Wund Care Equipment and Supply Benefits t Change fr Texas Medicaid July 1, 2018 Infrmatin psted May 11, 2018 Nte: Texas Medicaid managed care rganizatins (MCOs) must prvide all medically necessary, Medicaid-cvered services t eligible clients. Administrative prcedures such as prir authrizatin, pre-certificatin, referrals, and claims/encunter data filing may differ frm traditinal Medicaid (fee-fr-service) and frm MCO t MCO. Prviders shuld cntact the client's specific MCO fr details. Effective fr dates f service n r after July 1, 2018, wund care equipment and supply benefits will change fr Texas Medicaid. Overview f Benefit Changes Majr changes t this medical benefit plicy include the fllwing: Updated benefit language Revised quantity limitatins New prir authrizatin criteria Updated dcumentatin requirements New prir authrizatin frm Place f service and prvider type updates Updated Benefit Language Wunds are defined as acute r chrnic, as fllws: Acute wunds prgress thrugh the nrmal stages f wund healing and shw definite signs f healing within fur weeks. Chrnic wunds d nt prgress nrmally thrugh the stages f healing (ften getting stalled in ne phase) and d nt shw evidence f healing within fur weeks. Prviders are t cnsider the clinical efficacy f the wund care prduct, the client s functinal status, as well as the measurable signs f effective wund management when rdering prducts t treat wunds. Measureable signs f wund management include, but are nt limited t, the fllwing: A decrease in wund size, either in surface area r vlume A decrease in amunt f exudate A decrease in amunt f necrtic tissue Imprved infectin status Cleansers Wund cleansing helps create an ptimal healing envirnment and decreases the ptential fr infectin. Cleansing agents and methds vary based n effectiveness and
individual client needs. Wund cleansing agents may include, but are nt limited t, the fllwing: Nrmal saline Cmmercial wund cleansers Pvidne idine Hydrgen perxide Sdium hypchlrite Cmpressin Cmpressin dressings, wraps r stckings apply pressure t bdy parts t cntrl edema and aid circulatin by redirecting bld centrally. Belw the knee and abve the knee cmpressin stckings may be benefits fr Texas Medicaid clients. Cmpressin dressings r stckings may be used fr, but nt limited t, the fllwing indicatins: Edema in pregnancy Pstural hyptensin Lymphedema Treatment f any f the fllwing cmplicatins f chrnic venus insufficiency: Venus edema Stasis ulcers Varicse veins (nt including spider veins) Lipdermatsclersis Custm burn cmpressin garments may be a benefit with prir authrizatin and dcumentatin supprting medical necessity. Dressings A dressing is a wet r dry, sterile r nn-sterile, pad r cmpress that is designed t be in direct cntact with the wund. A dressing is applied t prmte healing and prtect the wund frm further harm. Dressings and related supplies may include, but are nt limited t, the fllwing: Wund packing and fillers Gauze, impregnated r nn-impregnated, sterile r nn-sterile Dry dressings Cllagen dressings Alginate r ther fiber gelling dressings Cmpsite dressings Antimicrbials Fam dressings
Cntact layers and transparent films Hydrcllid, Hydrfiber, and Hydrgel dressings Specialty absrptive dressings Cmpressin dressings and wraps Tape t secure dressings Additinal Exclusins The fllwing services are nt a benefit f Texas Medicaid: Cntact r nn-cntact ultrasund treatment fr wunds Electrchemical lw-dse tissue xygenatin systems Quantity Limitatins The fllwing quantity limitatins will be effective fr dates f service n r after July 1, 2018: Table A: Prcedure Cdes Limitatin Effective July 1, 2018 A4213 A4216 A4217 A4244 A4246 A4247 A4320 A4322 A4364 A4450 A4452 A4455 A4456 A4461 A4465 A4490 A4495 A4500 A4510 A4927 A5120 60 per mnth 10 per mnth 4 per mnth 4 per mnth 6 per mnth 15 per mnth 8 per mnth 100 per mnth 100 per mnth 4 per mnth 60 per mnth 4 per mnth 4 per year 4 per year 4 per year 4 per year 1 per mnth 50 per mnth
