Negative Wound Pressure Therapy

Clinical Medical Policy Department
Clinical Affairs Division
Negative Pressure Wound Therapy (NPWT)

[For the list of services and procedures that need preauthorization, please refer to www.mcs.com.pr, go to “Comunicados a Proveedores”
and click “Políticas Médicas”.]
Medical Policy: MP-DME-03-09

Original Effective Date: November 17, 2009
Revised: June 27, 2023
Next Revision: June, 2024
This policy applies to products subscribed by the following corporations, MCS Life Insurance Company (Commercial), and MCS Advantage,
Inc. (Classicare) and Medical Card System, Inc., provider’s contract; unless specific contract limitations, exclusions or exceptions
apply. Please refer to the member’s benefit certification language for benefit availability. Managed care guidelines related to referral
authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply subject to the
aforementioned exceptions.
DESCRIPTION
Negative pressure wound therapy (NPWT), also called vacuum-assisted wound closure, refers to wound
dressing systems that continuously or intermittently apply sub-atmospheric pressure to the surface of a
wound (UpToDate®, 2023). NPWT applies a localized vacuum to draw the edges of the wound together
while providing a moist environment conducive to rapid wound healing. The development of negative
pressure techniques for wound healing is based on two theories:
• The removal of excess interstitial fluid decreases edema and concentrations of inhibitory
factors, and increases local blood flow; and
• Stretching and deformation of the tissue by the negative pressure is believed to disturb the
extracellular matrix and introduce biochemical responses that promote wound healing.
NPWT systems include a vacuum pump, drainage tubing, and a dressing set. The pump may be
stationary or portable, may rely on Alternating Current (AC) or battery power, allows for regulation of
the suction strength, has alarms to indicate loss of suction, and has a replaceable collection canister.
The dressing sets may contain either foam or gauze dressing to be placed in the wound and an adhesive
film drape for sealing the wound. The drainage tubes come in a variety of configurations depending on
the dressings used or wound being treated.
This technology is primarily intended for chronic wounds that have not healed when treated with other
forms of wound care and for minimizing scarring on acute wounds by promoting healing through
granulation tissue formation and re-epithelization (second intention). Therefore, NPWT may be used as
either a primary or secondary line of treatment, depending on the type of wound.
COVERAGE
Benefits may vary between groups and contracts. Please refer to the appropriate member certificate
and subscriber agreement contract for applicable diagnostic imaging, DME, laboratory, machine tests,
benefits and coverage.
This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 1
Medical technology is constantly changing and we reserves the right to review and update our policies periodically.
Medical Card System, Inc.
All Rights Reserved®
In order to obtain medical coverage by Medical Card System, Inc., (MCS), a Written Order Prior to
Delivery (WOPD) for these services is required. Please refer to the section entitled New Order
(Prescription) Requirements for further details.
INDICATIONS
I. Medical Card System, Inc., (MCS) considers the use of Negative Wound Pressure Therapy (NWPT) and
supplies as medically necessary, for Both the Commercial and Classicare Lines of Business (LOB), when
Either criterion A or B is met:
A. Ulcers and Wounds in the Home Setting: The patient has a chronic Stage III or IV pressure ulcer
(See Appendix A), neuropathic ulcer (for example, diabetic), venous or arterial insufficiency
ulcer, or a chronic ulcer of mixed etiology (being present for at least 30 days). A complete
wound therapy program described below (A-1 through A-4), as applicable depending on the
type of wound, must have been tried, or considered, and ruled out Prior to application of NPWT.
1. For All ulcers or wounds, the following components of a wound therapy program must
include a minimum of All of the following general measures, which should either be
addressed, applied, or considered, and ruled out, Prior to application of NPWT:
a. Documentation in the patient’s medical record of evaluation, care, and wound

measurements by a licensed medical professional; and
b. Application of dressings to maintain a moist wound environment; and
c. Debridement of necrotic tissue if present; and
d. Evaluation of and provision for adequate nutritional status.
2. For Stage III or IV pressure ulcers:
a. The patient has been appropriately turned and positioned, and
b. The patient has used a group 2 or 3 support surface (See Appendix B) for pressure
ulcers on the posterior trunk or pelvis, and
c. The patient’s moisture and incontinence have been appropriately managed.
3. For neuropathic ulcers (for example, diabetic):
a. The patient has been on a comprehensive diabetic management program, and
b. Reduction in pressure on a foot ulcer has been accomplished with appropriate

modalities.
4. For venous insufficiency ulcers:
a. Compression bandages and/or garments have been consistently applied, and

b. Leg elevation and ambulation have been encouraged.
B. Ulcers and Wounds Encountered in an Inpatient Setting:
1. An ulcer or wound (described under Criteria I–A of the Indications Section above) is
encountered in the inpatient setting and, after wound treatments described under A–1
through A–4 above, have been tried, or considered and ruled out, NPWT is initiated because
it is considered in the judgment of the treating physician, the best available treatment
option.
2. The patient has complications of a surgically created wound (for example, dehiscence) or a
traumatic wound (for example, pre-operative flap or graft) where there is documentation of
the medical necessity for accelerated formation of granulation tissue which cannot be
achieved by other available topical wound treatments (for example, other conditions of the
patient that will not allow for healing times achievable with other topical wound
treatments).
• Limitations for Ulcers and Wounds Encountered in an Inpatient Setting:
1. In either situation, B-1 or B-2 above, NPWT will be considered medically necessary when
treatment is ordered to continue beyond discharge to the home setting.
2. If criteria A or B from part I of the Indications Section above are NOT MET, then the NPWT
pump and supplies will be considered as NOT medically necessary, and therefore NOT
covered.
3. NPWT pumps (i.e., HCPCS Code E2402) must be capable of accommodating more than one
wound dressing set for multiple wounds on a patient. Therefore, more than one pump (i.e.,
HCPCS Code E2402) billed per patient for the same time period will be considered NOT
medically necessary, and therefore NOT covered.
II. Medical Card System, Inc., (MCS) will consider as medically necessary the Continued Medical
Coverage for NPWT, for Both the Commercial and Classicare LOB, under the following
circumstances:
A. For wounds and ulcers described under Criteria I–A or I–B of the Indications Section above,
once placed on a NPWT pump and supplies, in order for medical coverage to continue, a
licensed medical professional (See General Limitation # 1) must do All of the following:
1. On a regular basis:
a. Directly assess the wound(s) being treated with the NPWT pump; and
b. Supervise or directly perform the NPWT dressing changes; and
2. On at least a monthly basis, document changes in the ulcer’s dimensions and

characteristics.
• Limitations for Continued Medical Coverage for NPWT:
1. If criteria from A–1 through A–2 from the Indications Section Set II are not fulfilled, then
Continued Coverage of the NPWT pump and supplies will be considered as NOT medically
necessary, and therefore NOT covered.
III. Medical Card System, Inc., (MCS) will consider the Discontinuation and/or End of medical coverage
for NPWT pump and supplies, for Both the Commercial and Classicare LOB, for wounds and ulcers as
described under Criteria I–A or I–B of the Indications Section above, and with Any of the following
events, whichever occurs earliest:
1. Criteria from A–1 through A–2 from the Indications Section Set II above, under “Continued
Medical Coverage”, ceases to occur or be met; or
2. In the judgment of the treating physician, adequate wound healing has occurred to the
degree that NPWT may be discontinued; or
3. Any measurable degree of wound healing has failed to occur over the prior month. Wound
healing is defined as improvement occurring in either surface area (length times width) or
depth of the wound; or
4. Four (4) months (including the time NPWT was applied in an inpatient setting prior to
discharge to the home) have elapsed using an NPWT pump in the treatment of the most
recent wound. Medical necessity of NPWT beyond 4 months will be given individual
consideration based upon required additional documentation (See General Limitation # 2);
or
5. Once equipment or supplies are no longer being used for the patient, whether or not by the
physician’s order.
IV. Medical Card System, Inc., (MCS) will consider as medically necessary the Medical Coverage for
NPWT Supplies, for both the Commercial and Classicare LOB, when Any of the following are required:
1. Medical coverage is provided up to a maximum of 15 dressing kits (i.e., HCPCS Code A6550)
per wound per month.
2. Medical coverage is provided up to a maximum of 10 canister sets (i.e., HCPCS Code A7000)
per month unless there is documentation evidencing a large volume of drainage (greater
than 90 ml of exudate per day). For high volume exudative wounds, a stationary pump with
the largest capacity canister must be used.
3. When billing for quantities of canisters greater than those described in the policy as the
usual maximum amounts, there must be clear and explicit information in the medical record
that justifies the additional quantities.
• Limitations for Medical Coverage for NPWT Supplies:
1. For NPWT and supplies provided on a recurring basis, billing must be based on prospective,
not retrospective use.
2. For NPWT supplies (i.e., HCPCS Codes A6550 and A7000) that are provided as refills to the
original order, suppliers must contact the patient prior to dispensing the refill and not
automatically ship on a pre-determined basis, even if authorized by the patient. This shall
be done to ensure that the refilled item remains reasonable and medically necessary, that
existing supplies are approaching exhaustion, and to confirm any changes/modifications to
the order.
3. Contact with the patient or designee regarding refills must take place no sooner than 14
calendar days prior to the delivery/shipping date.
4. For delivery of refills, the supplier must deliver the NPWT device and/or supplies no sooner
than 10 calendar days prior to the end of usage for the current product. This is regardless of
which delivery method is utilized.
5. For all NPWT devices and/or supplies that are provided on a recurring basis, suppliers are
required to have contact with the patient or caregiver/designee prior to dispensing a new
supply of items. Suppliers must not deliver refills without a refill request from the patient.
Items delivered without a valid, documented refill request will be considered as NOT
reasonable and medically necessary, and therefore NOT covered.
6. Suppliers must not dispense a quantity of supplies exceeding a patient’s expected

