Negative Pressure Wound Therapy (NPWT) Pumps/Vacuum Assisted Closure (VAC) of Chronic Wounds

Section: Durable Medical Equipment
Effective Date: July 01, 2018
Revised Date: May 14, 2018
Last Reviewed: July 16, 2019

Description

The purpose of the NPWT device is to promote wound healing. Wound healing is defined as improvement occurring in either surface area or depth of the wound. Lack of improvement of a wound is defined as a lack of progress in quantitative measurements of wound characteristics including wound length and width (surface area), or depth measured serially and documented over a specified time interval. 

Criteria

NPWT pumps/VAC for nonhealing wounds may be considered medically necessary when the following conditions are met: 

Ulcers and Wounds in the Outpatient Setting

  • Chronic, nonhealing stage III or IV pressure ulcer, neuropathic (e.g., diabetic) ulcer, venous or arterial insufficiency ulcer, or chronic ulcer of mixed etiology (i.e., present for at least 30 days); and
  • Wound therapy program, as described below, (applicable to the type of wound) have been tried or considered and ruled out prior to application of NPWT pumps/VAC.
    • All ulcers or wound types (i.e., surgically created, traumatic), must include ALL of the following therapeutic measures addressed, applied, or considered and ruled out prior to application of NPWT pumps/VAC:
      • Documentation in the patient’s medical record of evaluation, care and wound measurements by a licensed medical professional (i.e., physician, PA, CRNP, RN, LPN, RPT); and
      • Application of dressings to maintain a moist wound environment; and
      • Debridement of necrotic tissue if present; and
      • Evaluation of and provision for adequate nutritional status; or
    • Chronic stage III or IV pressure ulcers:
      • The patient has been on an appropriately turned and positioned schedule; and
      • The patient has used a support surface for pressure ulcers on the trunk or pelvis; and
      • The patient’s moisture and incontinence have been appropriately managed; or
    • Neuropathic (e.g., diabetic, ulcers)
      • The patient has been on a comprehensive diabetic management program; and
      • Reduction in pressure on a foot ulcer has been accomplished with appropriate modalities (i.e., saline wet-to-dry dressings; debridement etc.); and
      • Appropriate foot care (i.e., visual inspection, appropriate foot wear, etc.); or
    • Venous or arterial insufficiency ulcers:
      • Compression bandages and/or garments have been consistently applied; and
      • Leg elevation and ambulation have been encouraged; or
    • Surgically created wound or traumatic wound:
      • The wound requires accelerated formation of granulation tissue that cannot be achieved by other available topical wound treatments (e.g., comorbidities that prevent healing); and
      • Results of previous wound treatments are documented.

Ulcers and Wounds Encountered in an Inpatient Setting

  • NPWT pumps/VAC may be considered medically necessary when continuation of treatment is ordered beyond discharge to the home setting.
  • An ulcer or wound is encountered in the inpatient setting and after wound treatments have been tried or considered and ruled out, NPWT pumps/VAC is initiated because it is considered, in the judgment of the treating physician, the best available treatment option.
  • Complications of a surgically created wound (e.g., dehiscence, post-sternotomy disunion with exposed sternal bone, etc.) or traumatic wound, (e.g., preoperative flap or graft, exposed bones), where there is documentation of the medical necessity for accelerated formation of granulation tissue which cannot be achieved by other available topical wound treatments (e.g., other conditions that will not allow for healing times achievable with other topical wound treatments).

If the above criteria are not met for the use of NPWT pumps/VAC systems in either setting, the pump and supplies will be considered not medically necessary.

NPWT pumps/VAC systems and their supplies used in the treatment of children from birth up to and including 12 years of age are considered experimental/investigational and, therefore, non-covered. According to the U.S. Food and Drug Administration (FDA), the safety and effectiveness of NPWT pumps/VAC systems in newborns, infants and children (greater than or equal to 12 years of age) has not been established at this time. Currently there are no NPWT pumps/VAC systems cleared for use in these populations.

