Negative Pressure Wound Therapy

Affected Providers

Treating practitioners who order and supervise negative pressure wound therapy (NPWT) and DME NPWT equipment suppliers.

HCPCS & CPT Codes

Local Coverage Determination (LCD): Negative Pressure Wound Therapy Pumps (L33821) has the current HCPCS and CPT codes.

Background

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the improper payment rate for NPWT is 17%, with a projected improper payment amount of $12.1 million.

We outline other policy requirements in LCD L33821 and Article: Negative Pressure Wound Therapy Pumps (A52511).

NPWT is the application of sub-atmospheric pressure to a wound to remove exudate and debris. An integrated system delivers NPWT to a qualified wound, including:

• Suction pump
• Separate exudate collection chamber
• Dressing sets

In these systems, the exudate is wholly removed from the wound site to the collection chamber.

Preventing Denials

We cover NPWT in both home and inpatient settings for patients with chronic Stage 3 or 4 pressure ulcers, neuropathic (for example, diabetic) ulcers, venous or arterial insufficiency ulcers, or a chronic (present at least 30 days) ulcer of mixed etiology.

Before applying NPWT, a patient must’ve tried or considered and ruled out a complete wound therapy program as described in criteria 1–4

1. For all ulcers or wounds, a wound therapy program must include all 1.a.–1.d. general measures, which should be either discussed, applied, or considered and ruled out before applying NPWT:
   1. Documentation in the patient’s medical record of evaluation, care, and wound measurements by a licensed medical provider
   2. Dressings applied to keep a moist wound environment
   3. Debridement of necrotic tissue if present
   4. Evaluation of and provision for adequate nutritional status
2. For Stage 3 or 4 pressure ulcers:
   1. The patient was properly turned and correctly positioned
   2. The patient used a group 2 or 3 support surface for pressure ulcers on the posterior trunk or pelvis (see LCD: Pressure Reducing Support Surfaces - Group 2 (L33642) or LCD: Pressure Reducing Support Surfaces - Group 3 (L33692))
   3. The patient’s moisture and incontinence were properly managed
3. For neuropathic (for example, diabetic) ulcers:
   1. The patient was on a comprehensive diabetic management program
   2. The provider applied proper modalities to reduce pressure on the foot ulcer
4. For venous insufficiency ulcers:
   1. Compression bandages or garments were consistently applied
   2. The provider encouraged leg elevation and ambulation

In the inpatient setting, we may cover NPWT for patients with complications from a surgically created wound (for example, dehiscence) or a traumatic wound (for example, pre-operative flap or graft) where the provider documents the medical necessity for the accelerated formation of granulation tissue that other available topical wound treatments can’t achieve (for example, other patient conditions that won’t allow the same healing time with other topical wound treatments).

Information describing the wound evaluation and treatment, recorded in the patient’s medical record, must show their wounds were regularly evaluated and treated:

• At least monthly, document quantitative measurements of wound characteristics, including wound length and width (surface area), depth, and amount of wound exudate (drainage), showing the progress of healing
• To decide whether equipment and supplies continue to qualify for Medicare coverage, the NPWT equipment and supplies supplier must get a wound healing progress assessment from the treating clinician based on the wound measurement documented in the patient’s medical record
• We may ask for the patient’s medical records to verify the wound is or was healing as shown on the supplier’s claims for payment

When billing NPWT:

• Include a diagnosis code describing the wound treated on each claim for the equipment and related supplies
• Medical records must include a statement from the treating practitioner describing the wound’s initial condition, including measurements, and efforts to manage all wound care aspects
• For each later month, medical records must include updated wound measurements and changes made to effect wound healing
• Month-to-month wound size comparisons must use like measurements (in other words, depth compared to depth or surface area compared to surface area)

If you start NPWT during an inpatient stay, document the first inpatient date of service to correctly account for the treatment duration. Make this date available upon request.

Refill Requirements

For DMEPOS items and supplies provided on a recurring basis, base your billing on prospective, not retrospective use.

Documentation Requirements

To justify payment, you must meet specific requirements when ordering DMEPOS.

Example of Improper Payments Due to Medical Necessity for NPWT

A supplier bills the claim for HCPCS code E2402 (Negative pressure wound therapy electrical pump, stationary or portable) and submits the following documentation per the review contractor’s request:

• Medical record
• Documentation of a neuropathic (diabetic) ulcer on the left foot

What Documentation Was Missing?

According to medical records, the patient hasn’t been evaluated or treated for adequate nutritional status. The provider didn’t send proof that the patient has:

• Been on a comprehensive diabetic management program
• Had proper modalities applied to reduce pressure on the foot ulcer

What Happens Next?

The review contractor completes the claim as an insufficient documentation error, and the Medicare Administrative Contractor recoups payment.

Recommendation

To avoid billing errors and improper payments, the certifying physician must include all medical necessity documentation in the patient’s medical record for DMEPOS.