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Payers: V.A.C.® Therapy: Medicare Reimbursement for V.A.C.® Therapy*
Medicare Reimbursement for V.A.C.® Therapy*
KCI's V.A.C.® Therapy SystemTM became eligible for coverage as part of the establishment of Negative Pressure Wound Therapy (NPWT) Medicare Part B codes in October 2000.  CMS also developed a medical coverage policy for NPWT, which defines the information required to determine medical necessity. 
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Initial Coverage Requirements for Part B
Coverage

Medicare requires all of the information below before a coverage determination can be made.

Complete Physician's Order/Prescription

  1. The patient's full name and address
  2. Description of V.A.C.® Therapy, with the start date and length of need (in months)
  3. Frequency of dressing changes and quantity of supplies (Medicare allows up to 15 dressings per wound and 10 canisters per month.)
  4. Physician's signature and date
  5. Diagnosis

When a patient qualifies for Medicare Part B coverage and payment for NPWT, Medicare reimburses KCI directly for V.A.C.® Therapy and the related canisters and dressings. KCI submits claims directly to the DMERC. Medicare pays KCI 80% of the established allowable charge, and the remaining 20% is the patient's co-insurance.

The NPWT Medical Policy allows for up to 15 dressing kits per wound per month and 10 canisters per month. Additional dressing kits may be used and reimbursed by Medicare if documentation of the medical need is provided to KCI. If there is no justified medical necessity for excess dressings, the patient will be requested to complete an Advance Beneficiary Notice (ABN).  This document notifies the patient of his or her financial responsibility for those excessive dressings should Medicare deny.  

Clinical Information

The following components of a wound therapy program must have included all of the following measures, each of which should have been addressed, applied or considered and ruled out prior to application of NPWT:

  1. Documentation in the medical record of evaluation, care and wound measurements by a licensed professional, AND
  2. Application of dressings to maintain a moist wound environment, AND
  3. Debridement of necrotic tissue, if present, AND
  4. Evaluation of and provision for adequate nutritional status.

Additional Information Required by Wound Type

Stage III or IV Pressure Ulcers

  1. The patient has been turned/positioned, AND
  2. The patient has used a Group 2 or 3 support surface for posterior trunk or pelvis, or it has been ruled out by the physician in writing, AND
  3. Patient's moisture and incontinence have been appropriately managed.

Neuropathic (Diabetic Ulcers)

  1. The patient has been on a comprehensive diabetic management program, AND
  2. Reduced pressure on any foot ulcer has been accomplished.

Venous Insufficiency Ulcers

  1. Compression bandages and/or garments have been consistently applied, AND
  2. Legs have been elevated and ambulation has been encouraged.

Surgically Created (Dehiscence) or Traumatic Wound (ex. Flap/Graft)

  1. Documentation of the medical necessity for accelerated formation of granulation tissue which cannot be achieved by other available topical wound treatments, i.e., condition of patient will not allow for healing times achievable with other topical wound treatments. 

Non-Covered Wounds

Medicare does not cover NPWT for the following types of wounds:

  • Wounds containing eschar (without attempted/serial debridements)
  • Wounds with untreated osteomyelitis
  • Cancer present in the wound
  • Enteric fistulae
Links to Durable Medical Equipment Medicare Administrative Contractor (DMAC) Coverage Policies
To see the Jurisdiction A medical policy for NPWT for the states of:  Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont click here.

To see the Jurisdiction B medical policy for NPWT for the states of:  Indiana, Illinois, Kentucky, Michigan, Minnesota, Ohio and Wisconsin, click here.

To see the Jurisdiction C medical policy for NPWT for the states of:  Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, the Virgin Islands, Virginia and West Virginia click here.

To see the Jurisdiction D medical policy for NPWT for the states of:  Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Iowa, Kansas, Marianna Islands, Missouri, Montana, Nebraska, Nevada, North Dakota, Oregon, South Dakota, Utah, Washington and Wyoming click here.
Recertifying V.A.C.® Therapy and Reordering Supplies
Initial certification for V.A.C.® Therapy under Medicare covers 30 days of therapy.  Medicare and many other payors also require the submission of a monthly report showing the effectiveness of V.A.C.® Therapy and justification for another 30-day continuation.  This report can be found by clicking .  Complete sections one and two of the form answering questions by checking "yes" or "no".  Also please obtain a recent record of the patient's wound measurements.  When complete, please print your name, title, employer and phone number; sign and date.  Fax to KCI at 1-888-245-2295. 
Discontinuing V.A.C.® Therapy
When the physician discontinues V.A.C.® Therapy, call KCI at 1-800-275-4524 within 24 hours of discontinuation.  Inform the KCI Customer Service Representative that V.A.C.® Therapy has been discontinued and you need to arrange for a pick-up of the V.A.C.® Therapy unit and unopened supplies. 

Be prepared to give the patient's name, phone number and the date therapy ended.  In addition, please complete the Discharge from Negative Pressure Wound Therapy form.  Fax the completed form to KCI at 1-888-245-2295. 

If the V.A.C.® Therapy unit has not been picked up after two days, call KCI at 1-800-275-4524. 

Other Coverage Issues
Medicare Part A (Hospital Insurance)
Medicare Part A facility reimbursement includes payment for the V.A.C.® Therapy in all inpatient settings (Acute Care, Skilled Nursing Facility, etc.) as part of the prospectively determined payment rates.  KCI's business practice is to bill the inpatient or extended care facility for V.A.C.® Therapy placements. 
Medicare Advantage (Medicare Managed Care)
The managed healthcare plan that provides medical benefits through Medicare Advantage is obligated to provide the patient with the same level of benefits that would be available under the original Medicare plan for those items of DME for which a National Coverage Determination (NCD) exists. NPWT is covered under a Local Coverage Determination (LCD), therefore each individual Medicare Advantage plan can decide whether it will reimburse for NPWT.
* This summary is not intended to be all-inclusive and should not be relied on for final coverage determinations.  The complete NPWT policy can be accessed on each of the DMERC websites.  Links to each DMERC website may be accessed via the main CMS website under "Durable Medical Equipment" and should be reviewed prior to making any coverage determinations.  NPWT criteria in this Summary are subject to change without notice based on changes to the NPWT Medical Policy and DMERC Bulletins.  KCI cannot guarentee eligibility or coverage of any patient.  Additional criteria may be required for coverage of eligible patients depending on individual circumstances.  The information contained in this website is provided for informational purposes only and represents no statement, promise or guarentee by KCI concerning the levels of reimbursement, payment, calculations, eligibility, charge or that these policies and codes will be appropriate for specific services or products provided or that reimbursement will be made.  Information is current as of the date of publication and is subject to change at anytime.  KCI recommends that you consult your local CMS contracted carrier, Medicaid carrier or other applicable payor organization with regard to specific reimbursement policies, coverage, documentation, payment and criteria.  Individual situations and situations may vary.