Clinical UM Guideline

 

Subject: Wound Care in the Home Setting
Guideline #: CG-MED-71 Publish Date:    08/29/2018
Status: Revised Last Review Date:    07/26/2018

Description

This document addresses wound care in the home setting for a variety of wounds such as ulcers related to pressure sores, venous or arterial insufficiency, or neuropathy. This document does not address wound care in a primary care provider office, hospital, or other medical setting. This document also does not address the use of pressure reducing support surfaces, the use of hyperbaric oxygen therapy, the use of vacuum assisted wound therapy (also known as negative pressure wound therapy or NPWT), the use of low-frequency, non-contact, non-thermal ultrasound therapy for wound management, the use of growth factors, silver-based products, and autologous tissues for wound treatment and soft tissue grafting, and the use of soft tissue (for example, skin, ligament, cartilage, etc.) substitutes in wound healing and surgical procedures. For more information regarding these topics, please see:

Note: Please see the following related documents for additional information:

Clinical Indications

Medically Necessary:

Initial wound care in the home setting is considered medically necessary when:

  1. The individual is confined to the home as defined in CG-MED-23 Home Health; and
  2. The wound care is prescribed by the attending physician, health care provider practicing within the scope of license, or the primary care physician in coordination with the attending physician as part of a written plan of care; and
  3. The wound care is so inherently complex that it can only be safely and effectively performed by or under the general supervision of a licensed medical professional (for example, but not limited to stage III or IV pressure ulcers, non-healing neuropathic ulcers, venous or arterial insufficiency related ulcers, persistent wounds); and
  4. A complete, individualized wound care program appropriate to the type of wound being treated, which meets all of the requirements below, has been initiated:
    1. Initial documentation in the individual’s medical record of evaluation, plan of care, wound care, wound characteristics, and wound measurements by a licensed medical professional; and
    2. Application of dressings according to manufacturer guidelines; and
    3. Debridement of necrotic tissue if present; and
    4. Evaluation of and provision for adequate nutritional status; and
    5. Underlying medical conditions (for example, venous insufficiency or diabetes) are being appropriately managed.

Continued wound care in the home setting is considered medically necessary when:

  1. The wound care provided meets all the criteria under initial wound care; and
  2. The plan of care, wound care, wound characteristics, and wound measurements are documented at least once a week by a licensed medical professional; and
  3. The primary care physician, health care provider practicing within the scope of license, or attending physician in coordination with the primary care physician should review the plan of care at least once every 30 days to assess the continued need for wound care in the home setting; and
  4. Progressive wound healing is demonstrated through measurable changes in wound characteristics and wound measurements taken no more than 30 days apart.

Not Medically Necessary:

Wound care in the home setting is considered not medically necessary when:

  1. The plan of care does not demonstrate the need for skilled intervention performed by or under the general supervision of a licensed medical professional; or
  2. Criteria for initial wound care in the home as defined above have not been met; or
  3. Criteria for continuing wound care in the home as defined above have not been met; or
  4. The goals have been achieved per the plan of care; or
  5. The wound care is custodial as defined in CG-MED-19 Custodial Care.
Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

HCPCS

 

S9097

Home visit for wound care

 

 

ICD-10 Diagnosis

 

 

All diagnoses

Discussion/General Information

Wound care is a general term for the treatment of a variety of wounds such as ulcers related to pressure sores, venous or arterial insufficiency, or neuropathy, and is often provided in the home setting. The treatment of these wounds is determined by a detailed assessment that includes, but is not limited to underlying medical conditions, wound measurements, wound characteristics, and nutritional status. Due to the complexities of the types of wounds, underlying medical conditions, and other factors, treatment strategies typically vary for each individual. The plan of care should be a multimodal approach that includes managing underlying medical conditions. An evaluation of the plan of care should occur at least once a week. If the wound shows no measurable improvement within 30 days, the plan of care should be evaluated and changed.

Neuropathic ulcers

Neuropathic ulcers can be caused by various disease processes, including diabetes. The Society for Vascular Surgery published a clinical practice guideline on the management of the diabetic foot, which includes recommendations for diabetic foot ulcers. The guideline recommends off-loading diabetic foot ulcers stating “most plantar ulcers result from repetitive or high plantar pressures…therefore…such pressures must be ameliorated or reduced to allow healing to occur” (Hingorani, 2016). In regards to wound dressings, the guideline states there is little evidence to support the use of one product over another and recommends basing dressing selection on the characteristics of the wound and ease of use of the product.

