligraf®. The member must be trained and/or have the support system necessary to participate in the follow-up care associated with the Dermagraft® wound treatment. Re-treatment of the same ulcer with Dermagraft® within one year of the last successful or unsuccessful treatment is not considered medically necessary.
The member must be competent and/or have the necessary support system to participate in the follow-up care associated with wound treatment with GRAFTJACKET® Regenerative Tissue Matrix Repair-Ulcer. Not covered for retreatment of the same ulcer using PriMatrix® after an unsuccessful course of treatment. There is no re-covering of the same ulcer using Theraskin® after an unsuccessful course of treatment.
General Notes
Adequate arterial blood supply as evidenced by an ankle-brachial index (ABI) of 0.65 or greater in the limb undergoing the procedure Full-thickness ulcers at least 3 weeks in duration and extending through the dermis. Adequate arterial blood supply as evidenced by ankle-brachial index (ABI) of 0.65 or higher in the limb undergoing the procedure. For use as a temporary wound dressing for surgically excised full-thickness and partial-thickness thermal burn wounds in persons requiring such a dressing prior to autograft placement; OR.
For the treatment of medium dermal to undetermined depth burn wounds which usually require debridement and which can be expected to heal without autografting. Repeat application within three weeks for the same ulcer (within one week for Apligraf® and TheraSKIN®). All sharp selective debridements (CPT Active Wound Care Codes (CPT 97597 and 97598) and bioengineered wound care products that replace the skin require physician review for duration and
Code Listing
A single application to any given ulcer is usually all that is needed to affect wound healing in those wounds likely to be helped by this therapy (for Apligraf®, GRAFTJACKET® Regenerative Tissue Matrix-Ulcer Repair). Typically, treatment is expected to last no longer than twelve (12) weeks and will include a maximum of five applications (Apligraf®), two applications (GRAFTJACKET® Matrix) or five applications (TheraSKIN®) for any ulcer initially suitable for treatment. Reapplication where the original application did not result in a decrease in size or depth or an increase in granulation tissue, epithelialization, or progress toward constipation.
Re-treatment of a wound after the failed treatment, where it consisted of two failed applications of Sharp Selective Debridements. Documentation for medical review requires description of wound with size (length and width in cm and measured in square centimetres) and description of granulation tissue, exudate and presence of fascia, subcutaneous tissue, muscle and bone. Failure to provide documentation will result in denial due to lack of sufficient medical information to make an appropriate medical necessity determination.
Covered CPT Codes
C5276 Application of an inexpensive skin replacement graft to the face, scalp, eyelids, mouth, neck, ears, eye socket, genitals, hands, feet and/or multiple fingers, total wound area maximum 100 cm2; each additional 25 cm² of wound area, or part thereof (mentioned separately next to the code for the primary procedure). C5273 Application of an inexpensive skin replacement graft to the trunk, arms, legs, with a total wound area greater than or equal to 100 cm²; first 100 cm² wound area, or 1% of the body surface area of infants and children C5274 Application of an inexpensive skin replacement graft to trunk, arms, legs, with a total wound area greater than or. C5278 Application of an inexpensive skin replacement graft to the face, scalp, eyelids, mouth, neck, ears, eye socket, genitals, hands, feet and/or multiple fingers, with a total wound area greater than or equal to 100 cm²; each additional 100 cm² of wound area, or part thereof, or each additional 1% of the body surface area of infants and children, or part thereof (listed separately next to the code for the primary procedure).
29581 Use of multilayer compression system; leg (below knee), including ankle and foot 97014 Use of modality in 1 or more areas; electrical stimulation (unsupervised). 97606 Negative pressure wound therapy (eg, vacuum-assisted drainage collection), including topical application(s), wound assessment, and ongoing care instruction(s), per session; the total area of the wound is greater than 50 square centimeters. G0281 Electrical stimulation, (unsupervised), of one or more sites, for stage iii and iv chronic pressure ulcers, arterial ulcers, diabetic ulcers, and venous static ulcers that show no measurable signs of healing after 30 days of normal.
Non Covered CPT Codes – None listed
Vascular studies include patient care required to perform the studies, monitoring of the studies, and interpretation of study results with patient record copies of paper printouts with analysis of all data, including bidirectional vascular flow or imaging, when provided. The use of a simple handheld or other Doppler device that does not produce paper prints or that produces a record that does not allow analysis of bidirectional vascular flow is considered part of the physical examination of the vascular system and is not separately reported. Ankle-Brachial Index (or ABI) can be reported with 93922 or 93923 as long as simultaneous Doppler recording and analysis of bidirectional blood flow, volume plethysmography, or transcutaneous oxygen tension measurements are also performed.
