V.A.C. Therapy Reimbursement
Because of the demonstrated effectiveness of V.A.C.® Therapy in managing complex wounds, it is eligible for reimbursement by many different agencies, organizations and insurance providers. The following information has been compiled to assist facilities when applying V.A.C. Therapy.
If you have any further questions or comments about the reimbursement of KCI products, please email us at Reimbursement@KCI1.com.
CPT/HCPCS Codes for NPWT
V.A.C. Therapy Medicare Information
V.A.C. Therapy Managed Care Information
V.A.C. Therapy Medicaid Information
CPT/HCPCS Codes for Negative Pressure Wound Therapy
V.A.C. Therapy is verified by the Centers for Medicare & Medicaid Services (CMS) to deliver Negative Pressure Wound Therapy (NPWT). Physicians and other healthcare providers treating patients with V.A.C. Therapy may be eligible for reimbursement for services associated with NPWT Dressing Changes.
Current CPT Codes for NPWT Dressing Changes
| CPT Code | Wound Size | Relative Value Units (RVUs) |
|---|---|---|
| 97605 | ≤ 50 cm2 in surface area | 0.55 |
| 97606 | > 50 cm2 in surface area | 0.60 |
Current HCPCS Codes for NPWT Dressing Changes
The appearance of a code in this section does not necessarily indicate coverage.
HCPCS MODIFIER:
EY - No physician or other licensed health care provider order for this item or service
KX - Specific required documentation on file.
| HCPCS Code | Type | Description |
|---|---|---|
| E2402 | Equipment | NEGATIVE PRESSURE WOUND THERAPY ELECTRICAL PUMP, STATIONARY OR PORTABLE |
| A6550 | Supplies | WOUND CARE SET, FOR NEGATIVE PRESSURE WOUND THERAPY ELECTRICAL PUMP, INCLUDES ALL SUPPLIES AND ACCESSORIES |
| A7000 | Supplies | CANISTER, DISPOSABLE, USED WITH SUCTION PUMP, EACH |
Additional information about NPWT CPT Codes is available on the CMS website, the AMA website or by calling the KCI Reimbursement Helpline at 1-800-275-4524 extension 56008.
Source: Current Procedural Terminology ©2006 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. The information contained in this document is provided for informational purposes only and represents no statement, promise or guarantee by KCI concerning the levels of reimbursement, payment, calculations, eligibility, charge or that these codes will be appropriate for specific services provided or that reimbursement will be made. KCI recommends that you consult your local CMS contracted carrier or other applicable payer organization with regard to specific reimbursement policies, coverage, payment and criteria. Individual circumstances and situations may vary. Consult the AMA CPT Handbook and the ICD-9 CM coding manual for complete listings and descriptions.
Medicare Reimbursement for V.A.C. Therapy*
V.A.C. Therapy is eligible for coverage as part of the Negative Pressure Wound Therapy (NPWT) Medicare Part B codes. Additionally, the Centers for Medicare & Medicaid Services (CMS) also has a medical coverage policy for NPWT, which defines the information required to determine medical necessity.
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/signed prescription
- The patient's full name and delivery address
- Description of V.A.C. Therapy, with the start date and length of need (in months)
- Frequency of dressing changes and quantity of supplies (Medicare allows up to 15 dressings per wound and 10 canisters per month.)
- Physician's signature and date
- 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 DME MAC. 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 a waiver of liability, an Advance Beneficiary Notice (ABN). This document notifies the patient of his or her financial responsibility for those excessive dressings should Medicare deny the claim.
Clinical Information
Prior to application of NPWT, each of the following measures must be addressed:
- Documentation in the medical record of evaluation, care and wound measurements by a licensed professional, 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.
Additional Information Required by Wound Type
Stage III or IV Pressure Ulcers
- The patient has been turned/positioned, AND
- 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
- Patient's moisture and incontinence have been appropriately managed.
Neuropathic (Diabetic Ulcers)
- The patient has been on a comprehensive diabetic management program, AND
- Reduced pressure on any foot ulcer has been accomplished.
Surgically Created (Dehiscence) or Traumatic Wound
- 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
*For more information, visit the CMS Medicare Coverage Database.
Durable Medical Equipment Medicare Administrative Contractor (DMAC) Coverage Policies
DMAC medical policies are separated into different jurisdictions. The CMS Website can provide additional information for your state:
Jurisdiction A:
Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont
Jurisdiction B:
Indiana, Illinois, Kentucky, Michigan, Minnesota, Ohio and Wisconsin
Jurisdiction C:
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
Jurisdiction D:
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
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 payers also require the submission of a monthly report showing the effectiveness of V.A.C. Therapy and justification for another 30-day continuation.
Other Coverage Issues
Medicare Part A (Hospital Insurance)
Medicare Part A facility reimbursement includes payment for V.A.C. Therapy in all inpatient settings (Acute Care, Skilled Nursing Facility, etc.) as part of the prospectively determined payment rates. It is KCI business practice 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.
Managed Care Reimbursement for V.A.C. Therapy
Many managed care companies throughout the United States have contracted with KCI to provide V.A.C. Therapy access to their members. Currently, over 200 million managed care patients have access to V.A.C. Therapy.
Managed Care Coverage Requirements (General Commercial Population)
Most managed care companies follow Medicare's criteria for determining medical necessity. Please check with the individual health plan to review its specific V.A.C. Therapy coverage criteria. KCI collects the following information for managed care plans before a coverage determination can be made:
- Complete physician's order/prescription
- The patient's full name and address
- Description of V.A.C. Therapy, with the start date and length of need (in months)
- Frequency of dressing changes and quantity of supplies (Medicare allows up to 15 dressings and 10 canisters per month.)
- Physician's signature and date (no stamps allowed)
- Diagnosis
- Goal of therapy
When a patient qualifies for managed care coverage and payment, managed care plans reimburse KCI directly for V.A.C. Therapy and the related canisters and dressings. KCI submits claims directly to the plan.
Most V.A.C. Therapy Medical Policies allow for up to 15 dressing kits per wound per month and 10 canisters per month. Additional dressing kits may be used and reimbursed by the managed care plan 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 a waiver of liability (known as an Advance Beneficiary Notice). This document notifies the patient of his or her financial responsibility for these excess dressings.
Reauthorizing V.A.C. Therapy
Initial certification for V.A.C. Therapy can vary for managed care patients from 14 to 30 days of therapy. Most payers require the submission of a report showing the effectiveness of V.A.C. Therapy and justification for another reauthorization cycle.
Claims Modification Policy
Due to the complexity of the claims administration process, managed care organizations and private insurance payers must participate as required in this policy for the successful administration and final resolution of modifications to claims. View the Claims Modification Policy for more information.
Medicare Advantage Information
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.
State Medicaid Reimbursement for V.A.C. Therapy
Medicaid reimbursement coverage policies for V.A.C. Therapy vary from state to state. To learn more about each state’s guidelines, click on the appropriate link.
For additional information on our participating provider status and coverage of KCI products, contact KCI Reimbursement Policy and Compliance at 1-800-275-4524 extension 21685.
State
Alaska
Arizona
Arkansas
California
Colorado
Delaware
District of Columbia
Hawaii
Idaho
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Minnesota
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*This summary is not intended to be all-inclusive and should not be relied on for final coverage determinations. Specific DMERC, Medicaid or Health Plan coverage policies should be reviewed prior to making any coverage determinations. 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 guarantee 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 circumstances and situations may vary.