A5121 A5122 A5126 A6010 A6011 A6021 A6022 A6023 A6024 A6025 A6196 A6197 A6198 A6199 A6203 A6204 A6205 A6206 A6207 A6208 A6209 A6210 A6211 A6212 A6213 A6214 A6216 A6217 A6218 A6219 A6220 A6221 A6222 A6223 A6224 A6228 A6229 15 per mnth 40 per mnth 10 per mnth 10 per mnth 10 per mnth 2 per mnth 4 per mnth 15 per mnth 15 per mnth 4 per mnth 15 per mnth 10 per mnth 60 per mnth 4 per mnth 15 per mnth 4 per mnth 10 per mnth 200 per mnth 200 per mnth 15 per mnth 120 per mnth 15 per mnth 60 per mnth 60 per mnth 60 per mnth 120 per mnth
A6230 A6231 A6232 A6233 A6234 A6235 A6236 A6237 A6238 A6239 A6240 A6241 A6242 A6243 A6244 A6245 A6246 A6247 A6248 A6250 A6251 A6252 A6253 A6254 A6255 A6256 A6257 A6258 A6259 A6261 A6262 A6266 A6402 A6403 A6404 A6407 A6410 15 per mnth 60 per mnth 10 per mnth 15 per mnth 10 per mnth 10 per mnth 15 per mnth 8 per mnth 15 per mnth 15 per mnth 4 per mnth 10 per mnth 8 per mnth 2 per mnth 60 per mnth 15 per mnth 60 per mnth 15 per mnth 15 per mnth 8 per mnth 8 per mnth 120 per mnth 200 per mnth 100 per mnth 15 per mnth 60 per mnth
A6411 A6412 A6441 A6442 A6443 A6444 A6445 A6446 A6447 A6448 A6449 A6450 A6451 A6452 A6453 A6454 A6455 A6456 A6457 A6530 A6531 A6532 A6533 A6534 A6535 A6536 A6537 A6538 A6539 A6540 A6541 A6544 A6545 with mdifier AW A6550 A7000 60 per mnth 120 per mnth 120 per mnth 120 per mnth 120 per mnth 120 per mnth 120 per mnth 60 per mnth 60 per mnth 60 per mnth 60 per mnth 60 per mnth 4 per year 8 per year 15 per mnth 10 per mnth E2402* 1 per mnth fr up t 3 mnths *Nte: The initial 90 days f treatment with negative pressure wund therapy des nt require prir authrizatin. Prir authrizatin is required fr cntinued
therapy after the initial 90 days f treatment. New Prir Authrizatin Criteria Quantities that exceed the limitatins identified in the tables abve will require prir authrizatin with dcumentatin supprting medical necessity. Prir authrizatin with dcumentatin supprting medical necessity and the quantity requested, will be required fr the fllwing prcedure cdes: Table B: Prcedure Cdes A6215 A6260 A6501 A6502 A6503 A6504 A6505 A6506 A6507 A6508 A6509 A6510 A6511 A6512 A6513 A6549 A9272 T1999 Infrmatin frm the sectin belw, Updated Dcumentatin Requirements, must be submitted anytime that prir authrizatin is required. Cmpressin Burn Garments The fllwing prcedure cdes fr cmpressin burn garments will require dcumentatin f an apprpriate diagnsis and evidence f medical necessity: Table C: Prcedure Cdes A6501 A6502 A6503 A6504 A6505 A6506 A6507 A6508 A6509 A6510 A6511 A6512 A6513 Prir authrizatin requests fr cmpressin burn garments will be reviewed by the medical directr. Dispsable Wund Suctin Dcumentatin fr prcedure cde A9272 must include justificatin addressing why n ther wund care equipment and supplies will meet the client s need. Negative Pressure Wund Therapy (NPWT) Prir authrizatin fr NPWT may be cnsidered fr additinal 30-day treatment perids beynd the initial 90-day treatment perid. Fr each prir authrizatin request, prviders must submit dcumentatin t supprt cntinued use f NPWT, including the measurements at the initiatin f NPWT and the current measurements (length, width, depth and any undermining r tunneling.) Prviders must als dcument if any f the fllwing cntraindicatins are present: N measurable imprvement f wund status ccurring ver the prir 90-day perid The wund care equipment r supplies are n lnger being used by the client as prescribed