utilization. Suppliers must stay attuned to changed or atypical utilization patterns on the
part of their patients. Suppliers must verify with the treating practitioner that any changed
or atypical utilization is warranted. Regardless of utilization, a supplier MUST NOT dispense
more than a one (1)-month quantity at a time.
GENERAL LIMITATIONS
1. A licensed health care professional, for the purposes of this medical policy, may be a
physician (MD), physician’s assistant (PA), registered nurse (RN), licensed practical nurse
(LPN), or Physical Therapist (PT). The treating practitioner should be licensed to assess
wounds and/or administer wound care within the state where the patient is receiving
NPWT.
2. When NPWT therapy exceeds 4 months on the most recent wound and medical coverage
ends, individual consideration for one additional month at a time may be sought using the
appeals process. Information from the treating practitioner’s medical record,
contemporaneous with each requested one-month treatment time period extension, must
be submitted with each appeal explaining the special circumstances necessitating the
extended month of therapy. This medical policy provides coverage for the use of NPWT
limited to initiating healing of the problem wounds described in the Indications and
Limitations sections, rather than continuation of therapy to complete healing, since there is
no published medical literature demonstrating evidence of a clinical benefit for the use of
NPWT to complete wound healing. Therefore, general, vague or nonspecific statements in
the medical record such as “doing well”, “want to continue until “healed”, provide
insufficient information to justify the medical need for extension of treatment. The medical
record must provide specific and detailed information to explain the continuing problems
with the wound, what additional measures are being undertaken to address those problems
and promote healing and why a switch to alternative treatments alone is not possible.
3. Suppliers must add a KX modifier to a code only if ALL of the criteria within the “Indications
and Limitations of Medical Coverage” Sections of this medical policy have been met.
4. The KX modifier must NOT be used with an NPWT pump and supplies for wounds if:
a. The pump has been used to treat a single wound and the claim is for the 5th or
subsequent month’s rental, or
b. The pump has been used to treat more than one wound and the claim is for the 5 th or
subsequent month’s rental after therapy has begun on the most recently treated
wound. In this situation, the KX modifier may be billed for more than 4 total months of
rental.
5. In all of the situations above describing use of the KX modifier, if all of the coverage criteria
have not been met, the GA or GZ modifier must be added to a claim line for the NPWT pump
and supplies. When there is an expectation of a medical necessity denial, suppliers must
enter the GA modifier on the claim line if they have obtained a properly executed Advance
Beneficiary Notice (ABN) or the GZ modifier if they have not obtained a valid ABN. Claim
lines billed without a KX, GA or GZ modifier will be rejected as missing information.
6. Disposable wound suction pumps (i.e., HCPCS Code A9272) and related supplies are NOT
covered.
7. NPWT is provided with an integrated system of components. This system contains a pump
(i.e., HCPCS Code E2402), dressing sets or supplies (i.e., HCPCS Code A6550), and a separate
collection canister (i.e., HCPCS Code A7000). Wound suction systems that do not contain all
of the required components are NOT classified as NPWT. The proper components’
specifications are as follows:
a. HCPCS Code E2402 describes a stationary or portable Negative Pressure Wound Therapy
(NPWT) electrical pump which provides controlled sub-atmospheric pressure that is
designed for use with NPWT dressings (i.e., HCPCS Code A6550) and canisters (i.e.,
HCPCS Code A7000) to promote wound healing. The NPWT pump must be capable of
being selectively switched between continuous and intermittent modes of operation
and is controllable to adjust the degree of sub-atmospheric pressure conveyed to the
wound in a range of 40-80 mm Hg sub-atmospheric pressure. The system must contain
sensors and alarms to monitor pressure variations and exudate volume in the collection
canister.
b. HCPCS Code A6550 describes an allowance for a dressing set which is used in
conjunction with a stationary or portable NPWT pump (i.e., HCPCS Code E2402). A
single HCPCS Code A6550 is used for each single, complete dressing change, and
contains all necessary components, including but not limited to any separate, non-
adherent porous dressing(s), drainage tubing, and an occlusive dressing(s) which creates
a seal around the wound site for maintaining sub-atmospheric pressure at the wound.
c. HCPCS Code A7000 describes a canister set which is used in conjunction with a
stationary or portable NPWT pump and contains all necessary components, including
but not limited to a container, to collect wound exudate. Canisters may be various sizes
to accommodate stationary or portable NPWT pumps.
8. An order for each item billed must be signed and dated by the treating practitioner. This
written order/prescription is referred to as the Standard Written Order (SWO). Items
dispensed and/or billed that do not meet these order/prescription requirements and those
below must be submitted with an EY modifier added to each affected HCPCS code. For more
information make reference to the LCA Standard Documentation Requirements for All
Claims Submitted to DME MACs (A55426).
CONTRAINDICATIONS/WARNINGS
1. A Negative Pressure Wound Therapy (NPWT) pump and Supplies Will Not be considered
medically necessary, and therefore NOT covered for Both LOB, if One or More of the
following are present:
a. The presence in the wound of necrotic tissue with eschar, if debridement is not
attempted;
b. Osteomyelitis within the vicinity of the wound that is not concurrently being treated
with intent to cure;
c. The presence of an open fistula to an organ or body cavity within the vicinity of the
wound;
d. Cancer present in the wound.
2. NPWT should be used cautiously when there is active bleeding, when the patient is on
anticoagulants, when there is difficult wound homeostasis, or when placing dressing in
proximity to blood vessels.
Note1: NPWT systems, pumps and their associated supplies, that have not been specifically
designated as being qualified to use HCPCS codes E2402 via written instructions from the Pricing,
Data Analysis and Coding (PDAC) Contractor will be denied as not reasonable and necessary.
RATIONALE
MCS framework is designed to improve access, outcomes, and our enrollee’s experience of care and to
ensure all enrollees achieve their best health. This policy acts as a guideline for nursing staff in the initial
screening of service requests, meticulously upholding a hierarchy that prioritizes Local Coverage
Determinations (LCDs) and National Coverage Determinations (NCDs) established by the Centers for
Medicare & Medicaid Services (CMS), followed by our organization's medical policy, recognized medical
association guidelines, and clinical decision-making processes. It is crafted to ensure that preliminary
assessments are in harmony with these layers of guidance, underscoring that all final coverage
determinations strictly adhere to the relevant LCDs and NCDs, while also considering the insights from
recognized medical associations and the clinical judgment of healthcare professionals (MD’s and DMD’s)
as necessary.
CODING INFORMATION
CPT® Codes (List may not be all inclusive)
CPT® Codes DESCRIPTION
97605 Negative pressure wound therapy (eg, vacuum assisted drainage collection), utilizing
durable medical equipment (DME), including topical application(s), wound
assessment, and instruction(s) for ongoing care, per session; total wound(s) surface
area less than or equal to 50 square centimeters
97606 Negative pressure wound therapy (eg, vacuum assisted drainage collection), utilizing
durable medical equipment (DME), including topical application(s), wound
assessment, and instruction(s) for ongoing care, per session; total wound(s) surface
area greater than 50 square centimeters
Current Procedural Terminology (CPT®) 2023 American Medical Association: Chicago, IL.
HCPCS Codes (List may not be all inclusive)

HCPCS® CODES DESCRIPTION
A6550 Wound Care Set, for Negative Pressure Wound Therapy Electrical Pump, includes All
Supplies and Accessories
A7000 Canister, disposable, used with suction pump, each
E2402 Negative Pressure Wound Therapy Electrical Pump, Stationary or Portable
2023 HCPCS LEVEL II Professional Edition® (American Medical Association).
HCPCS Modifiers (List may not be all inclusive)

HCPCS DESCRIPTION
MODIFIERS
EY No physician or other licensed health care provider order for this item or service
GA Waiver of liability statement issued as required by payer policy, individual case
GZ Item or service expected to be denied as not reasonable and necessary
KX Requirements specified in the medical policy have been met
HCPCS Codes Not Covered for Both LOB (List may not be all inclusive)
HCPCS® CODES DESCRIPTION
A9270 Non-covered item or service
A9272 Wound suction, disposable, includes dressing, all accessories and components, any
type, each
ICD-10 Codes (List may not be all inclusive)

