| Mountain State Medical Policy Bulletin |
| Section: | Therapy |
| Number: | Y-16 |
| Topic: | Chronic Wound Management |
| Effective Date: | January 1, 2011 |
| Issued Date: | January 3, 2011 |
| Date Last Reviewed: |
Indications and Limitations of Coverage
Electrical Stimulation Electrical stimulation for the treatment of wounds is the application of electrical current through electrodes placed directly on the skin in close proximity to the wound. Electrical stimulation (G0281) is covered for the management of the following types of chronic ulcers when it is used as adjunctive therapy after there are no measurable signs of healing for at least 30 days of treatment with conventional wound treatments (Electrical stimulation will not be covered as an initial treatment modality.):
Continued treatment is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment. Measurable signs of improved healing include a decrease in wound size either in surface area or volume, decrease in amount of exudates, and decrease in amount of necrotic tissue. If electrical stimulation is being used, wounds must be evaluated at least monthly by the treating physician. All other uses of electrical stimulation for the treatment of chronic ulcers will be denied as not medically necessary and, therefore, not covered. This includes code G0282 that references all other stimulation not described in code description G0281. Electrical stimulation for wound healing is not covered in the home setting, as unsupervised use by patients in the home has not been found to be medically reasonable and necessary. Therefore, payment will not be made for an electrical stimulation device used to treat wounds, code E0769. Electromagnetic Therapy Electromagnetic therapy for the treatment of wounds uses a pulsed magnetic field to induce current. Electromagnetic therapy (G0329) is covered for the management of the following types of chronic ulcers when it is used as adjunctive therapy after there are no measurable signs of healing for at least 30 days of treatment with conventional wound treatments (Electromagnetic therapy will not be covered as an initial treatment modality.):
Continued treatment is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment. Measurable signs of improved healing include a decrease in wound size either in surface area or volume, decrease in amount of exudates, and decrease in amount of necrotic tissue. If electromagnetic therapy is being used, wounds must be evaluated at least monthly by the treating physician. All other uses of electromagnetic therapy for the treatment of chronic ulcers will be denied as not medically necessary and, therefore, not covered. This includes code G0295 that references all other therapy not described in code description G0329. Electromagnetic therapy for wound healing is not covered in the home setting, as unsupervised use by patients in the home has not been found to be medically reasonable and necessary. Therefore, payment will not be made for an electromagnetic wound treatment device used to treat wounds, code E0769. Electrical stimulation or electromagnetic therapy services that do not meet the medical necessity criteria on this policy will be considered not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records.
Coverage for electrical stimulation and/or electromagnetic therapy are subject to any applicable physical medicine limitation in the individual or group member's contract. A participating, preferred, or network provider can bill the member for the denied services that exceed the member's benefit limitations. Bio-engineered Tissues The application of bio-engineered tissues (Q4100-Q4108, Q4110-Q4111, Q4114-Q4115) is eligible under the prosthetic benefit when used for FDA-approved indications. Coverage for prosthetics is determined according to individual or group customer benefits. Description Conventional or standard therapy for chronic wounds involves local wound care as well as systemic measures. Standard wound care includes: optimization of nutritional status; debridement by any means to remove devitalized tissue; maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings; and necessary treatment to resolve any infection that may be present. Standard wound care based on the specific type of wound includes: frequent repositioning of a patient with pressure ulcers (usually every two hours); off-loading of pressure and good glucose control for diabetic ulcers; establishment of adequate circulation for arterial ulcers, and the use of a compression system for patients with venous ulcers. There are other therapeutic modalities that may apply to certain patients depending on their type of wound. |
|
| E0769 | G0281 | G0282 | G0295 | G0329 | Q4100 |
| Q4101 | Q4102 | Q4103 | Q4104 | Q4105 | Q4106 |
| Q4107 | Q4108 | Q4110 | Q4111 | Q4114 | Q4115 |
This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits or a contract. Benefits are determined by the Federal Employee Program. |
Centers for Medicare and Medicaid Services (CMS). Electrostimulation for wounds. Decision Memorandum # CAG-00068N. Baltimore, MD: CMS; July, 2002. CMS Online Manual Pub. 100-03, Section 270.1 CMS Online Manual Pub. 100-04, Chapter 32, Sections 10.1, 10.2 Transmittal 7, CR 3149 Transmittal 124, CR 3149 |
| [Version 007 of Y-16] |
| [Version 006 of Y-16] |
| [Version 005 of Y-16] |
| [Version 004 of Y-16] |
| [Version 003 of Y-16] |
| [Version 002 of Y-16] |
| [Version 001 of Y-16] |
| Term | Description |
|---|---|
| Arterial Ulcer | Ulcer resulting from inadequate blood flow to the site of any lesion where blood flow is compromised. The ulcer may be very deep and usually appears black, necrotic, and has no granulation tissue. The surrounding tissue typically shows signs of arterial insufficiency, such as loss of nail growth or atrophic skin. |
| Diabetic Ulcer | Ulcer develops from a combination of both small and large vessel disease. This affects tissue perfusion, and peripheral neuropathy, which leads to a loss of protective sensation. Injuries are often slow to heal and might go unnoticed. |
| Pressure Ulcer | Areas of localized skin/tissue damage caused by unrelieved pressure. This pressure squeezes the skin blood vessels causing hypoxia. If the pressure is prolonged it results in tissue necrosis. Pressure ulcers are most common over bony prominences such as the sacrum, heels, hips and elbows. Also known as decubitus ulcers, bedsores or pressure sores they are generally classified by stage.
|
| Venous Ulcer | Ulcer results from venous obstruction or valvular incompetence usually in the lower extremities. The subsequent venous hypertension then affects the vascular supply to surrounding tissue, resulting in tissue hypoxia and ulcer formation. |