Ulcers related to pressure sores

Pressure ulcers, also known as pressure sores or pressure injuries, result from decreased blood supply to the tissue due to friction or prolonged pressure on a part of the body. Both the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance (Haesler, 2014) and the Wound, Ostomy and Continence Nurses Society-Wound Guidelines Task Force (2017) released guidelines on the management of pressure ulcers, and recommend the use of support surfaces that meet the individual’s needs and to minimize moisture by managing incontinence.

Venous or arterial insufficiency

Venous or arterial insufficiency results from impairment of blood flow and can lead to tissue ischemia creating an ulcer. The Society for Vascular Surgery published a clinical practice guideline on the management of venous leg ulcers. Compression therapy is recommended for venous leg ulcers to help increase the healing rate (O’Donnell, 2014). In 2016, the Wound Ostomy and Continence Nurses Society published guidelines on the management of wounds caused by lower-extremity arterial disease (Bonham, 2016). Two treatments that the Wound Ostomy and Continence Nurses Society recommends are compression therapy and offloading foot ulcers.

Definitions

Initial wound care in the home setting: The first wound care service provided in the individual’s place of residence.

Neuropathic ulcer: An ulcer resulting from the loss of sensation (for instance, pain, touch, stretch) as well as protective reflexes, due to loss of nerve supply to a body part.

Pressure ulcer (National Pressure Ulcer Advisory Panel, 2016): A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.

Pressure ulcer stages:

Pressure Injury:
A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.

Stage 1 Pressure Injury: Non-blanchable erythema of intact skin
Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.

Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis
Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel.  This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).

Stage 3 Pressure Injury: Full-thickness skin loss
Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

Stage 4 Pressure Injury: Full-thickness skin and tissue loss
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss
Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on an ischemic limb or the heel(s) should not be removed.

Deep Tissue Pressure Injury:
Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin.  This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface.  The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.

Medical Device Related Pressure Injury:
This describes an etiology. Medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system.

Mucosal Membrane Pressure Injury: 
Mucosal membrane pressure injury is found on mucous membranes with a history of a medical device in use at the location of the injury. Due to the anatomy of the tissue these injuries cannot be staged.

References

Government Agency, Medical Society, and Other Authoritative Publications:

  1. First Coast Service Options, Inc. Jurisdiction J-N. Local Coverage Determination for Wound Care (L37166). Revised 12/07/2017. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx?list_type=ncd. Accessed on May 30, 2018.
  2. Bonham PA, Flemister BG, Droste LR, et al. 2014 guideline for management of wounds in patients with lower-extremity arterial disease (LEAD): an executive summary. J Wound Ostomy Continence Nurs. 2016; 43(1):23-31.
  3. Haesler, E (Editor). National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Osborne Park, Western Australia: Cambridge Media. 2014.
  4. Hingorani A, LaMuraglia GM, Henke P, et al. The management of diabetic foot: a clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine. J Vasc Surg. 2016; 63(2 Suppl):3S-21S.
  5. McGinnis E, Stubbs N. Pressure-relieving devices for treating heel pressure ulcers. Cochrane Database Syst Rev. 2014; (2):CD005485.
  6. Moore ZEH, Cowman S. Repositioning for treating pressure ulcers. Cochrane Database Syst Rev. 2015; (1):CD006898.
  7. National Pressure Ulcer Advisory Panel. Pressure Ulcer Stages Revised by NPUAP. April 13, 2016. Available at: http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury/. Accessed on May 30, 2018.
  8. Novitas Solutions, Inc. Jurisdiction J-L. Local Coverage Determination for Wound Care (L35125). Revised 11/09/2017. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx?list_type=ncd. Accessed on May 30, 2018.
  9. O'Donnell TF Jr, Passman MA, Marston WA, et al. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery® and the American Venous Forum. J Vasc Surg. 2014; 60(2 Suppl):3S-59S.
  10. Wisconsin Physicians Service Insurance Corporation. Jurisdiction J-08. Local Coverage Determination for Wound Care (L34587). Revised 11/01/2017. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx?list_type=ncd. Accessed on May 30, 2018.
  11. Wound, Ostomy and Continence Nurses Society-Wound Guidelines Task Force. WOCN 2016 guideline for prevention and management of pressure injuries (ulcers): An executive summary. J Wound Ostomy Continence Nurs. 2017; 44(3):241-246.
Index

Wound Care

History

Status

Date

Action

Revised

07/26/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. Revised Description section to clarify setting. Revised medically necessary criteria regarding initial wound care and continued wound care in the Clinical Indications section. Added additional criteria to the not medically necessary statement in the Clinical Indications section. Updated Discussion/General Information and References section.

New

05/03/2018

MPTAC review. Initial document development.