ICD-10-Codes DESCRIPTION
E10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecified
E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy
E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy
42
E10.43 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy
E10.44 Type 1 diabetes mellitus with diabetic amyotrophy
E10.49 Type 1 diabetes mellitus with other diabetic neurological complication
E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene
E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E10.59 Type 1 diabetes mellitus with other circulatory complications
E10.610 Type 1 diabetes mellitus with diabetic neuropathic arthropathy
E10.618 Type 1 diabetes mellitus with other diabetic arthropathy
E10.620 Type 1 diabetes mellitus with diabetic dermatitis
E10.621 Type 1 diabetes mellitus with foot ulcer
E10.622 Type 1 diabetes mellitus with other skin ulcer
E10.628 Type 1 diabetes mellitus with other skin complications
E10.630 Type 1 diabetes mellitus with periodontal disease
E10.638 Type 1 diabetes mellitus with other oral complications
E10.641 Type 1 diabetes mellitus with hypoglycemia with coma
E10.649 Type 1 diabetes mellitus with hypoglycemia without coma
E10.65 Type 1 diabetes mellitus with hyperglycemia
E10.69 Type 1 diabetes mellitus with other specified complication
E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified
E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy
E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy
E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy
E11.44 Type 2 diabetes mellitus with diabetic amyotrophy
E11.49 Type 2 diabetes mellitus with other diabetic neurological complication
E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene
E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E11.59 Type 2 diabetes mellitus with other circulatory complications
E11.610 Type 2 diabetes mellitus with diabetic neuropathic arthropathy
E11.618 Type 2 diabetes mellitus with other diabetic arthropathy
E11.620 Type 2 diabetes mellitus with diabetic dermatitis
E11.621 Type 2 diabetes mellitus with foot ulcer
E11.622 Type 2 diabetes mellitus with other skin ulcer
E11.628 Type 2 diabetes mellitus with other skin complications
E11.630 Type 2 diabetes mellitus with periodontal disease
E11.638 Type 2 diabetes mellitus with other oral complications
E11.641 Type 2 diabetes mellitus with hypoglycemia with coma
E11.649 Type 2 diabetes mellitus with hypoglycemia without coma
E11.65 Type 2 diabetes mellitus with hyperglycemia
E11.69 Type 2 diabetes mellitus with other specified complication
E13.29 Other specified diabetes mellitus with other diabetic kidney complication
E13.311 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular
E13.319 edemaspecified diabetes mellitus with unspecified diabetic retinopathy without
Other
E13.3211 macular
Other edema diabetes mellitus with mild nonproliferative diabetic retinopathy with
specified
macular edema, right eye
E13.3212 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with
macular edema, left eye
macular edema, bilateral
macular edema, unspecified eye
E13.3291 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy
without macular edema, right eye
without macular edema, left eye
without macular edema, bilateral
without macular edema, unspecified eye
E13.3311 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy
with macular edema, right eye
with macular edema, left eye
with macular edema, bilateral
with macular edema, unspecified eye
E13.3411 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy
with macular edema, right eye
with macular edema, left eye
with macular edema, bilateral
with macular edema, unspecified eye
E13.3511 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular
edema, right eye
edema, left eye
edema, bilateral
edema, unspecified eye
E13.3521 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction
retinal detachment involving the macula, right eye
retinal detachment involving the macula, left eye
retinal detachment involving the macula, bilateral
retinal detachment involving the macula, unspecified eye
retinal detachment not involving the macula, right eye
retinal detachment not involving the macula, left eye
retinal detachment not involving the macula, bilateral
retinal detachment not involving the macula, unspecified eye
E13.3541 Other specified diabetes mellitus with proliferative diabetic retinopathy with
combined traction retinal detachment and rhegmatogenous retinal, right eye
E13.3542 detachment
Other specified diabetes mellitus with proliferative diabetic retinopathy with
combined traction retinal detachment and rhegmatogenous retinal, left eye
combined traction retinal detachment and rhegmatogenous retinal, bilateral
combined traction retinal detachment and rhegmatogenous retinal, unspecified eye
E13.3551 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, right
eye
E13.3552 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, left eye
E13.3553 Other specified diabetes mellitus with stable proliferative diabetic retinopathy,
bilateral
E13.3559 Other specified diabetes mellitus with stable proliferative diabetic retinopathy,
unspecified eye
E13.3591 Other specified diabetes mellitus with proliferative diabetic retinopathy without
macular edema, right eye
macular edema, left eye
macular edema, bilateral
macular edema, unspecified eye
E13.36 Other specified diabetes mellitus with diabetic cataract
E13.37X1 Other specified diabetes mellitus with diabetic macular edema, resolved following
treatment, right eye
treatment, left eye
treatment, bilateral
treatment, unspecified eye
E13.39 Other specified diabetes mellitus with other diabetic ophthalmic complication
E13.40 Other specified diabetes mellitus with diabetic neuropathy, unspecified
E13.51 Other specified diabetes mellitus with diabetic peripheral angiopathy without
gangrene
E13.52 Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene
E13.59 Other specified diabetes mellitus with other circulatory complications
E13.610 Other specified diabetes mellitus with diabetic neuropathic arthropathy
E13.618 Other specified diabetes mellitus with other diabetic arthropathy
E13.620 Other specified diabetes mellitus with diabetic dermatitis
E13.621 Other specified diabetes mellitus with foot ulcer
E13.622 Other specified diabetes mellitus with other skin ulcer
E13.628 Other specified diabetes mellitus with other skin complications
E13.630 Other specified diabetes mellitus with periodontal disease
E13.638 Other specified diabetes mellitus with other oral complications
E13.641 Other specified diabetes mellitus with hypoglycemia with coma
E13.649 Other specified diabetes mellitus with hypoglycemia without coma
E13.65 Other specified diabetes mellitus with hyperglycemia
E13.69 Other specified diabetes mellitus with other specified complication
I70.231 Atherosclerosis of native arteries of right leg with ulceration of thigh
I70.232 Atherosclerosis of native arteries of right leg with ulceration of calf
I70.233 Atherosclerosis of native arteries of right leg with ulceration of ankle
I70.234 Atherosclerosis of native arteries of right leg with ulceration of heel and midfoot
I70.235 Atherosclerosis of native arteries of right leg with ulceration of other part of foot
I70.238 Atherosclerosis of native arteries of right leg with ulceration of other part of lower
right leg
I70.239 Atherosclerosis of native arteries of right leg with ulceration of unspecified site
I70.241 Atherosclerosis of native arteries of left leg with ulceration of thigh
I70.242 Atherosclerosis of native arteries of left leg with ulceration of calf
I70.243 Atherosclerosis of native arteries of left leg with ulceration of ankle
I70.244 Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot
I70.245 Atherosclerosis of native arteries of left leg with ulceration of other part of foot
I70.248 Atherosclerosis of native arteries of left leg with ulceration of other part of lower left
leg
I70.249 Atherosclerosis of native arteries of left leg with ulceration of unspecified site
I70.25 Atherosclerosis of native arteries of other extremities with ulceration
I70.261 Atherosclerosis of native arteries of extremities with gangrene, right leg
I70.262 Atherosclerosis of native arteries of extremities with gangrene, left leg
I70.263 Atherosclerosis of native arteries of extremities with gangrene, bilateral legs
I70.268 Atherosclerosis of native arteries of extremities with gangrene, other extremity
I70.269 Atherosclerosis of native arteries of extremities with gangrene, unspecified extremity
I73.9 Peripheral vascular disease, unspecified
I83.001 Varicose veins of unspecified lower extremity with ulcer of thigh
I83.002 Varicose veins of unspecified lower extremity with ulcer of calf
I83.003 Varicose veins of unspecified lower extremity with ulcer of ankle
I83.004 Varicose veins of unspecified lower extremity with ulcer of heel and midfoot
I83.005 Varicose veins of unspecified lower extremity with ulcer other part of foot
I83.008 Varicose veins of unspecified lower extremity with ulcer other part of lower leg
I83.009 Varicose veins of unspecified lower extremity with ulcer of unspecified site
I83.011 Varicose veins of right lower extremity with ulcer of thigh
I83.012 Varicose veins of right lower extremity with ulcer of calf
I83.013 Varicose veins of right lower extremity with ulcer of ankle
I83.014 Varicose veins of right lower extremity with ulcer of heel and midfoot
I83.015 Varicose veins of right lower extremity with ulcer other part of foot
I83.018 Varicose veins of right lower extremity with ulcer other part of lower leg
I83.019 Varicose veins of right lower extremity with ulcer of unspecified site
I83.021 Varicose veins of left lower extremity with ulcer of thigh
I83.022 Varicose veins of left lower extremity with ulcer of calf
I83.023 Varicose veins of left lower extremity with ulcer of ankle
I83.024 Varicose veins of left lower extremity with ulcer of heel and midfoot
I83.025 Varicose veins of left lower extremity with ulcer other part of foot
I83.028 Varicose veins of left lower extremity with ulcer other part of lower leg
I83.029 Varicose veins of left lower extremity with ulcer of unspecified site
L89.003 Pressure ulcer of unspecified elbow, stage 3
L89.004 Pressure ulcer of unspecified elbow, stage 4
L89.013 Pressure ulcer of right elbow, stage 3
L89.014 Pressure ulcer of right elbow, stage 4
L89.023 Pressure ulcer of left elbow, stage 3
L89.024 Pressure ulcer of left elbow, stage 4
L89.103 Pressure ulcer of unspecified part of back, stage 3
L89.104 Pressure ulcer of unspecified part of back, stage 4
L89.113 Pressure ulcer of right upper back, stage 3
L89.114 Pressure ulcer of right upper back, stage 4
L89.123 Pressure ulcer of left upper back, stage 3
L89.124 Pressure ulcer of left upper back, stage 4
L89.133 Pressure ulcer of right lower back, stage 3
L89.134 Pressure ulcer of right lower back, stage 4
L89.143 Pressure ulcer of left lower back, stage 3
L89.144 Pressure ulcer of left lower back, stage 4
L89.153 Pressure ulcer of sacral region, stage 3
L89.154 Pressure ulcer of sacral region, stage 4
L89.203 Pressure ulcer of unspecified hip, stage 3
L89.204 Pressure ulcer of unspecified hip, stage 4
L89.213 Pressure ulcer of right hip, stage 3
L89.214 Pressure ulcer of right hip, stage 4
L89.223 Pressure ulcer of left hip, stage 3
L89.224 Pressure ulcer of left hip, stage 4
L89.303 Pressure ulcer of unspecified buttock, stage 3
L89.304 Pressure ulcer of unspecified buttock, stage 4
L89.313 Pressure ulcer of right buttock, stage 3
L89.314 Pressure ulcer of right buttock, stage 4
L89.323 Pressure ulcer of left buttock, stage 3
L89.324 Pressure ulcer of left buttock, stage 4
L89.43 Pressure ulcer of contiguous site of back, buttock and hip, stage 3
L89.44 Pressure ulcer of contiguous site of back, buttock and hip, stage 4
L89.503 Pressure ulcer of unspecified ankle, stage 3
L89.504 Pressure ulcer of unspecified ankle, stage 4
L89.513 Pressure ulcer of right ankle, stage 3
L89.514 Pressure ulcer of right ankle, stage 4
L89.523 Pressure ulcer of left ankle, stage 3
L89.524 Pressure ulcer of left ankle, stage 4
L89.603 Pressure ulcer of unspecified heel, stage 3
L89.604 Pressure ulcer of unspecified heel, stage 4
L89.613 Pressure ulcer of right heel, stage 3
L89.614 Pressure ulcer of right heel, stage 4
L89.623 Pressure ulcer of left heel, stage 3
L89.624 Pressure ulcer of left heel, stage 4
L89.813 Pressure ulcer of head, stage 3
L89.814 Pressure ulcer of head, stage 4
L89.893 Pressure ulcer of other site, stage 3
L89.894 Pressure ulcer of other site, stage 4
S31.100A Unspecified open wound of abdominal wall, right upper quadrant without penetration
into peritoneal cavity, initial encounter
S31.100D Unspecified open wound of abdominal wall, right upper quadrant without penetration
into peritoneal cavity, subsequent encounter
S31.100S Unspecified open wound of abdominal wall, right upper quadrant without penetration
into peritoneal cavity, sequela
S31.101A Unspecified open wound of abdominal wall, left upper quadrant without penetration
S31.101D Unspecified open wound of abdominal wall, left upper quadrant without penetration
S31.101S Unspecified open wound of abdominal wall, left upper quadrant without penetration
S31.102A Unspecified open wound of abdominal wall, epigastric region without penetration into
peritoneal cavity, initial encounter
S31.102D Unspecified open wound of abdominal wall, epigastric region without penetration into
peritoneal cavity, subsequent encounter
S31.102S Unspecified open wound of abdominal wall, epigastric region without penetration into
peritoneal cavity, sequela
S31.103A Unspecified open wound of abdominal wall, right lower quadrant without penetration
S31.103D Unspecified open wound of abdominal wall, right lower quadrant without penetration
S31.103S Unspecified open wound of abdominal wall, right lower quadrant without penetration
S31.104A Unspecified open wound of abdominal wall, left lower quadrant without penetration
S31.104D Unspecified open wound of abdominal wall, left lower quadrant without penetration
S31.104S Unspecified open wound of abdominal wall, left lower quadrant without penetration
S31.105A Unspecified open wound of abdominal wall, periumbilic region without penetration
S31.105D Unspecified open wound of abdominal wall, periumbilic region without penetration
S31.105S Unspecified open wound of abdominal wall, periumbilic region without penetration
S31.109A Unspecified open wound of abdominal wall, unspecified quadrant without penetration
S31.109D Unspecified open wound of abdominal wall, unspecified quadrant without penetration
S31.109S Unspecified open wound of abdominal wall, unspecified quadrant without penetration
