Provider Notice issued 04/30/03

Wound Care Treatment

 This notice is being sent to clarify the Department's coverage of specialized wound care treatment, specifically the use of Negative Pressure Wound Therapy (Wound V.A.C.) and Non-Contact Wound Warming Therapy (Warm-Up Therapy).

The Department of Public Aid requires providers to use non-specialized or routine wound care for a period of at least 30 days before requesting use of the Wound V.A.C. or Warm-Up Therapy. This policy is consistent with Medicare's policy for wound care treatment.

Approval for specialized wound care is based upon documentation of medical necessity. Documentation must include, but is not limited to, the initial wound measurements, measurements taken at the time the prior approval is being requested, and the history of routine wound care used, including treatment outcome. Extenuating circumstances that the provider believes are relevant must be detailed in the prior approval request.

Reimbursement for decubitus ulcers prevention is included in the long term care facility's (LTC) per diem rate. The nursing component of the LTC per diem rate allows for staff time to perform interventions that prevent decubitus ulcers. The Department will not reimburse for specialized wound care of any preventable wounds that occur during a resident's stay in a long term care facility even after a 30 day period. The long term care facility is responsible for the cost of any specialized wound care required in this situation not the Department. If a resident is admitted with a decubitus ulcer and properly documented conventional treatment of adequate duration has failed, reimbursement may be available for specialized treatment with prior approval.

Questions regarding billing issues and prior approval should be directed to the Bureau of Comprehensive Health Services at 217-782-5565. Other questions should be directed to the Bureau of Long Term Care at 217-782-0545.

A. George Hovanec, Administrator
Division of Medical Programs