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Specialized Wound Treatment Technology
Revised: 07-26-2013
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Overview
Eligible Providers
Covered Services
Noncovered Services
Eligible Recipients
Authorization
Billing
Overview
Specialized wound treatment technology is used to treat non-healing wounds.
Eligible Providers
The following providers may provide specialized wound treatment technology and related supplies:
 Federally Qualified Health Center
 Home health agencies
 Hospitals
 Indian Health Services
 Medical suppliers
 Pharmacies
 Rural Health Clinic
TPL and Medicare
Providers must meet any provider criteria, including accreditation, for third party insurance (TPL) or for
Medicare in order to assist recipients for whom MHCP is not the primary payer.
MHCP quantity limits and thresholds apply to all recipients unless only Medicare co-insurance or
deductible is requested.
Eligible Recipients
Specialized wound treatment technology may be medically necessary for eligible MHCP recipients with
wounds that have not responded to standard wound treatment for at least a 30 – 60 day period. Negative
Pressure Wound Therapy (NPWT) may be medically necessary for eligible MHCP recipients with wounds
of less than 30 days duration if the patient is inpatient and preparing for discharge.
Covered Services
Codes: These are not all-inclusive codes:
E2402, A6550, A6551, K0743, K0744, K0745: Negative Pressure Wound Therapy
E1399, A4649: Platelet rich plasma systems (i.e., AutoloGel, Magellan)
The platelet rich plasma centrifuge is not covered in long term care facilities. Device-specific supplies (i.e.,
applicators, reagents) may be covered in long term care facilities.
Authorization
Authorization is always required for Negative Pressure Wound Therapy devices and coverage may be
approved in 3 month intervals. If there is no significant improvement to the wound at the 3-month interval,
additional authorization will be denied; and other treatments must be tried. If there is improvement to the
wound at the 3-month interval, an additional 3 months may be authorized. Authorization is required for
platelet rich plasma treatment kits / component kits if the submitted charge is over $400.
Submit authorization request and required documentation to the Authorization Medical Review Agent.
Criteria for Specialized Wound Treatment for Chronic Wounds
Authorization for specialized wound therapy for chronic wounds will be considered when a wound does
not respond to standard wound treatment for at least a 30 day period. Complete the Specialized Wound
Therapy Authorization Form (DHS-4045) with a physician's order and submit.
Documentation for Authorization Requests
For all wounds, document and include the following in a comprehensive treatment plan before
requesting authorization for a specialized wound therapy product:
 Wound type, including:
 Etiology and stage when appropriate
 Date of onset
 Evaluation
 Previous wound care and assessments done by a licensed medical professional (every 30 days
by MD, PA, DO, NP is strongly recommended)
 Weekly wound measurements to assess the appropriateness of current wound treatment. If no
improvement to the wound, the wound treatment must be changed. This must be done by nursing
staff in the skilled facility or by a licensed medical professional in the home setting
 Application of dressings to maintain a continuously moist wound environment must have been tried
prior to requesting a specialized wound therapy product (gel dressings)
 Impregnated dressings have been tried when applicable (e.g., sodium, antimicrobial, collagen
petroleum)
 Debridement of necrotic tissue - mechanical, surgical/chemical
 Evaluation and provision for adequate nutritional status. If the recipient has nutritional deficits, enteral
nutritional support may be covered. Refer to Enteral Nutritional Products policy.
 Moisture and incontinence have been addressed and appropriately managed
 Compliance issues are addressed (i.e., missed medical appointments, refusing dressing changes,
repositioning, smoking, poor nutritional intake or choices)
 Medical intervention/correction of underlying conditions that may hinder the healing process of the
wound (i.e., local or distant infections are addressed)
 Assessment of medications that may delay healing (i.e. systemic steroids, immunosuppressive drugs)
 Evaluation of arterial sufficiency when appropriate
 Licensed professional (RN, LPN, PT) services in place for treatment in the home
 Document how this request is appropriate for the type of wound being treated
For pressure ulcers, also document the following:
 Recipient is appropriately turned and positioned
 Appropriate pressure management surface is in place while in bed/wheelchair
For diabetic neuropathic ulcers, also document the following:
 Appropriate offloading is in place. Appropriate offloading may include crutches, walkers, wheelchairs,
custom shoes, depth shoes, shoe modifications, custom inserts, custom relief orthotic walkers,
diabetic boots, forefoot and heel relief shoes, or total contact casts
 Blood glucose levels are monitored and managed
For venous ulcers: also document that appropriate compression is in place
Respond to the following:
Are any of the following contraindications present for the negative pressure wound therapy:
 Untreated osteomyelitis within the vicinity of the wound
 Presence in the wound of necrotic tissue with eschar, if debridement has not been attempted
 Cancer present in the wound
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Presence of a fistula to an organ or body cavity within the vicinity of the wound
Are any of the following contraindications present for AutoloGel System:
 Active cancer at wound site
 Chemotherapy within the past 5 years
 Hematological disorder
 Bleeding disorder
 Perfusion to extremity of wound
 Untreated osteomyelitis at wound site
 Recipient being treated with Methotrexate
 Allergy to beef or dairy
Included with AutoloGel Therapy System: Each authorized unit includes the AutoloGel MultiPack
Component Kit and the necessary reagents for one treatment. A maximum of 8 units will be approved per
month. The centrifuge is not separately authorized in home care; it must be billed on a separate claim,
with the PA number in the notes field.