S31.110A Laceration without foreign body of abdominal wall, right upper quadrant without
penetration into peritoneal cavity, initial encounter
S31.110D Laceration without foreign body of abdominal wall, right upper quadrant without
penetration into peritoneal cavity, subsequent encounter
S31.110S Laceration without foreign body of abdominal wall, right upper quadrant without
penetration into peritoneal cavity, sequela
S31.111A Laceration without foreign body of abdominal wall, left upper quadrant without
S31.111D Laceration without foreign body of abdominal wall, left upper quadrant without
S31.111S Laceration without foreign body of abdominal wall, left upper quadrant without
S31.112A Laceration without foreign body of abdominal wall, epigastric region without
S31.112D Laceration without foreign body of abdominal wall, epigastric region without
S31.112S Laceration without foreign body of abdominal wall, epigastric region without
S31.113A Laceration without foreign body of abdominal wall, right lower quadrant without
S31.113D Laceration without foreign body of abdominal wall, right lower quadrant without
S31.113S Laceration without foreign body of abdominal wall, right lower quadrant without
S31.114A Laceration without foreign body of abdominal wall, left lower quadrant without
S31.114D Laceration without foreign body of abdominal wall, left lower quadrant without
S31.114S Laceration without foreign body of abdominal wall, left lower quadrant without
S31.115A Laceration without foreign body of abdominal wall, periumbilic region without
S31.115D Laceration without foreign body of abdominal wall, periumbilic region without
S31.115S Laceration without foreign body of abdominal wall, periumbilic region without
S31.119A Laceration without foreign body of abdominal wall, unspecified quadrant without
S31.119D Laceration without foreign body of abdominal wall, unspecified quadrant without
S31.119S Laceration without foreign body of abdominal wall, unspecified quadrant without
S31.120A Laceration of abdominal wall with foreign body, right upper quadrant without
S31.120D Laceration of abdominal wall with foreign body, right upper quadrant without
S31.120S Laceration of abdominal wall with foreign body, right upper quadrant without
S31.121A Laceration of abdominal wall with foreign body, left upper quadrant without
S31.121D Laceration of abdominal wall with foreign body, left upper quadrant without
S31.121S Laceration of abdominal wall with foreign body, left upper quadrant without
S31.122A Laceration of abdominal wall with foreign body, epigastric region without penetration
S31.122D Laceration of abdominal wall with foreign body, epigastric region without penetration
S31.122S Laceration of abdominal wall with foreign body, epigastric region without penetration
S31.123A Laceration of abdominal wall with foreign body, right lower quadrant without
S31.123D Laceration of abdominal wall with foreign body, right lower quadrant without
S31.123S Laceration of abdominal wall with foreign body, right lower quadrant without
S31.124A Laceration of abdominal wall with foreign body, left lower quadrant without
S31.124D Laceration of abdominal wall with foreign body, left lower quadrant without
S31.124S Laceration of abdominal wall with foreign body, left lower quadrant without
S31.125A Laceration of abdominal wall with foreign body, periumbilic region without
S31.125D Laceration of abdominal wall with foreign body, periumbilic region without
S31.125S Laceration of abdominal wall with foreign body, periumbilic region without
S31.129A Laceration of abdominal wall with foreign body, unspecified quadrant without
S31.129D Laceration of abdominal wall with foreign body, unspecified quadrant without
S31.129S Laceration of abdominal wall with foreign body, unspecified quadrant without
S31.130A Puncture wound of abdominal wall without foreign body, right upper quadrant
without penetration into peritoneal cavity, initial encounter
S31.130D Puncture wound of abdominal wall without foreign body, right upper quadrant
without penetration into peritoneal cavity, subsequent encounter
S31.130S Puncture wound of abdominal wall without foreign body, right upper quadrant
without penetration into peritoneal cavity, sequela
S31.131A Puncture wound of abdominal wall without foreign body, left upper quadrant without
S31.131D Puncture wound of abdominal wall without foreign body, left upper quadrant without
S31.131S Puncture wound of abdominal wall without foreign body, left upper quadrant without
S31.132A Puncture wound of abdominal wall without foreign body, epigastric region without
S31.132D Puncture wound of abdominal wall without foreign body, epigastric region without
S31.132S Puncture wound of abdominal wall without foreign body, epigastric region without
S31.133A Puncture wound of abdominal wall without foreign body, right lower quadrant without
S31.133D Puncture wound of abdominal wall without foreign body, right lower quadrant without
S31.133S Puncture wound of abdominal wall without foreign body, right lower quadrant without
S31.134A Puncture wound of abdominal wall without foreign body, left lower quadrant without
S31.134D Puncture wound of abdominal wall without foreign body, left lower quadrant without
S31.134S Puncture wound of abdominal wall without foreign body, left lower quadrant without
S31.135A Puncture wound of abdominal wall without foreign body, periumbilic region without
S31.135D Puncture wound of abdominal wall without foreign body, periumbilic region without
S31.135S Puncture wound of abdominal wall without foreign body, periumbilic region without
S31.139A Puncture wound of abdominal wall without foreign body, unspecified quadrant
without penetration into peritoneal cavity, initial encounter
S31.139D Puncture wound of abdominal wall without foreign body, unspecified quadrant
without penetration into peritoneal cavity, subsequent encounter
S31.139S Puncture wound of abdominal wall without foreign body, unspecified quadrant
without penetration into peritoneal cavity, sequela
S31.140A Puncture wound of abdominal wall with foreign body, right upper quadrant without
S31.140D Puncture wound of abdominal wall with foreign body, right upper quadrant without
S31.140S Puncture wound of abdominal wall with foreign body, right upper quadrant without
S31.141A Puncture wound of abdominal wall with foreign body, left upper quadrant without
S31.141D Puncture wound of abdominal wall with foreign body, left upper quadrant without
S31.141S Puncture wound of abdominal wall with foreign body, left upper quadrant without
S31.142A Puncture wound of abdominal wall with foreign body, epigastric region without
S31.142D Puncture wound of abdominal wall with foreign body, epigastric region without
S31.142S Puncture wound of abdominal wall with foreign body, epigastric region without
S31.143A Puncture wound of abdominal wall with foreign body, right lower quadrant without
S31.143D Puncture wound of abdominal wall with foreign body, right lower quadrant without
S31.143S Puncture wound of abdominal wall with foreign body, right lower quadrant without
S31.144A Puncture wound of abdominal wall with foreign body, left lower quadrant without
S31.144D Puncture wound of abdominal wall with foreign body, left lower quadrant without
S31.144S Puncture wound of abdominal wall with foreign body, left lower quadrant without
S31.145A Puncture wound of abdominal wall with foreign body, periumbilic region without
S31.145D Puncture wound of abdominal wall with foreign body, periumbilic region without
S31.145S Puncture wound of abdominal wall with foreign body, periumbilic region without
S31.149A Puncture wound of abdominal wall with foreign body, unspecified quadrant without
S31.149D Puncture wound of abdominal wall with foreign body, unspecified quadrant without
S31.149S Puncture wound of abdominal wall with foreign body, unspecified quadrant without
S31.150A Open bite of abdominal wall, right upper quadrant without penetration into peritoneal
cavity, initial encounter
S31.150D Open bite of abdominal wall, right upper quadrant without penetration into peritoneal
cavity, subsequent encounter
S31.150S Open bite of abdominal wall, right upper quadrant without penetration into peritoneal
cavity, sequela
S31.151A Open bite of abdominal wall, left upper quadrant without penetration into peritoneal
S31.151D Open bite of abdominal wall, left upper quadrant without penetration into peritoneal
S31.151S Open bite of abdominal wall, left upper quadrant without penetration into peritoneal
cavity, sequela
S31.152A Open bite of abdominal wall, epigastric region without penetration into peritoneal
S31.152D Open bite of abdominal wall, epigastric region without penetration into peritoneal
S31.152S Open bite of abdominal wall, epigastric region without penetration into peritoneal
cavity, sequela
S31.153A Open bite of abdominal wall, right lower quadrant without penetration into peritoneal
S31.153D Open bite of abdominal wall, right lower quadrant without penetration into peritoneal
S31.153S Open bite of abdominal wall, right lower quadrant without penetration into peritoneal
cavity, sequela
S31.154A Open bite of abdominal wall, left lower quadrant without penetration into peritoneal
S31.154D Open bite of abdominal wall, left lower quadrant without penetration into peritoneal
S31.154S Open bite of abdominal wall, left lower quadrant without penetration into peritoneal
cavity, sequela
S31.155A Open bite of abdominal wall, periumbilic region without penetration into peritoneal
S31.155D Open bite of abdominal wall, periumbilic region without penetration into peritoneal
S31.155S Open bite of abdominal wall, periumbilic region without penetration into peritoneal
cavity, sequela
S31.159A Open bite of abdominal wall, unspecified quadrant without penetration into peritoneal
S31.159D Open bite of abdominal wall, unspecified quadrant without penetration into peritoneal
S31.159S Open bite of abdominal wall, unspecified quadrant without penetration into peritoneal
cavity, sequela
S31.600A Unspecified open wound of abdominal wall, right upper quadrant with penetration
S31.600D Unspecified open wound of abdominal wall, right upper quadrant with penetration
S31.600S Unspecified open wound of abdominal wall, right upper quadrant with penetration
S31.601A Unspecified open wound of abdominal wall, left upper quadrant with penetration into
S31.601D Unspecified open wound of abdominal wall, left upper quadrant with penetration into
S31.601S Unspecified open wound of abdominal wall, left upper quadrant with penetration into
S31.602A Unspecified open wound of abdominal wall, epigastric region with penetration into
S31.602D Unspecified open wound of abdominal wall, epigastric region with penetration into
S31.602S Unspecified open wound of abdominal wall, epigastric region with penetration into
S31.603A Unspecified open wound of abdominal wall, right lower quadrant with penetration
S31.603D Unspecified open wound of abdominal wall, right lower quadrant with penetration
S31.603S Unspecified open wound of abdominal wall, right lower quadrant with penetration
S31.604A Unspecified open wound of abdominal wall, left lower quadrant with penetration into
S31.604D Unspecified open wound of abdominal wall, left lower quadrant with penetration into
S31.604S Unspecified open wound of abdominal wall, left lower quadrant with penetration into
S31.605A Unspecified open wound of abdominal wall, periumbilic region with penetration into
S31.605D Unspecified open wound of abdominal wall, periumbilic region with penetration into
S31.605S Unspecified open wound of abdominal wall, periumbilic region with penetration into
S31.609A Unspecified open wound of abdominal wall, unspecified quadrant with penetration
S31.609D Unspecified open wound of abdominal wall, unspecified quadrant with penetration
S31.609S Unspecified open wound of abdominal wall, unspecified quadrant with penetration
S31.610A Laceration without foreign body of abdominal wall, right upper quadrant with
S31.610D Laceration without foreign body of abdominal wall, right upper quadrant with
S31.610S Laceration without foreign body of abdominal wall, right upper quadrant with
S31.611A Laceration without foreign body of abdominal wall, left upper quadrant with
S31.611D Laceration without foreign body of abdominal wall, left upper quadrant with
S31.611S Laceration without foreign body of abdominal wall, left upper quadrant with
S31.612A Laceration without foreign body of abdominal wall, epigastric region with penetration
S31.612D Laceration without foreign body of abdominal wall, epigastric region with penetration
S31.612S Laceration without foreign body of abdominal wall, epigastric region with penetration
S31.613A Laceration without foreign body of abdominal wall, right lower quadrant with
S31.613D Laceration without foreign body of abdominal wall, right lower quadrant with
S31.613S Laceration without foreign body of abdominal wall, right lower quadrant with
S31.614A Laceration without foreign body of abdominal wall, left lower quadrant with
S31.614D Laceration without foreign body of abdominal wall, left lower quadrant with
S31.614S Laceration without foreign body of abdominal wall, left lower quadrant with
S31.615A Laceration without foreign body of abdominal wall, periumbilic region with
S31.615D Laceration without foreign body of abdominal wall, periumbilic region with
S31.615S Laceration without foreign body of abdominal wall, periumbilic region with
S31.619A Laceration without foreign body of abdominal wall, unspecified quadrant with
S31.619D Laceration without foreign body of abdominal wall, unspecified quadrant with
S31.619S Laceration without foreign body of abdominal wall, unspecified quadrant with
S31.620A Laceration with foreign body of abdominal wall, right upper quadrant with penetration
S31.620D Laceration with foreign body of abdominal wall, right upper quadrant with penetration
S31.620S Laceration with foreign body of abdominal wall, right upper quadrant with penetration
S31.621A Laceration with foreign body of abdominal wall, left upper quadrant with penetration
S31.621D Laceration with foreign body of abdominal wall, left upper quadrant with penetration
S31.621S Laceration with foreign body of abdominal wall, left upper quadrant with penetration
S31.622A Laceration with foreign body of abdominal wall, epigastric region with penetration into
S31.622D Laceration with foreign body of abdominal wall, epigastric region with penetration into
S31.622S Laceration with foreign body of abdominal wall, epigastric region with penetration into
