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TRICARE Policy Manual 6010.60-M, April 1, 2015
Chapter 4
Section 5.8
Negative Pressure Wound Therapy (NPWT)
Issue Date:  December 15, 2009
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  
1.0  CPT PROCEDURE CODES
11000 - 11044, 97597 - 97606
2.0  HCPCS Codes
A6550, A7000, E2402
3.0  DESCRIPTION
NPWT applies a localized vacuum to draw the edges of an open wound together while providing a moist environment conducive to rapid wound healing. NPWT is also known as Topical Negative Pressure (TNP) and Vacuum-Assisted Closure (VAC). The goal of NPWT is to create a controlled, closed wound amenable to surgical closure, grafting, or healing by secondary intention. An evacuation tube is embedded in a dressing made of foam. After thorough wound debridement, the foam dressing is placed within the wound bed and covered by a dressing to form an airtight seal, and the tube is attached to a vacuum unit. Continuous or intermittent negative pressure is applied. The amount of pressure is determined by the wound type. NPWT is designed to result in: (1) removal of excess fluid; (2) increased blood flow and decreased bacterial colonization; (3) granulation tissue formation; and (4) partial or complete wound closure with or without the need for additional procedures.
4.0  POLICY
4.1  A NPWT pump and supplies are covered when one of the following conditions exists:
4.1.1  Complications of surgically created wound (e.g., dehiscence, poststernotomy disunion with exposed sternal bone, poststernotomy mediastinitis, or postoperative disunion of the abdominal wall).
4.1.2  Traumatic wound (e.g., preoperative flap or graft, exposed bones, tendons, or vessels) and a need for accelerated formation of granulation tissue not achievable by other topical wound treatments (e.g., the individual has comorbidities that will not allow for healing times usually achievable with other available topical wound treatments).
4.1.3  Chronic nonhealing Stage III or IV pressure ulcer, diabetic neuropathic ulcer or chronic venous ulcer with lack of improvement for at least the previous 30 days despite standard wound therapy, including the application of moist topical dressings, debridement of necrotic tissue (if present), maintenance of an adequate nutritional status, and weekly evaluations with documentation of wound measurements (i.e., length, width, and depth).
4.2  NPWT is covered:
4.2.1  Only after careful consideration has been given to the following risk factors:
•  Patients with friable vessels and infected blood vessels, sharp edges in the wound (i.e., bone fragments), or Spinal Cord Injury (SCI) (stimulation of sympathetic nervous system);
•  Patients requiring Magnetic Resonance Imaging (MRI), hyperbaric chamber, defibrillation;
•  Patient size and weight;
•  Use near vagus nerve (bradycardia);
•  Circumferential dressing application;
•  Mode of therapy-intermittent versus continuous negative pressure.
4.2.2  For a period of up to four months (including the time NPWT was applied in an inpatient setting prior to discharge to the home) in the treatment of any wound. The medical necessity of NPWT beyond four months will be given individual consideration based upon required additional documentation including but not limited to:
4.2.2.1  Documentation of progression of healing of the wound on two successive dressing changes, as determined by quantitative measurements of wound characteristics including wound length and width (surface area), or depth, serially observed and documented; and
4.2.2.2  Documentation of appropriate medical professional supervision or performance of weekly wound measurement and assessment functions as well as the negative pressure wound therapy dressing changes required; or
4.2.3  In the judgment of the treatment physician, until adequate wound healing has occurred to the degree that NPWT may be discontinued; or
4.2.4  Until equipment or supplies are no longer being used for the patient, whether or not by the physician’s order.
4.3  When the patient is monitored frequently in an appropriate care setting by a licensed health care professional. Frequency of monitoring shall be determined by the patient’s condition, wound status, wound location, and co-morbidities.
4.4  When the patient is determined to be a proper candidate for using the NPWT system at home, a licensed health care professional will ensure the patient receives appropriate training prior to using the NPWT system to include:
•  Demonstration and documentation of the patient’s proficiency in using the system;
•  Potential complications and their signs and symptoms, and what to do if complications occur;
•  Ensuring patient understanding of the warnings associated with NPWT system use; and
•  Providing patient with a written copy of the patient labeling from the NPWT manufacturer, if available.
4.5  A licensed health care professional, for the purposes of this policy, may be a physician, Physician’s Assistant (PA), Registered Nurse (RN), Licensed Practical Nurse (LPN), or Physical Therapist (PT). The practitioner should be licensed to assess wounds and/or administer wound care within the state where the beneficiary is receiving NPWT.
5.0  EXCLUSIONs
5.1  An NPWT pump and supplies are excluded under any of the following conditions:
5.1.1  For patients whose wounds respond to standard therapeutic measures.
5.1.2  The patient cannot tolerate the use of NPWT.
5.1.3  For patients with the following contraindications:
•  Active bleeding;
•  Anticoagulant use;
•  Difficult wound hemostasis;
•  Exposed organs;
•  Exposed vasculature;
•  Exposed nerves;
•  Exposed anastomotic site;
•  Inadequately debrided wounds;
•  Untreated osteomyelitis;
•  Necrotic tissue with eschar present;
•  Infection in the wound;
•  Malignancy in the wound; and
•  Non-enteric and unexplored fistulas.
5.1.4  Uniform granulation tissue has been obtained.
5.1.5  The depth of the wound is less than one mm, as wounds of this depth cannot accommodate the sponge.
6.0  Effective Date
November 9, 2007.
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