Criteria for Specialized Wound Treatment for Non-chronic Wounds
Authorization for specialized wound therapy for non-chronic wounds will be considered when a recipient
is inpatient and planning for discharge with a wound that is less than 30 days old and is determined to be
at risk for delayed healing, infection or other negative outcomes or when there is documentation of
medical necessity for accelerated formation of granulation tissue. Complete the Specialized Wound
Therapy Authorization Form (DHS-4045) with a physician's order and submit.
Documentation for Authorization Requests
For all wounds, document and include the following in a comprehensive treatment plan before
requesting authorization for a specialized wound therapy product:
 Wound type, including:
 Etiology and stage when appropriate
 Date of onset
 Evaluation
 Previous wound care and assessments done by a licensed medical professional (every 30 days
by MD, PA, DO, NP is strongly recommended)
 Medical intervention/correction of underlying conditions that may hinder the healing process of the
wound (i.e., local or distant infections are addressed)
 Assessment of medications that may delay healing (i.e. systemic steroids, immunosuppressive drugs)
 Evaluation of arterial sufficiency when appropriate
 Specific medical factors that inform the determination that the recipient is at risk of delayed healing,
infection or other negative outcomes or that there is medical necessity for accelerated formation of
granulation tissue.
 Discharge plan including all of the following:
 Plan for weekly wound measurements to assess the appropriateness of current wound treatment.
If no improvement to the wound, the wound treatment must be changed. This must be done by
nursing staff in the skilled facility or by licensed medical professionals in the home setting
 Evaluation and provision for adequate nutritional status. If the recipient has a nutritional deficit,
enteral nutritional support may be covered. Refer to Enteral Nutritional Products policy.
 Moisture and incontinence have been addressed and a plan for appropriate management is in
place
 Compliance issues are addressed (i.e., missed medical appointments, refusing dressing
changes, repositioning, smoking, poor nutritional intake or choices)
 Appropriate medical services (RN, LPN, PT) are arranged for care in a licensed facility or home
For pressure ulcers, also document the discharge plan for the following:
 Recipient will be appropriately turned and positioned
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Appropriate pressure management surface will be in place while in bed/wheelchair
For diabetic neuropathic ulcers, also document discharge plan for the following:
 Appropriate offloading will be in place. Appropriate offloading may include crutches, walkers,
wheelchairs, custom shoes, depth shoes, shoe modifications, custom inserts, custom relief orthotic
walkers, diabetic boots, forefoot and heel relief shoes, or total contact casts
 Blood glucose levels will be monitored and managed
For venous ulcers: also document the discharge plan for appropriate compression
Respond to the following:
Are any of the following contraindications present for the negative pressure wound therapy:
 Untreated osteomyelitis within the vicinity of the wound
 Presence in the wound of necrotic tissue with eschar, if debridement has not been attempted
 Cancer present in the wound
 Presence of a fistula to an organ or body cavity within the vicinity of the wound
Noncovered Services
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Electrical stimulation using low-intensity direct current, high voltage pulsed current, alternative
current, and transcutaneous electrical stimulation for the treatment of wounds is considered
investigative due to a lack of evidence demonstrating its impact on improved health outcomes
Electrical stimulation for the treatment of wounds performed by the patient in the home setting is
considered investigative due to a lack of evidence demonstrating its impact on improved health
outcomes
Electromagnetic therapy for the treatment of wounds is considered investigative due to a lack of
evidence demonstrating its impact on improved health outcomes
Non-contact ultrasound treatment for wounds is considered investigative due to a lack of evidence
demonstrating its impact on improved health outcomes
Topical hyperbaric oxygen for the treatment of wounds is considered investigative due to a lack of
evidence demonstrating its impact on improved health outcomes
Electrochemical low-dose tissue oxygenation systems are considered investigative due to a lack of
evidence demonstrating impact on improved health outcomes
Documentation when Authorization is not Required
Providers must maintain documentation
 Wound type, including:
 Etiology and stage when appropriate
 Date of onset
 Evaluation
 Previous wound care and assessments done by a licensed medical professional (every 30 days
by MD, PA, DO, NP is strongly recommended)
 Weekly wound measurements to assess the appropriateness of current wound treatment. If no
improvement to the wound, the wound treatment must be changed. This must be done by nursing
staff in the long term care facility
Billing
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Use MN–ITS 837P Professional
Report the ordering provider in the Other Provider Types section of MN–ITS Direct Data Entry (DDE)
claims or X12 Batch billing refer to the Minnesota Uniform Companion Guides
For rental, one unit = one month rental
Negative Pressure Wound Care Devices, suction pumps and platelet rich plasma centrifuges are
capped rental items. After 13 months rental, the equipment is considered purchased and no further
rental payments will be made.
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If the recipient has Medicare, MHCP will pay the deductible/co-insurance on any units for which
Medicare made payment. Any units for which Medicare denies payment must meet MHCP
authorization, quantity and coverage limits
Shipping costs are included in the MHCP maximum allowable payment and may not be separately
billed to MHCP or the recipient