S31.623A Laceration with foreign body of abdominal wall, right lower quadrant with penetration
S31.623D Laceration with foreign body of abdominal wall, right lower quadrant with penetration
S31.623S Laceration with foreign body of abdominal wall, right lower quadrant with penetration
S31.624A Laceration with foreign body of abdominal wall, left lower quadrant with penetration
S31.624D Laceration with foreign body of abdominal wall, left lower quadrant with penetration
S31.624S Laceration with foreign body of abdominal wall, left lower quadrant with penetration
S31.625A Laceration with foreign body of abdominal wall, periumbilic region with penetration
S31.625D Laceration with foreign body of abdominal wall, periumbilic region with penetration
S31.625S Laceration with foreign body of abdominal wall, periumbilic region with penetration
S31.629A Laceration with foreign body of abdominal wall, unspecified quadrant with penetration
S31.629D Laceration with foreign body of abdominal wall, unspecified quadrant with penetration
S31.629S Laceration with foreign body of abdominal wall, unspecified quadrant with penetration
S31.630A Puncture wound without foreign body of abdominal wall, right upper quadrant with
S31.630D Puncture wound without foreign body of abdominal wall, right upper quadrant with
S31.630S Puncture wound without foreign body of abdominal wall, right upper quadrant with
S31.631A Puncture wound without foreign body of abdominal wall, left upper quadrant with
S31.631D Puncture wound without foreign body of abdominal wall, left upper quadrant with
S31.631S Puncture wound without foreign body of abdominal wall, left upper quadrant with
S31.632A Puncture wound without foreign body of abdominal wall, epigastric region with
S31.632D Puncture wound without foreign body of abdominal wall, epigastric region with
S31.632S Puncture wound without foreign body of abdominal wall, epigastric region with
S31.633A Puncture wound without foreign body of abdominal wall, right lower quadrant with
S31.633D Puncture wound without foreign body of abdominal wall, right lower quadrant with
S31.633S Puncture wound without foreign body of abdominal wall, right lower quadrant with
S31.634A Puncture wound without foreign body of abdominal wall, left lower quadrant with
S31.634D Puncture wound without foreign body of abdominal wall, left lower quadrant with
S31.634S Puncture wound without foreign body of abdominal wall, left lower quadrant with
S31.635A Puncture wound without foreign body of abdominal wall, periumbilic region with
S31.635D Puncture wound without foreign body of abdominal wall, periumbilic region with
S31.635S Puncture wound without foreign body of abdominal wall, periumbilic region with
S31.639A Puncture wound without foreign body of abdominal wall, unspecified quadrant with
S31.639D Puncture wound without foreign body of abdominal wall, unspecified quadrant with
S31.639S Puncture wound without foreign body of abdominal wall, unspecified quadrant with
S31.640A Puncture wound with foreign body of abdominal wall, right upper quadrant with
S31.640D Puncture wound with foreign body of abdominal wall, right upper quadrant with
S31.640S Puncture wound with foreign body of abdominal wall, right upper quadrant with
S31.641A Puncture wound with foreign body of abdominal wall, left upper quadrant with
S31.641D Puncture wound with foreign body of abdominal wall, left upper quadrant with
S31.641S Puncture wound with foreign body of abdominal wall, left upper quadrant with
S31.642A Puncture wound with foreign body of abdominal wall, epigastric region with
S31.642D Puncture wound with foreign body of abdominal wall, epigastric region with
S31.642S Puncture wound with foreign body of abdominal wall, epigastric region with
S31.643A Puncture wound with foreign body of abdominal wall, right lower quadrant with
S31.643D Puncture wound with foreign body of abdominal wall, right lower quadrant with
S31.643S Puncture wound with foreign body of abdominal wall, right lower quadrant with
S31.644A Puncture wound with foreign body of abdominal wall, left lower quadrant with
S31.644D Puncture wound with foreign body of abdominal wall, left lower quadrant with
S31.644S Puncture wound with foreign body of abdominal wall, left lower quadrant with
S31.645A Puncture wound with foreign body of abdominal wall, periumbilic region with
S31.645D Puncture wound with foreign body of abdominal wall, periumbilic region with
S31.645S Puncture wound with foreign body of abdominal wall, periumbilic region with
S31.649A Puncture wound with foreign body of abdominal wall, unspecified quadrant with
S31.649D Puncture wound with foreign body of abdominal wall, unspecified quadrant with
S31.649S Puncture wound with foreign body of abdominal wall, unspecified quadrant with
S31.650A Open bite of abdominal wall, right upper quadrant with penetration into peritoneal
S31.650D Open bite of abdominal wall, right upper quadrant with penetration into peritoneal
S31.650S Open bite of abdominal wall, right upper quadrant with penetration into peritoneal
cavity, sequela
S31.651A Open bite of abdominal wall, left upper quadrant with penetration into peritoneal
S31.651D Open bite of abdominal wall, left upper quadrant with penetration into peritoneal
S31.651S Open bite of abdominal wall, left upper quadrant with penetration into peritoneal
cavity, sequela
S31.652A Open bite of abdominal wall, epigastric region with penetration into peritoneal cavity,
initial encounter
S31.652D Open bite of abdominal wall, epigastric region with penetration into peritoneal cavity,
initial encounter, subsequent encounter
S31.652S Open bite of abdominal wall, epigastric region with penetration into peritoneal cavity,
initial encounter, sequela
S31.653A Open bite of abdominal wall, right lower quadrant with penetration into peritoneal
S31.653D Open bite of abdominal wall, epigastric region with penetration into peritoneal cavity,
initial encounter, subsequent encounter
S31.653S Open bite of abdominal wall, epigastric region with penetration into peritoneal cavity,
initial encounter, sequela
S31.654A Open bite of abdominal wall, left lower quadrant with penetration into peritoneal
S31.654D Open bite of abdominal wall, left lower quadrant with penetration into peritoneal
S31.654S Open bite of abdominal wall, left lower quadrant with penetration into peritoneal
cavity, sequela
S31.655A Open bite of abdominal wall, periumbilic region with penetration into peritoneal
S31.655D Open bite of abdominal wall, periumbilic region with penetration into peritoneal
S31.655S Open bite of abdominal wall, periumbilic region with penetration into peritoneal
cavity, sequela
S31.659A Open bite of abdominal wall, unspecified quadrant with penetration into peritoneal
S31.659D Open bite of abdominal wall, unspecified quadrant with penetration into peritoneal
S31.659S Open bite of abdominal wall, unspecified quadrant with penetration into peritoneal
cavity, sequela
S39.001A Unspecified injury of muscle, fascia and tendon of abdomen, initial encounter
S39.001D Unspecified injury of muscle, fascia and tendon of abdomen, subsequent encounter
S39.001S Unspecified injury of muscle, fascia and tendon of abdomen, sequela
S39.021A Laceration of muscle, fascia and tendon of abdomen, initial encounter
S39.021D Laceration of muscle, fascia and tendon of abdomen, subsequent encounter
S39.021S Laceration of muscle, fascia and tendon of abdomen, sequela
S39.091A Other injury of muscle, fascia and tendon of abdomen, initial encounter
S39.091D Other injury of muscle, fascia and tendon of abdomen, subsequent encounter
S39.091S Other injury of muscle, fascia and tendon of abdomen, sequela
S39.81XA Other specified injuries of abdomen, initial encounter
S39.81XD Other specified injuries of abdomen, subsequent encounter
S39.81XS Other specified injuries of abdomen, sequela
S39.91XA Unspecified injury of abdomen, initial encounter
S39.91XD Unspecified injury of abdomen, subsequent encounter
S39.91XS Unspecified injury of abdomen, sequela
S41.021A Laceration with foreign body of right shoulder, initial encounter
S41.021D Laceration with foreign body of right shoulder, subsequent encounter
S41.021S Laceration with foreign body of right shoulder, sequela
S41.022A Laceration with foreign body of left shoulder, initial encounter
S41.022D Laceration with foreign body of left shoulder, subsequent encounter
S41.022S Laceration with foreign body of left shoulder, sequela
S41.029A Laceration with foreign body of unspecified shoulder, initial encounter
S41.029D Laceration with foreign body of unspecified shoulder, subsequent encounter
S41.029S Laceration with foreign body of unspecified shoulder, sequela
S41.041A Puncture wound with foreign body of right shoulder, initial encounter
S41.041D Puncture wound with foreign body of right shoulder, subsequent encounter
S41.041S Puncture wound with foreign body of right shoulder, sequela
S41.042A Puncture wound with foreign body of left shoulder, initial encounter
S41.042D Puncture wound with foreign body of left shoulder, subsequent encounter
S41.042S Puncture wound with foreign body of left shoulder, sequela
S41.049A Puncture wound with foreign body of unspecified shoulder, initial encounter
S41.049D Puncture wound with foreign body of unspecified shoulder, subsequent encounter
S41.049S Puncture wound with foreign body of unspecified shoulder, sequela
S41.121A Laceration with foreign body of right upper arm, initial encounter
S41.121D Laceration with foreign body of right upper arm, subsequent encounter
S41.121S Laceration with foreign body of right upper arm, sequela
S41.122A Laceration with foreign body of left upper arm, initial encounter
S41.122D Laceration with foreign body of left upper arm, subsequent encounter
S41.122S Laceration with foreign body of left upper arm, sequela
S41.129A Laceration with foreign body of unspecified upper arm, initial encounter
S41.129D Laceration with foreign body of unspecified upper arm, subsequent encounter
S41.129S Laceration with foreign body of unspecified upper arm, sequela
S41.141A Puncture wound with foreign body of right upper arm, initial encounter
S41.141D Puncture wound with foreign body of right upper arm, subsequent encounter
S41.141S Puncture wound with foreign body of right upper arm, sequela
S41.142A Puncture wound with foreign body of left upper arm, initial encounter
S41.142D Puncture wound with foreign body of left upper arm, subsequent encounter
S41.142S Puncture wound with foreign body of left upper arm, sequela
S41.149A Puncture wound with foreign body of unspecified upper arm, initial encounter
S41.149D Puncture wound with foreign body of unspecified upper arm, subsequent encounter
S41.149S Puncture wound with foreign body of unspecified upper arm, sequela
S51.021A Laceration with foreign body of right elbow, initial encounter
S51.021D Laceration with foreign body of right elbow, subsequent encounter
S51.021S Laceration with foreign body of right elbow, sequela
S51.022A Laceration with foreign body of left elbow, initial encounter
S51.022D Laceration with foreign body of left elbow, subsequent encounter
S51.022S Laceration with foreign body of left elbow, sequela
S51.029A Laceration with foreign body of unspecified elbow, initial encounter
S51.029D Laceration with foreign body of unspecified elbow, subsequent encounter
S51.029S Laceration with foreign body of unspecified elbow, sequela
S51.041A Puncture wound with foreign body of right elbow, initial encounter
S51.041D Puncture wound with foreign body of right elbow, subsequent encounter
S51.041S Puncture wound with foreign body of right elbow, sequela
S51.042A Puncture wound with foreign body of left elbow, initial encounter
S51.042D Puncture wound with foreign body of left elbow, subsequent encounter
S51.042S Puncture wound with foreign body of left elbow, sequela
S51.049A Puncture wound with foreign body of unspecified elbow, initial encounter
S51.049D Puncture wound with foreign body of unspecified elbow, subsequent encounter
S51.049S Puncture wound with foreign body of unspecified elbow, sequela
S51.821A Laceration with foreign body of right forearm, initial encounter
S51.821D Laceration with foreign body of right forearm, subsequent encounter
S51.821S Laceration with foreign body of right forearm, sequela
S51.822A Laceration with foreign body of left forearm, initial encounter
S51.822D Laceration with foreign body of left forearm, subsequent encounter
S51.822S Laceration with foreign body of left forearm, sequela
S51.829A Laceration with foreign body of unspecified forearm, initial encounter
S51.829D Laceration with foreign body of unspecified forearm, subsequent encounter
S51.829S Laceration with foreign body of unspecified forearm, sequela
S51.841A Puncture wound with foreign body of right forearm, initial encounter
S51.841D Puncture wound with foreign body of right forearm, subsequent encounter
S51.841S Puncture wound with foreign body of right forearm, sequela
S51.842A Puncture wound with foreign body of left forearm, initial encounter
..
S51.842D Puncture wound with foreign body of left forearm, subsequent encounter
./…
S51.842S Puncture wound with foreign body of left forearm, sequela
S51.851A Open bite of right forearm, initial encounter
S51.851D Open bite of right forearm, subsequent encounter
S51.851S Open bite of right forearm, sequela
S51.852A Open bite of left forearm, initial encounter
S51.852D Open bite of left forearm, subsequent encounter
S51.852S Open bite of left forearm, sequela
S51.859A Open bite of unspecified forearm, initial encounter
S51.859D Open bite of unspecified forearm, subsequent encounter
S51.859S Open bite of unspecified forearm, sequela
S71.021A Laceration with foreign body, right hip, initial encounter
S71.021D Laceration with foreign body, right hip, subsequent encounter
S71.021S Laceration with foreign body, right hip, sequela
S71.022A Laceration with foreign body, left hip, initial encounter
S71.022D Laceration with foreign body, right hip, subsequent encounter
S71.022S Laceration with foreign body, right hip, sequela
S71.029A Laceration with foreign body, unspecified hip, initial encounter
S71.029D Laceration with foreign body, unspecified hip, subsequent encounter
S71.029S Laceration with foreign body, unspecified hip, sequela
S71.041A Puncture wound with foreign body, right hip, initial encounter
S71.041D Puncture wound with foreign body, right hip, subsequent encounter
S71.041S Puncture wound with foreign body, right hip, sequela
S71.042A Puncture wound with foreign body, left hip, initial encounter
S71.042D Puncture wound with foreign body, left hip, subsequent encounter
S71.042S Puncture wound with foreign body, left hip, sequela