Procedure Codes

97605 97606 97607 97608 A6550 A7000 E2402
K0743 K0744 K0745 K0746

Supplies

Supplies for NPWT pumps/VAC are limited to the following. Requests for amounts greater than the stated limits will be denied as not medically necessary.

  • Fifteen (15) dressing kits per wound per month – Additional dressing kits per month must be supported by documentation that the wound size requires more than one dressing kit for each dressing change.
  • Ten (10) canister sets per month – Additional canister sets per month must be supported by documentation that a large volume of drainage (greater than 90 ml of exudate per day) requires more than one canister set.

Procedure Codes

A6550 A7000 K0743 K0744 K0745 K0746

The NPWT pumps/VAC must be prescribed by a physician and be capable of accommodating more than one (1) wound dressing set for multiple wounds on a individual. Therefore, more than one (1) pump billed per individual for the same time period will be considered not medically necessary.

Procedure Codes

E2402

The pump and supplies will be considered not medically necessary with ANY of the following, whichever occurs first:

  • Adequate wound healing has occurred to the degree that NPWT pumps/VAC may be discontinued, in the judgment of the treating physician; or
  • Any measurable degree of wound healing has failed to occur over the prior month as documented in the individual’s records; or
  • Four (4) months (including the time NPWT was applied in an inpatient setting prior to discharge to the home) have elapsed using an NPWT pumps/VAC device in the treatment of any wound.

Coverage beyond four (4) months will be given individual consideration based upon additional documentation.

This additional documentation must address the initial condition of the wound including measurements, efforts to address all aspects of wound care, subsequent monthly wound measurements, and what changes in wound therapy are being applied to effect wound healing. This information must be updated with each subsequent request for additional months of use of NPWT pumps/VAC.

Procedure Codes

97605 97606 97607 97608 A6550 A7000 E2402
K0743 K0744 K0745 K0746

Diagnosis Codes

For Stage III and IV Pressure Ulcers

L89.003  L89.004  L89.013  L89.014  L89.023  L89.024  L89.103 
L89.104  L89.113  L89.114  L89.123  L89.124  L89.133  L89.134 
L89.143  L89.144  L89.153  L89.154  L89.203  L89.204  L89.213 
L89.214  L89.223  L89.224  L89.303  L89.304  L89.313  L89.314 
L89.323  L89.324  L89.43  L89.44  L89.503  L89.504  L89.513 
L89.514  L89.523  L89.524  L89.603  L89.604  L89.613  L89.614 
L89.623  L89.624  L89.813  L89.814  L89.893  L89.894  L89.93 
L89.94 

For diabetic ulcer of lower extremity, other than pressure ulcer

E08.621  E08.622  E09.621  E09.622  E10.621  E10.622  E11.621 
E11.622  E13.621  E13.622 

AND one of the following:

I70.231  I70.232  I70.233  I70.234  I70.235  I70.238  I70.239 
I70.241  I70.242  I70.243  I70.244  I70.245  I70.248  I70.249 
I70.331  I70.332  I70.333  I70.334  I70.335  I70.338  I70.339 
I70.341  I70.342  I70.343  I70.344  I70.345  I70.348  I70.349 
I70.431  I70.432  I70.433  I70.434  I70.435  I70.438  I70.439 
I70.441  I70.442  I70.443  I70.444  I70.445  I70.448  I70.449 
I70.531  I70.532  I70.533  I70.534  I70.535  I70.538  I70.539 
I70.541  I70.542  I70.543  I70.544  I70.545  I70.548  I70.549 
I70.631  I70.632  I70.633  I70.634  I70.635  I70.638  I70.639 
I70.641  I70.642  I70.643  I70.644  I70.645  I70.648  I70.649 
I70.731  I70.732  I70.733  I70.734  I70.735  I70.738  I70.739 
I70.741  I70.742  I70.743  I70.744  I70.745  I70.748  I70.749 
L97.101  L97.102  L97.103  L97.104  L97.105  L97.106  L97.108 
L97.109  L97.111  L97.112  L97.113  L97.114  L97.115  L97.116 
L97.118  L97.119  L97.121  L97.122  L97.123  L97.124  L97.125 
L97.126  L97.128  L97.129  L97.201  L97.202  L97.203  L97.204 
L97.205  L97.206  L97.208  L97.209  L97.211  L97.212  L97.213 
L97.214  L97.215  L97.216  L97.218  L97.219  L97.221  L97.222 
L97.223  L97.224  L97.225  L97.226  L97.228  L97.229  L97.301 
L97.302  L97.303  L97.304  L97.305  L97.306  L97.308  L97.309 
L97.311  L97.312  L97.313  L97.314  L97.315  L97.316  L97.318 
L97.319  L97.321  L97.322  L97.323  L97.324  L97.325  L97.326 
L97.328  L97.329  L97.401  L97.402  L97.403  L97.404  L97.405 
L97.406  L97.408  L97.409  L97.411  L97.412  L97.413  L97.414 
L97.415  L97.416  L97.418  L97.419  L97.421  L97.422  L97.423 
L97.424  L97.425  L97.426  L97.428  L97.429  L97.501  L97.502 
L97.503  L97.504  L97.505  L97.506  L97.508  L97.509  L97.511 
L97.512  L97.513  L97.514  L97.515  L97.516  L97.518  L97.519 
L97.521  L97.522  L97.523  L97.524  L97.525  L97.526  L97.528 
L97.529  L97.801  L97.802  L97.803  L97.804  L97.805  L97.806 
L97.808  L97.809  L97.811  L97.812  L97.813  L97.814  L97.815 
L97.816  L97.818  L97.819  L97.821  L97.822  L97.823  L97.824 
L97.825  L97.826  L97.828  L97.829  L97.901  L97.902  L97.903 
L97.904  L97.905  L97.906  L97.908  L97.913  L97.914  L97.915 
L97.916  L97.918  L97.923  L97.924  L97.925  L97.926  L97.928 
L97.929 

For venous ulcer of lower extremity, other than pressure ulcer

I83.001  I83.002  I83.003  I83.004  I83.005  I83.008  I83.009 
I83.011  I83.012  I83.013  I83.014  I83.015  I83.018  I83.019 
I83.021  I83.022  I83.023  I83.024  I83.025  I83.028  I83.029 
I83.201  I83.202  I83.203  I83.204  I83.205  I83.208  I83.209 
I83.211  I83.212  I83.213  I83.214  I83.215  I83.218  I83.219 
I83.221  I83.222  I83.223  I83.224  I83.225  I83.228  I83.229 

For arterial insufficiency with ulcer 

I70.231  I70.232  I70.233  I70.234  I70.235  I70.238  I70.239 
I70.241  I70.242  I70.243  I70.244  I70.245  I70.248  I70.249 
I70.25 

