WPS Issues New Wound Care LCD
Ambiguity and Confusion
In this month’s updates of the Medicare Administrative Contractors’ (MACs) Local Coverage Decisions (LCDs) and Coverage Articles, Wisconsin Physician Services (WPS), the MAC for Jurisdictions 5 and 8, replaced a retired LCD for Wound Care with a new one. The increasing numbers of Americans with diabetes, pre-diabetes, and obesity contributes to more and more people dealing with chronic wounds. Because of these factors and the aging of the baby-boomer generation, Medicare spending on wound care services continues to rise. Most MACs have an LCD and/or article related to wound care and debridement services.
|Wound Care/Debridement Policies|
|Policy ID #||LCD Title||MAC||Jurisdiction|
|A53001||Wound Care||Novitas Solutions, Inc.||JH/JL|
|A53296||Wound Care & Debridement – Provided by a Therapist, Physician, NPP or as Incident-to Services||Noridian Healthcare Solutions, LLC||JE|
|A52765||Wound Care & Dressing Changes||Noridian Healthcare Solutions, LLC||JF|
|A53046||Wound Care and Debridement - Provided by a Therapist, Physician, NPP, or as Incident-to Services||Noridian Healthcare Solutions, LLC||JF|
|A55909||Wound Care Coding Companion for Wound Care L37228||Wisconsin Physicians Service Insurance Corporation||J5/J8|
|A55818||Wound Care Coding Guidelines||First Coast Service Options, Inc.||JN|
|L37166||Wound Care||First Coast Service Options, Inc.||JN|
|L35125||Wound Care||Novitas Solutions, Inc.||JH/JL|
|L37228||Wound Care||Wisconsin Physicians Service Insurance Corporation||J5/J8|
|L34032||Debridement Services||CGS Administrators, LLC||J15|
|L33614||Debridement Services||National Government Services, Inc.||JK/J6|
I can only imagine how difficult it would be to write an LCD. The goal is to define the requirements for Medicare coverage and there are providers jumping to argue each and every point. However, I was disappointed in some of the ambiguity in the new WPS Wound Care LCD. Some discussions in the LCD were confusing and left uncertainty as to whether particular services were covered or not. Specifically, the following issues appear unclear:
- The LCD included clarification that wet-to-moist dressings, used to keep the wound moist and remove drainage and necrotic tissue from wounds, are different and distinct from dry-to-dry dressings and wet-to-dry dressings that are not considered wound debridement services. I did not think it was apparent however, as to whether wet-to-moist dressings are separately billable and covered as non-selective debridement. CPT 97602 (non-selective debridement) is listed in the Group 1 codes in the accompanying Wound Care Article but, are not listed in the list of Group 1 codes in the covered ICD-10 Covered Diagnosis Codes section.
- There is a perplexing discussion of the use of Evaluation and Management (E/M) codes in conjunction with debridements. The LCD states that wound care patients often have underlying medical conditions that may require concomitant management and also may require education, other services, and coordination of care. An E/M service on the same day as a debridement service should not be billed to Medicare unless it is a “separately identifiable service” distinct from the debridement service. The paragraph does not plainly address when management of other conditions in addition to debridement would be separately billable with an E/M code.
- The latest revision to the Hyperbaric Oxygen National Coverage Determination (NCD) removed the section related to Topical Oxygen Therapy and now allows coverage determination to be made by the local MACs. It is uncertain whether WPS is allowing coverage of topical oxygen therapy or not – they provide study evidence that generally concludes topical oxygen can have a great effect on healing but never specifically state they will cover the service.
- Commenters requested addition of diabetic foot ulcers as a type of ulcer for which debridement would be appropriate. WPS added neuroischaemic ulcers as one of the conditions for debridement. Their response was, “The draft does list the wound type categories of neuropathy or ischaemia. We agree that not all diabetic foot ulcers are neuropathic ulcers and therefore Neuroischaemia has been added to the LCD. Neuroischaemia is the term for the combined effect of diabetic neuropathy and ischaemia.” Does this address all diabetic foot ulcers that might require debridement or not?
Other components of the new LCD that are modified or expanded from the retired LCD:
- Change in the description concerning the expectation of improvement:
- Retired LCD: “Medicare expects that with appropriate care, wound volume or surface dimension should decrease by at least 10% per month or wounds will demonstrate margin advancement of no less than 1 mm/week.”
- New LCD: “Wounds that fail to demonstrate measurable reduction in size at 2 to 4 weeks despite appropriate therapy are unlikely to heal.”
- This change was in response to comments on the draft LCD received by WPS, specifically: “The rate of closure varies significantly by patient and is influenced by a number of factors including but not limited to the type and size of wound, comorbidities, and compliance with prescribed therapy.”
- Both LCDs stress that when appropriate healing is not achieved, the treatment plan should be modified.
- Addition of the following – removal of non-tissue integrated fibrin exudate, crusts, biofilms, or other materials from a wound without removal of tissue does not meet the definition of any debridement codes and may not be reported as such.
- Expanded discussions of
- Electrical Stimulation and Electromagnetic Therapy – covered only after appropriate standard wound therapy has been tried for at least 30 days and there are no measurable signs of improved healing,
- Negative Pressure Wound Therapy – for open wounds resistant to prior treatments and not to exceed a 120-day period, and
- Low-Frequency, Non-contact, Non-thermal Ultrasound (MIST Therapy) – documented wound improvement after 6 MIST treatments or further treatments are not necessary and limited to no more than 18 treatments in a six-week period.
Remember when providing wound care services, the documentation requirements of most LCDs insist on a plan of care. Here is the wording from the new WPS LCD:
“The medical record must include a certified plan of care containing a treatment plan with goals, physician follow-up, the expected frequency and duration of the skilled treatment, and the potential to heal. With continuation of a treatment plan, there needs to be ongoing evidence of the effectiveness of the plan, including diminishing area and depth of the ulceration, resolution of surrounding erythema and /or wound exudates, decreasing symptomatology, and overall assessment of wound status (such as stable, improved, worsening, etc.) documented. Appropriate modification of treatment plan, when necessitated by failure of wounds to improve, must be demonstrated. The record must document complicating factors for wound healing as well as measures taken to control complicating factors when debridement is part of the plan.”
Wound care providers need to be familiar with the LCD and/or article for their MAC jurisdiction. Read them carefully and make sure you are following the coverage guidelines and documenting the required components. If there is ambiguity in the policies, reach out to your MAC for clarification.
Other LCD/Article Updates from last month include:
Article by Debbie Rubio
This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.