S71.049A Puncture wound with foreign body, unspecified hip, initial encounter
S71.049D Puncture wound with foreign body, unspecified hip, subsequent encounter
S71.049S Puncture wound with foreign body, unspecified hip, sequela
S71.121A Laceration with foreign body, right thigh, initial encounter
S71.121D Laceration with foreign body, right thigh, subsequent encounter
S71.121S Laceration with foreign body, right thigh, sequela
S71.122A Laceration with foreign body, left thigh, initial encounter
S71.122D Laceration with foreign body, left thigh, subsequent encounter
S71.122S Laceration with foreign body, left thigh, sequela
S71.129A Laceration with foreign body, unspecified thigh, initial encounter
S71.129D Laceration with foreign body, unspecified thigh, subsequent encounter
S71.129S Laceration with foreign body, unspecified thigh, sequela
S71.141A Puncture wound with foreign body, right thigh, initial encounter
S71.141D Puncture wound with foreign body, right thigh, subsequent encounter
S71.141S Puncture wound with foreign body, right thigh, sequela
S71.142A Puncture wound with foreign body, left thigh, initial encounter
S71.142D Puncture wound with foreign body, left thigh, subsequent encounter
S71.142S Puncture wound with foreign body, left thigh, sequela
S71.149A Puncture wound with foreign body, unspecified thigh, initial encounter
S71.149D Puncture wound with foreign body, unspecified thigh, subsequent encounter
S71.149S Puncture wound with foreign body, unspecified thigh, sequela
S81.021A Laceration with foreign body, right knee, initial encounter
S81.021D Laceration with foreign body, right knee, subsequent encounter
S81.021S Laceration with foreign body, right knee, sequela
S81.022A Laceration with foreign body, left knee, initial encounter
S81.022D Laceration with foreign body, left knee, subsequent encounter
S81.022S Laceration with foreign body, left knee, sequela
S81.029A Laceration with foreign body, unspecified knee, initial encounter
S81.029D Laceration with foreign body, unspecified knee, subsequent encounter
S81.029S Laceration with foreign body, unspecified knee, sequela
S81.041A Puncture wound with foreign body, right knee, initial encounter
S81.041D Puncture wound with foreign body, right knee, subsequent encounter
S81.041S Puncture wound with foreign body, right knee, sequela
S81.042A Puncture wound with foreign body, left knee, initial encounter
S81.042D Puncture wound with foreign body, left knee, subsequent encounter
S81.042S Puncture wound with foreign body, left knee, sequela
S81.049A Puncture wound with foreign body, unspecified knee, initial encounter
S81.049D Puncture wound with foreign body, unspecified knee, subsequent encounter
S81.049S Puncture wound with foreign body, unspecified knee, sequela
S81.821A Laceration with foreign body, right lower leg, initial encounter
S81.821D Laceration with foreign body, right lower leg, subsequent encounter
S81.821S Laceration with foreign body, right lower leg, sequela
S81.822A Laceration with foreign body, left lower leg, initial encounter
S81.822D Laceration with foreign body, left lower leg, subsequent encounter
S81.822S Laceration with foreign body, left lower leg, sequela
S81.829A Laceration with foreign body, unspecified lower leg, initial encounter
S81.829D Laceration with foreign body, unspecified lower leg, subsequent encounter
S81.829S Laceration with foreign body, unspecified lower leg, sequela
S81.841A Puncture wound with foreign body, right lower leg, initial encounter
S81.841D Puncture wound with foreign body, right lower leg, subsequent encounter
S81.841A
S81.841S Puncture wound with foreign body, right lower leg, sequela
S81.842A Puncture wound with foreign body, left lower leg, initial encounter
S81.842D Puncture wound with foreign body, left lower leg, subsequent encounter
S81.842S Puncture wound with foreign body, left lower leg, sequela
S81.849A Puncture wound with foreign body, unspecified lower leg, initial encounter
S81.849D Puncture wound with foreign body, unspecified lower leg, subsequent encounter
S81.849S Puncture wound with foreign body, unspecified lower leg, sequela
T79.A0XA Compartment syndrome, unspecified, initial encounter
T79.A0XD Compartment syndrome, unspecified, subsequent encounter
T79.A0XS Compartment syndrome, unspecified, sequela
T79.A11A Traumatic compartment syndrome of right upper extremity, initial encounter
T79.A11D Traumatic compartment syndrome of right upper extremity, subsequent encounter
T79.A11S Traumatic compartment syndrome of right upper extremity, sequela
T79.A12A Traumatic compartment syndrome of left upper extremity, initial encounter
T79.A12D Traumatic compartment syndrome of left upper extremity, subsequent encounter
T79.A12S Traumatic compartment syndrome of left upper extremity, sequela
T79.A19A Traumatic compartment syndrome of unspecified upper extremity, initial encounter
T79.A19D Traumatic compartment syndrome of unspecified upper extremity, subsequent
encounter
T79.A19S Traumatic compartment syndrome of unspecified upper extremity, sequela
T79.A21A Traumatic compartment syndrome of right lower extremity, initial encounter
T79.A21D Traumatic compartment syndrome of right lower extremity, subsequent encounter
T79.A21S Traumatic compartment syndrome of right lower extremity, sequela
T79.A22A Traumatic compartment syndrome of left lower extremity, initial encounter
T79.A22D Traumatic compartment syndrome of left lower extremity, subsequent encounter
T79.A22S Traumatic compartment syndrome of left lower extremity, sequela
T79.A29A Traumatic compartment syndrome of unspecified lower extremity, initial encounter
T79.A29D Traumatic compartment syndrome of unspecified lower extremity, subsequent
T79.A29S encounter compartment syndrome of unspecified lower extremity, sequela
Traumatic
T79.A3XA Traumatic compartment syndrome of abdomen, initial encounter
T79.A3XD Traumatic compartment syndrome of abdomen, subsequent encounter
T79.A3XS Traumatic compartment syndrome of abdomen, sequela
T79.A9XA Traumatic compartment syndrome of other sites, initial encounter
T79.A9XD Traumatic compartment syndrome of other sites, subsequent encounter
T79.A9XS Traumatic compartment syndrome of other sites, sequela
T81.31XA Disruption of external operation (surgical) wound, not elsewhere classified, initial
encounter
T81.31XD Disruption of external operation (surgical) wound, not elsewhere classified,
subsequent encounter
T81.31XS Disruption of external operation (surgical) wound, not elsewhere classified, sequela
T81.32XA Disruption of internal operation (surgical) wound, not elsewhere classified, initial
encounter
T81.32XD Disruption of internal operation (surgical) wound, not elsewhere classified, subsequent
encounter
T81.32XS Disruption of internal operation (surgical) wound, not elsewhere classified, sequela
T81.40XA Infection following a procedure, unspecified, initial encounter
T81.40XD Infection following a procedure, unspecified, subsequent encounter
T81.40XS Infection following a procedure, unspecified, sequela
T81.41XA Infection following a procedure, superficial incisional surgical site, initial encounter
T81.41XD Infection following a procedure, superficial incisional surgical site, subsequent
T81.41XS encounter
Infection following a procedure, superficial incisional surgical site, sequela
T81.42XA Infection following a procedure, deep incisional surgical site, initial encounter
T81.42XD Infection following a procedure, deep incisional surgical site, subsequent encounter
T81.42XS Infection following a procedure, deep incisional surgical site, sequela
T81.43XA Infection following a procedure, organ and space surgical site, initial encounter
T81.43XD Infection following a procedure, organ and space surgical site, subsequent encounter
T81.43XS Infection following a procedure, organ and space surgical site, sequela
T81.44XA Sepsis following a procedure, initial encounter
T81.44XD Sepsis following a procedure, subsequent encounter
T81.44XS Sepsis following a procedure, sequela
T81.49XA Infection following a procedure, other surgical site, initial encounter
T81.49XD Infection following a procedure, other surgical site, subsequent encounter
T81.49XS Infection following a procedure, other surgical site, sequela
T81.89XA Other complications of procedures, not elsewhere classified, initial encounter
T81.89XD Other complications of procedures, not elsewhere classified, subsequent encounter
T81.89XS Other complications of procedures, not elsewhere classified, sequela
REFERENCES
1. Agency for Healthcare Research and Quality (AHRQ). (2009, November 12). Technology
Assessment Report: Negative Pressure Wound Therapy Devices. Accessed May 26, 2023.
Available at URL address: https://archive.ahrq.gov/research/findings/ta/negative-pressure-
wound-therapy/negative-pressure-wound-therapy.pdf
2. Centers for Medicare & Medicaid Services (CMS). Local Coverage Article (LCA) for Negative
Pressure Wound Therapy Pumps – Policy Article (A52511). Contractor Name: CGS
Administrators, LLC (18003, DME MAC). Geographical Jurisdiction: Puerto Rico. Original
Effective Date: 10/01/2015. Revision Effective Date: 08/15/2021. Accessed May 26, 2023.
Available at URL address: https://www.cms.gov/medicare-coverage-
database/view/article.aspx?articleid=52511&ver=28&DocID=A52511&bc=gAAAABAAEAAAAAAA
&=
3. Centers for Medicare & Medicaid Services (CMS). Local Coverage Article (LCA) for Standard
Documentation Requirements for All Claims Submitted to DME MACs (A55426). Contractor
Name: CGS Administrators, LLC (18003, DME MAC). Geographical Jurisdiction: Puerto Rico.
Original Effective Date: 01/01/2017. Revision Effective Date: 01/01/2023. Accessed May 26,
2023. Available at URL address: https://www.cms.gov/medicare-coverage-
database/view/article.aspx?articleid=55426&ver=98&LCDId=33821&DocID=L33821&bc=gAAAA
BAAEAAAAAAA&=
4. Centers for Medicare & Medicaid Services (CMS). Local Coverage Determination (LCD) for
Negative Pressure Wound Therapy Pumps (L33821). Contractor Name: CGS Administrators, LLC
(18003, DME MAC). Geographical Jurisdiction: Puerto Rico. Original Determination Effective
Date: For services performed on or after 10/01/2015. Revision Effective Date: For services
performed on or after 05/01/2021. Accessed May 26, 2023. Available at URL address:
https://www.cms.gov/medicare-coverage-
database/view/lcd.aspx?LCDId=33821&ver=25&DocID=L33821&bc=gAAAABAAoAAAAAAA&
Pressure Reducing Support Surfaces – Group 1 (L33830). Contractor Name: CGS Administrators,
LLC. (18003, DME MAC). Geographical Jurisdiction: Puerto Rico. Original Determination
Effective Date: For services performed on or after 10/01/2015. Revision Effective Date: For
services performed on or after 05/01/2021. Accessed May 26, 2023. Available at URL address:
https://www.cms.gov/medicare-coverage-database/details/lcd-
details.aspx?lcdid=33830&ver=22&bc=CAAAAAAAAAAA
https://www.cms.gov/medicare-coverage-database/details/lcd-
details.aspx?LCDId=33642&ver=26&CntrctrSelected=140*2&Cntrctr=140&s=46&DocType=Activ
e&bc=AggAAAQAoAAAAAAA&
https://www.cms.gov/medicare-coverage-
database/view/lcd.aspx?LCDId=33692&ver=21&CntrctrSelected=140*2&Cntrctr=140&s=46&Do
cType=Active&bc=AggAAAQAoAAAAAAA&
8. Centers for Medicare & Medicaid Services (CMS). Medicare Learning Network (MLN): Provider
Inquiry Assistance. Medicare Policy Regarding Pressure Reducing Support Surfaces (JA1014).
Date Revised: August 24, 2010. Accessed May 26, 2023. Available at URL address:
https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/JA1014.pdf
9. Centers for Medicare & Medicaid Services (CMS). State Operations Manual Appendix PP –
Guidance to Surveyors for Long Term Care Facilities. Rev. 211, done 02-03-2023. F314 §483.25I
Pressure Sores. Section: Under-Nutrition and Hydration Deficits. Pages 302 - 315. Accessed
May 26, 2023. Available at URL address: https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
10. Dirckx, J.H. (2008, December). Negative Pressure Wound Therapy. Accessed May 26, 2023.
Available at URL address: https://www.hpisum.com/17%20Dirckx,%20Wound%20Therapy.pdf
11. Journal of the American Academy of Nutrition and Dietetics (AAOND). (2012, May). Consensus
Statement of the AAOND/American Society for Parenteral and Enteral Nutrition: Characteristics
Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition).
DOI: http://dx.doi.org/10.1016/j.jand.2012.03.012. Accessed May 26, 2023. Available at URL
address: https://dietitiansondemand.com/wp-content/uploads/2017/09/ASPEN-AND-2012-
Consensus-Statement-Regarding-Malnutrition-Diagnosis-1.pdf
12. The National Pressure Ulcer Advisory Panel (NPUAP)/Dorner, B., Posthauer, M.E., & Thomas, D.
(2015). The Role of Nutrition in Pressure Ulcer Management. Accessed May 26, 2023. Available
at URL address:
https://pdfs.semanticscholar.org/2838/4e64cbd74256985effdb3fc6c47aeb6a1886.pdf?_ga=2.2
23047902.413749383.1589469365-77761295.1589469365
13. The National Pressure Ulcer Advisory Panel (NPUAP) (2008). NPUAP Pressure Ulcer Stages: A
Patient Safety Issue. Accessed May 26, 2023. Available at URL address:
https://www.ncbi.nlm.nih.gov/books/NBK2650/pdf/Bookshelf_NBK2650.pdf
14. UpToDate®/Armstrong, D.G. & Meyr, A.J. (2023). Basic principles of wound healing. Literature
review current through: May 2023. This topic last updated: May 19, 2022. Accessed June 07,
2023. Available at URL address: https://www.uptodate.com/contents/basic-principles-of-
wound-healing
15. UpToDate®/Gestring, M. (2023). Negative Pressure Wound Therapy. Literature review current
through: May 2023. This topic last updated: Nov 16, 2022. Accessed June 08, 2023. Available at
URL address: https://www.uptodate.com/contents/negative-pressure-wound-
therapy/print?source=search_result&search=Negative%20Pressure%20Wound%20Therapy%20
and%20albumin&selectedTitle=1~150
16. Wound Healing Society (WHS)/Litchford, M.D., Dorner, B., & Posthauer, M.E. (2014).
Malnutrition as a Precursor of Pressure Ulcer. Advances in Wound Care, 3(1), 54-63. DOI:
10.1089/wound.2012.0385. Accessed May 26, 2023. Available at URL address:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3899999/?report=classic, and at URL address:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3899999/pdf/wound.2012.0385.pdf
POLICY HISTORY
DATE ACTION COMMENT
November 17, 2009 Origination of Policy
November 17, 2010 Yearly Revision HCPCS Modifier table added to policy
October 31, 2011 Yearly Revision
November 7, 2012 Yearly Revision References updated.
March 7, 2013 Revised References updated. Added new references: numbers 5, 6, 7 & 11.
Contraindication / Limitation # 2 was revised and modified.
To Coding Information: Added new section of HCPCS Codes Not Covered:

G0456 & G0457.
Appendix A was revised & updated.
Appendix B was revised & updated.

July 23, 2013 Revised References updated.
New Prescription (Order) Requirements Section was added:

1. A detailed written order (DWO) is required before billing and prior to
delivery. Someone other than the ordering physician may produce
the DWO. However, the ordering physician must review the content
and sign and date the document. It must contain: a. Beneficiary’s
name; b. Physician’s name; c. Date of the order and the start date, if
start date is different from the date of the order. Please use the date
the supplier is contacted by the physician (for verbal orders), or the
date entered by the physician (for written dispensing orders); d.
Detailed description of the item(s); e. Physician signature and
signature date.
2. For items provided on a periodic basis, including drugs, the written
order must include: a. Item(s) to be dispensed; b. Dosage or
concentration, if applicable; c. Route of Administration, if applicable;
d. Frequency of use, if applicable. The frequency of use information
on orders must contain detailed instructions for use and specific
amounts to be dispensed; e. Duration of infusion, if applicable; f.
Quantity to be dispensed; g. Number of refills or length of need.
3. The DWO must be available upon request.
To Coding Information:
Added new ICD-9 Codes 707.20 – 707.25.

February 21, 2014 Revised To the Coding section: A new ICD-10 Codes (Preview Draft) section was
added to the policy.
September 18, 2014 Revised References updated. Added new references, numbers 4, 7-9, 12-15, 20, 22,
24-31.
To the Description Section:

