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Issue Number - Name
0081 - Complex Medical Necessity Negative Pressure Wound Therapy (NPWT) with DWO
Review Type
Complex
Claim Type
DME by supplier; DME by physician
Region and State
RAC 5
All States
Date Approved
2018-02-13

Description

Medical Necessity Review Negative Pressure Wound Therapy Pumps - Potential incorrect billing occurred when claims for Negative Pressure Wound Therapy Pumps were billed without an indication supporting Medical Necessity as outlined in Local Coverage Determination (LCD) L33821 (related MAC Policy Article A52511)

Affected Code(s)

  • E2402, A6550, A7000

Applicable Policy References

  • Title XVIII of the Social Security Act, Section 1862(a)(1)(A)
  • Title XVIII of the Social Security Act, Section 1833(e)
  • CMS Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110
  • CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 34, Sections 10.6.1 and 10.6.2  
  • CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.7, 5.8, and 5.9  
  • CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Sections 3.3.2, 3.3.2.4, 3.4.1.1 
  • Local Coverage Determination, L33821, Effective date 10/01/2015
  • MAC Policy Article, A52511, Effective date 10/01/2015
  • CMS Policy Article, A55426, Effective 1/1/2017