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PG0241 Dressings and Wound Care

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PG0241 Dressings and Wound Care Dressings and Wound Care Supplies Policy Number: PG0241 ADVANTAGE | ELITE | HMO Last Review: 09/14/2021 INDIVIDUAL MARKETPLACE | PROMEDICA MEDICARE PLAN | PPO GUIDELINES This policy does not certify benefits or authorization of benefits, which is designated by each individual policyholder terms, conditions, exclusions and limitations contract. It does not constitute a contract or guarantee regarding coverage or reimbursement/payment. Self-Insured group specific policy will supersede this general policy when group supplementary plan document or individual plan decision directs otherwise. Paramount applies coding edits to all medical claims through coding logic software to evaluate the accuracy and adherence to accepted national standards. This medical policy is solely for guiding medical necessity and explaining correct procedure reporting used to assist in making coverage decisions and administering benefits. SCOPE X Professional _ Facility DESCRIPTION Dressing and Wound Care Supplies are used to assist in the healing of a wound and has the challenge of protecting the site from additional infection, drainage of exudate, encouragement of new tissue growth, and to prevent further tissue damage. The Dressing and Wound Care Supplies are often chosen by a wound care specialist/medical provider after an examination and evaluation of the wound. It must be determined how often a dressing must be changed and the correct type of dressing to be applied for optimal healing. The documentation must be maintained throughout the entire care of the wound. Size, drainage, color, healing, new tissue growth, smell, dressing type, and other related wound information must all be noted with each dressing change. A surgical dressing is a therapeutic or protective covering applied to a wound. A surgical wound is identified as a wound caused by or treated by a surgical procedure or a debrided wound, regardless of the debridement technique. Lymphatic Exudate Drainage results from tissue damage caused by mechanical insufficiency (e.g., obstruction) or low-volume insufficiency of the lymphatic system (e.g., low oncotic pressure). Lymphedema refers to swelling that generally occurs in an extremity as a result of obstruction or accumulation of lymphatic fluid. Although lymphedema tends to affect just one arm or leg, depending upon the location of the blockage or disruption to lymphatic fluid flow, both limbs may be affected. It can also extend into the trunk. Surgical dressings are divided into two types, primary and secondary. Primary dressings are therapeutic or protective coverings that are applied directly to wounds or lesions on the skin. Secondary dressings are materials that serve a therapeutic or protective function and that are needed to secure a primary dressing. Examples of secondary dressings include tape, roll gauze bandages, and disposable compression material. The staging of pressure ulcers used in this policy is as follows (National Pressure Ulcer Advisory Panel, 2016 Revision): Stage 1 Pressure Injury: Non-blanchable erythema of intact skin 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. Color changes do not include purple or maroon discoloration; these may indicate PG0241 – 09/14/2021 deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis 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 not 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: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) 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: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), 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: Obscured full-thickness skin and tissue loss 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: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non- intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or 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. POLICY HMO, PPO, Individual Marketplace, Elite/ProMedica Medicare Plan Non-Institutional-Professional The following dressings and wound care supplies do not require prior authorization but are subject to coverage as listed below. A4450, A4452, A6010, A6011, A6021, A6022, A6023, A6024, A6154, A6196, A6197, A6198, A6199, A6203, A6204, A6205, A6206, A6207, A6208, A6209, A6210, A6211, A6212, A6213, A6214, A6215, A6216, A6217, A6218, A6219, A6220, A6221, A6223, A6224, A6231, A6232, A6233, A6234, A6235, A6236, A6237, A6238, A6239, A6240, A6241, A6242, A6243, A6244, A6245, A6246, A6247, A6248, A6251, A6252, A6253, A6254, A6255, A6256, A6257, A6258, A6259, A6261, A6262, A6266, A6402, A6403, A6404, A6407, A6441, A6442, A6443, A6444, A6445, A6446, A6447, A6448, A6449, A6450, A6451, A6452, A6453, A6454, A6455, A6456, A6457, A6501, A6502, A6503, A6504, A6505, A6506, A6507, A6508, A6509, A6510, A6511, A6512, A6513 The following are non-covered dressings and wound care supplies. PG0241 – 09/14/2021 A4461, A4463, A4465, A6000, A6025, A6228, A6229, A6230, A6250, A6260, A6413 Advantage Non-Institutional-Professional The following dressings and wound care supplies do not require prior authorization but are subject to coverage as listed below. A4450, A4452, A6010, A6011, A6021, A6022, A6023, A6154, A6196, A6197, A6198, A6199, A6203, A6204, A6205, A6206, A6207, A6208, A6209, A6210, A6211, A6212, A6213, A6214, A6215, A6216, A6217, A6218, A6219, A6220, A6221, A6223, A6224, A6231, A6232, A6233, A6234, A6235, A6236, A6237, A6238, A6239, A6240, A6241, A6242, A6243, A6244, A6245, A6246, A6247, A6248, A6251, A6252, A6253, A6254, A6255, A6256, A6257, A6258, A6259, A6261, A6262, A6266, A6402, A6403, A6404, A6441, A6442, A6443, A6444, A6445, A6446, A6447, A6448, A6449, A6450, A6451, A6452, A6453, A6454, A6455, A6501, A6502, A6503, A6504, A6505, A6506, A6507, A6508, A6509, A6510, A6511, A6512, A6513 The following are non-covered dressings and wound care supplies. A4461, A4463, A4465, A6000, A6024, A6025, A6228, A6229, A6230, A6250, A6260, A6407, A6413, A6456, A6457 COVERAGE CRITERIA HMO, PPO, Individual Marketplace, Elite/ProMedica Medicare Plan, Advantage Surgical Dressing and Wound Care Supplies are covered when a qualifying wound is present. A qualifying wound is defined as either of the following: A wound caused by, or treated by, a surgical procedure; or, A wound that requires debridement, regardless of the debridement technique; or Lymphatic Exudate Drainage resulting from tissue damage caused by mechanical insufficiency (e.g., obstruction) or low-volume insufficiency of the lymphatic system (e.g., low oncotic pressure) The surgical procedure or debridement must be performed by a physician or other healthcare professional to the extent permissible under State law. Debridement of a wound may be any type of debridement (examples given are not all-inclusive): Surgical (e.g., sharp instrument or laser) Mechanical (e.g., irrigation or wet-to-dry dressings) Chemical (e.g., topical application of enzymes) Autolytic (e.g., application
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