or

I87.2  I87.311  I87.312  I87.313  I87.319  I87.331  I87.332 
I87.333  I87.339 

AND one of the following 

I70.231  I70.232  I70.233  I70.234  I70.235  I70.238  I70.239 
I70.241  I70.242  I70.243  I70.244  I70.245  I70.248  I70.249 
I70.331  I70.332  I70.333  I70.334  I70.335  I70.338  I70.339 
I70.341  I70.342  I70.343  I70.344  I70.345  I70.348  I70.349 
I70.431  I70.432  I70.433  I70.434  I70.435  I70.438  I70.439 
I70.441  I70.442  I70.443  I70.444  I70.445  I70.448  I70.449 
I70.531  I70.532  I70.533  I70.534  I70.535  I70.538  I70.539 
I70.541  I70.542  I70.543  I70.544  I70.545  I70.548  I70.549 
I70.55  I70.631  I70.632  I70.633  I70.634  I70.635  I70.638 
I70.639  I70.641  I70.642  I70.643  I70.644  I70.645  I70.648 
I70.649  I70.731  I70.732  I70.733  I70.734  I70.735  I70.738 
I70.739  I70.741  I70.742  I70.743  I70.744  I70.745  I70.748 
I70.749  L97.101  L97.102  L97.103  L97.104  L97.105  L97.106 
L97.108  L97.109  L97.111  L97.112  L97.113  L97.114  L97.115 
L97.116  L97.118  L97.119  L97.121  L97.122  L97.123  L97.124 
L97.125  L97.126  L97.128  L97.129  L97.201  L97.202  L97.203 
L97.204  L97.205  L97.206  L97.208  L97.209  L97.211  L97.212 
L97.213  L97.214  L97.215  L97.216  L97.218  L97.219  L97.221 
L97.222  L97.223  L97.224  L97.225  L97.226  L97.228  L97.229 
L97.301  L97.302  L97.303  L97.304  L97.305  L97.306  L97.308 
L97.309  L97.311  L97.312  L97.313  L97.314  L97.315  L97.316 
L97.318  L97.319  L97.321  L97.322  L97.323  L97.324  L97.325 
L97.326  L97.328  L97.329  L97.401  L97.402  L97.403  L97.404 
L97.405  L97.406  L97.408  L97.409  L97.411  L97.412  L97.413 
L97.414  L97.415  L97.416  L97.418  L97.419  L97.421  L97.422 
L97.423  L97.424  L97.425  L97.426  L97.428  L97.429  L97.501 
L97.502  L97.503  L97.504  L97.505  L97.506  L97.508  L97.509 
L97.511  L97.512  L97.513  L97.514  L97.515  L97.516  L97.518 
L97.519  L97.521  L97.522  L97.523  L97.524  L97.525  L97.526 
L97.528  L97.529  L97.801  L97.802  L97.803  L97.804  L97.805 
L97.806  L97.808  L97.809  L97.811  L97.812  L97.813  L97.814 
L97.815  L97.816  L97.818  L97.819  L97.821  L97.822  L97.823 
L97.824  L97.825  L97.826  L97.828  L97.829  L97.901  L97.902 
L97.903  L97.904  L97.905  L97.906  L97.908  L97.909  L97.911 
L97.912  L97.913  L97.914  L97.915  L97.916  L97.918  L97.919 
L97.921  L97.922  L97.923  L97.924  L97.925  L97.926  L97.928 
L97.929 

Complications of a surgically created wound 

K68.11  T81.31XA  T81.31XD  T81.32XA  T81.32XD  T81.40XA  T81.40XD 
T81.41XA  T81.41XD  T81.42XA  T81.42XD  T81.43XA  T81.49XA  T81.49XD 
T81.89XA  T81.89XD 

Open wound of upper or lower limb, complicated

S41.001A  S41.002A  S41.009A  S41.021A  S41.022A  S41.029A  S41.041A 
S41.042A  S41.049A  S41.101A  S41.102A  S41.109A  S41.121A  S41.122A 
S41.129A  S41.141A  S41.142A  S41.149A  S51.001A  S51.002A  S51.009A 
S51.021A  S51.022A  S51.029A  S51.041A  S51.042A  S51.049A  S51.801A 
S51.802A  S51.809A  S51.821A  S51.822A  S51.829A  S51.841A  S51.842A 
S51.849A  S61.501A  S61.502A  S61.509A  S61.521A  S61.522A  S61.529A 
S61.541A  S61.542A  S61.549A  S71.021A  S71.022A  S71.029A  S71.041A 
S71.042A  S71.049A  S71.121A  S71.122A  S71.129A  S71.141A  S71.142A 
S71.149A  S81.021A  S81.022A  S81.029A  S81.041A  S81.042A  S81.049A 
S81.821A  S81.822A  S81.829A  S81.841A  S81.842A  S81.849A  S91.021A 
S91.022A  S91.029A  S91.041A  S91.042A  S91.049A  S91.321A  S91.322A 
S91.329A  S91.341A  S91.342A  S91.349A

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