Editor’s note: The following is not meant to be an all-inclusive guide to reimbursement. Please seek additional information from your coding or billing department or from a reimbursement specialist. Further, information herein is provided as of October 2021. If accessing this information past this date, please confirm continued validity of the information.

Introduction

Advanced therapeutic devices in wound care can be among your greatest tools for encouraging wound closure. However, it can be disappointing when you may have an advanced modality in mind, but it is denied by the patient’s insurance plan. Or it is simply too expensive to have the patient pay out of pocket. One type of healing device that has a tremendous positive impact on wound healing is negative pressure wound therapy (NPWT). If it is not reimbursed properly, however, the patient may be looking at a shocking expense of thousands of dollars. What’s a wound care clinician to do? Having a few knowledge tools in your pocket may help you to navigate some of the complexities of ordering an NPWT system.

• Know your rep: Most of the major vendors of NPWT have representatives who may be able to offer assistance in ordering.
• Streamline the process: Having a pre-filled form can help streamline the ordering process and minimize confusion or denial of therapy. There are many examples of NPWT authorization forms online, but you should work with your vendor about which specific form to use. These forms often include all pertinent information that will be needed to approve NPWT. This ensures that nothing is missed in the ordering process and keeps everything as simple as possible. Many of these forms can be found in either paper or electronic versions.
• These forms may include:
  • Patient demographics
  • Description of the wound: This may include the type of wound, location, measurements, characteristics of the wound bed or periwound, and other related treatment(s) or comorbidities.
  • Ordering instructions: This will often include types of dressings to use, frequency of use, estimated length of therapy, application instructions, and changing frequency, as well as indications for discontinuing the therapy.
• Determine whether your patient meets medical criteria and has had a trial of conventional wound care. This will be discussed in greater detail in the next section, but most insurance companies will require the wound duration to be greater than 30 days, and documentation of conventional wound treatment should be demonstrated.

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Preventing Denials

According to the Centers for Medicare & Medicaid Services (CMS),¹ in 2020, the most common reasons for denial of an NPWT were insufficient documentation (48%), other errors (46%), no documentation (2.7%), and medical necessity (2.7%). This shows how important it is to ensure a streamlined approach when it comes to documentation and why having an NPWT standard written order (SWO) can be helpful. To prevent denials, make sure that the SWO you use includes:

• Patient name and demographics (with specific diagnosis code)
• Order date
• General description of the medical device needed
• Quantity of device(s) needed and all components of equipment or supplies needed (list separately)
• Treating practitioner’s name and National Provider Identifier (NPI)
• Treating practitioner’s signature

In addition to this, most insurance companies will require certain criteria before approving the device, depending on the wound type. For example, patients with stage 3 or 4 pressure injuries, neuropathic ulcers, vascular ulcers, or other chronic ulcers will often need to show that more conservative wound care methods have been attempted before the NPWT will be approved. Depending on the specific ulcer, this may include:

• Management of underlying disease states (diabetic glucose control, vascularization of arterial wounds, compression of venous ulcers, reduction of pressure)
• Documentation of evaluation, treatment, and wound measurements
• Type(s) of dressings used
• Debridement of any necrotic tissue
• Evaluation and treatment of other comorbidities (assessing for adequate nutrition, checking for infection, etc.)

Surgical or traumatic wounds may be treated with NPWT in the inpatient setting, provided that there’s clear documentation of medical necessity. In short, provide written documentation that the NPWT device will achieve accelerated formation of granulation tissue that cannot be achieved by other topical wound therapies.
Once the treatment is approved and the therapy starts, ensure that regular updates are sent as indicated by your specific vendor and/or the patient’s insurance information. This may include updated wound measurements and regular comparison of wound size or character and quality of tissue.

Coding Tips

Let’s say your documentation is perfect. You’ve included all the necessary information and have streamlined your ordering process. However, despite this, you are still running into trouble with denials for coding problems. Entering the correct Current Procedural Terminology (CPT) code can demonstrate the specific medical service or procedure that is performed by a qualified health care professional.² Submitting the proper CPT code when preforming for NPWT services, the following CPT codes should be considered^2-4:

• 97605: NPWT ≤50 cm²; used when an electrical NPWT is the only therapy being performed
• 97606: NPWT >50 scm²; used when an electrical NPWT is the only therapy being performed
• 97607: NPWT ≤50 cm²; used for disposable NPWT; a mechanically powered NPWT is the only therapy being performed
• 97608: NPWT >50 cm²; used for disposable NPWT; a mechanically powered NPWT is the only therapy being performed (placing the NPWT on the open wound)
• 97697: NPWT ≤50 cm² care application of therapy in the home care setting
• 97698: NPWT >50 cm² care application of therapy in the home care setting

If an NPWT device is placed during a surgery, the charge will be considered part of the surgery and not billed as a separate code. All of the foregoing codes include ongoing therapy for an active and open wound.

Now that you have an idea of some CPT codes to use, let’s throw another type of code out there: the Healthcare Common Procedure Coding System (HCPCS).⁵ This is a code that is based on the CPT code used. Many major insurance companies require the HCPCS code because it is used to describe specific product or device that is being used. This coding can further differentiate any services, equipment, or procedures that aren’t covered by CPT codes⁶ and may be helpful to know. Some HCPCS codes that are associated with NPWT are:

• A6550: electrical NPWT; includes all supplies and accessories
• E2402: electrical NPWT pump, stationary or portable
• G0456: NPWT ≤50s cm²; mechanically powered device; includes cartridge, dressing, application, wound assessment, and instructions for care
• G0457: NPWT >50 cm²; mechanically powered device; includes cartridge, dressing, application, wound assessment, and instructions for care

Conclusion

Reimbursement can be a confusing world when it comes to obtaining a much-needed medical device for your patient. NPWT is an important healing modality and can be a great treatment for wounds that are having trouble healing. Understanding how to successfully navigate the required elements of ordering an NPWT device can lead you to a headache-free experience.

References

1. Medicare Learning Network. Provider compliance tips for negative pressure wound therapy. February 2021. Accessed September 27, 2021. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-ML…
2. Dotson P. CPT® codes: what are they, why are they necessary, and how are they developed?. Adv Wound Care (New Rochelle). 2013;2(10):583-587. https://doi.org/10.1089/wound.2013.0483
3. Grider D. Wound care coding. Society of Critical Care Medicine; 2018. Accessed September 27, 2021. https://www.sccm.org/Communications/Critical-Connections/Archives/2018/…
4. Medicare Learning Network. Clarification of billing and payment policies for negative pressure wound therapy (NPWT) using a disposable device. June 2019. Accessed September 27, 2021. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-ML…
5. Healthcare Common Procedure Coding System (HCPCS). HCPCS code A6550. HCPCS.codes; 2021. Accessed September 27, 2021. https://hcpcs.codes/a-codes/A6550/
6. Healthcare Common Procedure Coding System (HCPCS). Search HCPCS codes. HCPCS.codes; 2021. Accessed September 27, 2021. https://hcpcs.codes/search/?q=negative+pressure

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.