Updated Dcumentatin Requirements The requesting durable medical equipment (DME) prvider may be asked fr additinal infrmatin t clarify r cmplete a request fr the wund care equipment r supplies including, but nt limited t, the fllwing: Overall health status f clients whse wunds are nt prgressing thrugh the nrmal stages f healing, including, but nt limited t, the fllwing: Albumin r pre-albumin (within 30 days) Hemglbin A1C (within 30 days) Use f pressure-reducing surfaces, repsitining, and encuraged ambulatin Reauthrizatin will be cnsidered based n medical necessity, with a new prir authrizatin request. All f the fllwing infrmatin must be submitted with every prir authrizatin request. If prir authrizatin is nt required, this dcumentatin must be maintained in the client s medical recrd and is subject t retrspective review. Categry 1: Medical Histry and Cmpliance A cmprehensive treatment plan, including the prescribed wund care and management planned fr the client. This may include, but is nt limited t, dcumentatin f the fllwing: Any medical diagnsis r chrnic cnditin that affects wund healing Histry f previus wund care treatments and utcmes with dates (including therapies initiated in a hspital r skilled nursing facility) Cntinued management f unreslved cmpliance issues (e.g., missed medical appintments, refusing dressing changes, repsitining, smking, pr nutritinal intake r chices) Whether a family member, friend r caregiver agrees t be available t assist the client Categry 2: Wund Care Interventins Relevant infrmatin related t the current wund, including the fllwing: Any mechanical, surgical, enzymatic r autlytic tissue debridement (if perfrmed) Treatment fr infectin (if present) Categry 3: Wund Descriptin & Details Detailed descriptin f the wund, including the fllwing: Dates f previus and current assessments The measurements at the initiatin f wund care and the current measurements, including length, width, depth and any undermining r tunneling Wund clr
Amunt, quality, quantity and dr f drainage (if present) Presence f granulatin r eschar (if apprpriate) The currently prescribed wund care regimen, t include types f dressings, frequency f dressing changes and supplies needed fr each dressing change Frequency client will be seen by a licensed medical prfessinal t assess wund healing and current wund treatment regimen Categry 4: Cntraindicatins Absence f the fllwing cntraindicatins: Untreated stemyelitis within the vicinity f the wund Wund ischemia Gangrene Presence in the wund f necrtic tissue with eschar (if debridement has nt been attempted) Cancer present in the wund r arund the margins Presence f a fistula t an rgan r bdy cavity within the vicinity f the wund Dcumentatin explaining the apprpriateness f wund care is required if any f the abve cntraindicatins are present New Prir Authrizatin Frm The new prir authrizatin frm, titled Wund Care Equipment and Supplies Order Frm, is t be used when submitting prir authrizatin requests fr the fllwing services: Wund care supplies that exceed quantity limitatins All wund care supplies that require prir authrizatin, as identified in Table B abve The fllwing frms will be discntinued n June 30, 2018, and will n lnger be accepted after July 31, 2018: Statement fr Initial Wund Therapy System In-Hme Use (Frm #F00100) Statement fr Recertificatin f Wund Therapy System In-Hme Use (Frm #F00099) Prviders may refer t the article titled, "New Prir Authrizatin Frm fr Wund Care Equipment and Supplies t be Effective July 1, 2018," which was published n this website May 11, 2018, fr additinal infrmatin abut the new frm. Place f Service and Prvider Type Updates The fllwing prcedure cdes will nly be a benefit when services are prvided by hme health DME and medical supplier (DME) prviders in the hme setting: Table D:
Prcedure Cdes A4490 A4495 A4500 A4510 A6544 The fllwing prcedure cdes will nly be a benefit when services are prvided by hme health DME and medical supplier (DME) prviders in the hme setting, and hspital prviders in the utpatient hspital setting: Table E: Prcedure Cdes A6501 A6502 A6503 A6504 A6505 A6506 A6507 A6508 A6509 A6510 A6511 A6512 A6513 Fr mre infrmatin, call the TMHP Cntact Center at 1-800-925-9126 r the TMHP- CSHCN Services Prgram Cntact Center at 1-800-568-2413.