ATTENTION DME EQUALITYCARE PROVIDERS

Transcription

1 EqualityCare News March 2008 ATTENTION DME EQUALITYCARE PROVIDERS This bulletin contains DME policy changes for the following: Continuous Glucose Monitoring Systems Non Invasive Osteogenesis Stimulators Wound Vacuum-Assisted Closure System DME Bulletin Wyoming EqualityCare will be implementing changes to the DME policy effective immediately for the following: CONTINUOUS GLUCOSE MONITORING SYSTEMS As of January 1, 2008 Medicare assigned permanent HCPCS Codes for Continuous Glucose Monitoring Systems; the permanent codes are A9276, A9277, and A9278. Currently, Medicare does not cover services associated with these codes. Based upon recent interest in the use of A9276, A9277, and A9278, Wyoming EqualityCare has reviewed the available literature and data associated with Continuous Glucose Monitoring Systems and determined that, like Medicare, Wyoming EqualityCare will not cover A9276, A9277, and A9278. NON-INVASIVE OSTEOGENESIS STIMULATORS Wyoming Equality currently covers the rental of Non-Invasive Osteogenesis Stimulators for EqualityCare clients. Effective immediately, EqualityCare will cover the purchase of Non-Invasive Osteogenesis Stimulators for EqualityCare clients. Prior Authorization is still required. The following codes are affected: E0747, E0748 and E0760. Services will be reimbursed for EqualityCare clients if the following documentation is provided: A current physician s written order; A copy of the letter of medical necessity, signed and dated by the treating physician;

2 A detailed record of the item(s) provided to include brand name, model number, quantity and date of delivery; A minimum of two sets of radiographs obtained prior to starting treatment with the osteogenesis stimulator, separated by a minimum of 90 days. Each radiograph must include multiple views of the fracture site accompanied with a written interpretation by a physician stating that there has been no clinically significant evidence of fracture healing between the two sets of radiographs. WOUND VACUUM-ASSISTED CLOSURE SYSTEM Procedure Code: E2402 Modifier: RR Required for rental Rental: Covered for clients that have ulcers and/or wounds that meet specific criteria. No capped rental. Prior Authorization: Required Equipment/ Supplies: Vacuum assisted closure machine, canisters and dressings. Documentation: 1. Written order; and 2. Written measurement and location of one of the following wound types: Stage III or IV Pressure Ulcers Neuropathic (diabetic) ulcers Venous or arterial insufficiency ulcers Chronic - present for at least 30 days Acute Traumatic Dehisced wounds Flaps, grafts & burns on a case-by-case basis 3. Additional documentation MUST include: Circumstances that lead to wound development as well as detailed description of conservative treatments and alternative methods attempted and why they were deemed inappropriate or ineffective. Current wound labs as well as current nutritional status including any prescribed supplements. Evidence (as pertains to individual client) that client has been appropriately encouraged and/or turned and repositioned while seated or while in bed. Client s turning and/or repositioning schedule as pertains to individual

3 Explanation of client incontinence and how it is appropriately managed. Documentation of debridement of necrotic tissue AND documentation of how much necrosis CURRENTLY in wound bed. Description of any current infection; systemic and/or at wound site AND current treatment(s). For diabetic ulcers: documentation that client has been on a comprehensive diabetic management program, as evidenced by: fingerstick/ other blood glucose results current hemoglobin A1C current diabetic medication regimen For Venous insufficiency ulcers: evidence that the following interventions have been utilized: Compression stockings and/or bandages have been consistently applied. Leg elevation above the level of the heart. Avoidance of extended periods of time in one position; sitting or standing. Ambulation has been encouraged, as appropriate. 4. Written documentation that client does not fall into any of the contraindicated categories listed under Limitations below; and why vacuum assisted closure is appropriate if client does have any of the following precautionary therapy/ symptoms: Clients receiving anticoagulant therapy. Clients experiencing difficult hemostasis following debridment. 5. For continuation beyond one month of therapy, documentation must reflect the following: After eight weeks of therapy - a minimum of a sixty-percent decrease in size and volume of decubitus ulcer. After twelve weeks of therapy - a minimum of a ninety-percent decrease in size and volume of decubitus ulcer. Limitations: 1. Treatment is authorized for no more than one month at a time. 2. If a client falls into any of the following contraindicated categories, a wound vacuum-assisted closure system treatment is NOT appropriate: Fistulas to organs or body cavities. Presence of greater than approximately 20% necrotic tissue in wound bed. Necrotic tissue present & debridement not attempted. Osteomyelitis. Cancer in the wound margins.

4 3. Wound V.A.C. treatment is reimbursable outside of the per diem for client s residing in a nursing facility. If a client is in an acute care setting and must be placed in a nursing facility on a short term basis (three months or less) while the wound heals, the nursing facility will be reimbursed for that period of time, providing all other criteria has been met. For further information regarding this bulletin, please contact ACS Provider Relations at or visit ACS website at

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6 Important Changes! Please read! ACS, Inc P.O. Box 667 Cheyenne, WY PHONE: (800) IN CHEYENNE: (307) FAX: (307) We re on the Web!