Covered HCPCS Level II ®*Codes
Covered HCPCS Codes (Products) 38
Q4106 Dermagraft, per centimeter Q4107 Graftjacket, per centimeter Q4110 Primatrix, per centimeter Q4121 Theraskin, per centimeter.
Non-Covered HCPCS Codes (Products)
Non Covered HCPCS Level II ® Code
Covered ICD-9 Procedure Code
Covered ICD-9 CM Volume 1 - Diagnosis Code
873.59 Open wound of other and multiple places of the face, complicated 875.1 Open wound of chest (wall), complicated. 879.7 Open wound of other and unspecified parts of stem, complicated 879.9 Open wound(s) (plural) unspecified site(s), complicated. 880.19 Open wound of various places of shoulder and upper arm, complicated 881.12 Open wound of wrist, complicated.
887.7 Traumatic amputation of arm and hand (complete) (partial), bilateral [any level], complicated 890.1 Open wound of thigh and thigh, complicated. 891.1 Open wound of knee, leg [except thigh] and ankle, complicated 892.1 Open wound of leg, except toe(s) only, complicated.
Covered ICD-9-CM Diagnosis Codes
249.10* Diabetes mellitus secondary with ketoacidosis, not stated as uncontrolled or unspecified 249.11* Diabetes mellitus secondary with ketoacidosis, uncontrolled. 249.20* Diabetes mellitus secondary with hyperosmolarity, not stated as uncontrolled or unspecified 249.21* Diabetes mellitus secondary with hyperosmolarity, uncontrolled. 249.30* Secondary diabetes mellitus with other coma, not stated as uncontrolled or unspecified 249.31* Secondary diabetes mellitus with other coma, uncontrolled.
249.40* Secondary diabetes with renal manifestations, not specified as unregulated or unspecified 249.41* Secondary diabetes with renal manifestations, unspecified. 249.60* Secondary diabetes with neurological manifestations, not specified as uncontrolled or unspecified 249.61* Secondary diabetes with neurological manifestations, uncontrolled. 249.80* Secondary diabetes with other specified manifestations, not specified as unregulated or unspecified 249.81* Secondary diabetes with other specified manifestations, unspecified.
Non-Covered Draft ICD-9-CM Diagnosis Codes
249.00* Secondary diabetes mellitus without indication of complication, not stated as uncontrolled, or unspecified 249.01* Secondary diabetes mellitus without indication of complication, uncontrolled. 249.50* Secondary diabetes mellitus with ophthalmic manifestations, not stated as uncontrolled, or unspecified 249.51* Secondary diabetes mellitus with ophthalmic manifestations, uncontrolled. 249.70* Secondary diabetes mellitus with peripheral circulatory disorders, not stated as uncontrolled, or unspecified 249.71* Secondary diabetes mellitus with peripheral circulatory disorders, uncontrolled.
249.90* Secondary diabetes mellitus with unspecified complication, not listed as uncontrolled, or unspecified. 249.91* Secondary diabetes mellitus with unspecified complication, uncontrolled. 250.60 Diabetes with neurological manifestations, type II or unspecified type, not listed as uncontrolled 250.61 Diabetes with neurological manifestations, type I [juvenile type], not listed as uncontrolled '250.62' Diabetes with neurological manifestations, type II or unspecified type , uncontrolled. 250.80 Diabetes with other specified manifestations, type II or unspecified type, not listed as uncontrolled 250.81 Diabetes with other specified manifestations, type I [juvenile type], not listed as uncontrolled 250.82 Diabetes with other specified manifestations, type II or unspecified type, uncontrolled.
Covered Draft ICD-10-CM Diagnosis Codes
Non-Covered Codes 38
873.59 Open wound of the face, other and several places, complicated 874.9 Open wound of other and unspecified parts of the neck, complicated 875.1 Open wound of the chest (wall), complicated. 876.1 Open wound of the back, complicated 877.1 Open wound of the buttocks, complicated 879.1 Open wound of the breast, complicated. 880.10 Open wound of the shoulder region, complicated 880.11 Open wound of the scapular region, complicated 880.12 Open wound of the axillary region, complicated 880.13 Open wound of the upper arm, complicated.
880.19 Open wound in multiple places of shoulder and upper arm, complicated. 881.10 Open wound of forearm, complicated. 884.1 Multiple and unspecified open wound of upper limb, complicated. 885.1 Traumatic amputation of thumb (complete) (partial), complicated. 894.1 Multiple and unspecified open wound of lower extremity, complicated. 895.1 Traumatic amputation of toe(s) (complete) (partial), complicated.