• Added: Negative pressure wound therapy (NPWT), also called
vacuum-assisted wound closure, refers to wound dressing
systems that continuously or intermittently apply
subatmospheric pressure to the surface of a wound
(UpToDate®, 2014).
• Added citation: (AHRQ, 2009).
To the Coverage Statement:

• Moved previous Note, and removed the Note sub-title.
• Revised and modified content to read as follows: In order to
obtain medical coverage by Medical Card System, Inc., (MCS), a
Written Order Prior to Delivery (WOPD) for these services is
required. Please refer to the section entitled Prescription
(Order) Requirements for further details.
To the Indications Section:

• To Part I opening coverage statement revised and modified to
read as follows: Medical Card System, Inc., (MCS) considers the
use of Negative Wound Pressure Therapy (NWPT) & supplies as
medically necessary, for BOTH the Commercial & Classicare
Lines of Business (LOB), when EITHER criterion A or B is met.
• To Part I, sub-part A, regrouped and revised information to read
as follows: A.Ulcers and Wounds in the Home Setting: The
patient has a chronic Stage III or IV pressure ulcer (See Appendix
A), neuropathic (for example, diabetic) ulcer, venous or arterial
insufficiency ulcer, or a chronic ulcer (being present for at least
30 days) of mixed etiology. A complete wound therapy program
described below (A-1 through A-4), as applicable depending on
the type of wound, must have been tried, or considered, and
ruled out Prior to application of NPWT.
• To Part I, sub-part B, to #1, revised & modified content as
follows: 1. An ulcer or wound (described under Criteria I–A of
the Indications Section above) is encountered in the inpatient
setting and, after wound treatments described under A–1
through A–4 above, have been tried, or considered, and ruled
out, NPWT is initiated because it is considered in the judgment
of the treating physician, the best available treatment option.
• To Part I, sub-part B, created new section entitled Limitations for
Ulcers and Wounds Encountered in an Inpatient Setting. Its
content was relocated from the Indications Section to this
section.
• To Part I, sub-part B, revised and modified content to read as it
follows:
1. In either situation, B-1 or B-2 above, NPWT will be
considered medically necessary when treatment is
ordered to continue beyond discharge to the home
setting.
2. If criteria A or B from part I of the Indications Section
above are NOT MET, the NPWT pump and supplies will be
considered as NOT medically necessary, and therefore
NOT covered.
3. NPWT pumps (i.e., HCPCS Code E2402) must be capable
of accommodating more than one wound dressing set for
multiple wounds on a patient. Therefore, more than one
pump (i.e., HCPCS Code E2402) billed per patient for the
same time period will be considered NOT medically
necessary, and therefore NOT covered.
• To Part II, revised and modified opening coverage statement to
read as it follows: Medical Card System, Inc., (MCS) will consider
as medically necessary the Continued Medical Coverage for
NPWT, for Both the Commercial & Classicare LOB, under the
following circumstances
• To Part II, sub-part C, revised and modified content to read as it
follows: C. For wounds and ulcers described under Criteria I–A
or I–B of the Indications Section above, once placed on a NPWT
pump and supplies, in order for medical coverage to continue, a
licensed medical professional (See General Limitation # 1) must
do All of the following.
• To Part II, created new section entitled Limitations for
Continued Medical Coverage for NPWT. Its content was
previously in the Indications Section, which was numbered as 1
and modified to read as follows: If criteria from C–1 through C–2
from the Indications Section are not fulfilled, then Continued
Coverage of the NPWT pump and supplies will be considered as
NOT medically necessary, and therefore NOT covered.
• To Part III, revised and modified opening coverage statement to
read as follows: Medical Card System, Inc., (MCS) will consider
the Discontinuation and/or End of medical coverage for NPWT
pump & supplies, for Both the Commercial & Classicare LOB, for
wounds and ulcers as described under Criteria I–A or I–B of the
Indications Section above, and with Any of the following events,
whichever occurs earliest.
• To Part III, revised and modified #1 to read as follows: Criteria
from IC–1 through C–2 from the Indications Section above,
under “Continued Medical Coverage”, above ceases to occur or
be met.
• To Part III, added to #4: (See General Limitation # 2).
• To Part IV, revised and modified opening coverage statement to
read as follows: Medical Card System, Inc., (MCS) will consider
as medically necessary the Medical Coverage for NPWT Supplies,
for both the Commercial & Classicare LOB, when Any of the
following are required.
• To Part IV, revised and modified #1 to read as follows: Medical
Coverage is provided up to a maximum of 15 dressing kits (i.e.,
HCPCS Code A6550) per wound per month.
• To Part IV, revised and modified #2 to read as follows: Medical
Coverage is provided up to a maximum of 10 canister sets (i.e.,
HCPCS Code A7000) per month unless there is documentation
evidencing a large volume of drainage (greater than 90 ml of
exudate per day). For high volume exudative wounds, a
stationary pump with the largest capacity canister must be used.
• To Part IV, added new section entitled: Limitations for Medical
Coverage for NPWT Supplies. Also, added the following content:
1. For NPWT and Supplies provided on a recurring basis,
billing must be based on prospective, not retrospective
use.
2. For NPWT supplies (i.e., HCPCS Codes A6550 & A7000)
that are provided as refills to the original order,
suppliers must contact the patient prior to dispensing
the refill and not automatically ship on a pre-
determined basis, even if authorized by the patient.
This shall be done to ensure that the refilled item
remains reasonable and medically necessary, that
existing supplies are approaching exhaustion, and to
confirm any changes/modifications to the order.
3. Contact with the patient or designee regarding refills
must take place no sooner than 14 calendar days prior
to the delivery/shipping date.
4. For delivery of refills, the supplier must deliver the
NPWT device and/or supplies no sooner than 10
calendar days prior to the end of usage for the current
product. This is regardless of which delivery method is
utilized.
5. For all NPWT devices and/or supplies that are provided
on a recurring basis, suppliers are required to have
contact with the patient or caregiver/designee prior to
dispensing a new supply of items. Suppliers must not
deliver refills without a refill request from the patient.
Items delivered without a valid, documented refill
request will be considered as NOT reasonable and
medically necessary, and therefore NOT covered.
6. Suppliers must not dispense a quantity of supplies
exceeding a beneficiary’s patient’s expected utilization.
Suppliers must stay attuned to changed or atypical
utilization patterns on the part of their patients.
Suppliers must verify with the ordering physicians that
any changed or atypical utilization is warranted.
Regardless of utilization, a supplier MUST NOT dispense
more than a one (1)-month quantity at a time.
Suppliers may dispense a maximum of one month’s
supply of dressing kits or canisters at any one time.
To the Prescription (Order) Requirements Section:

• Changed the word ‘Beneficiary’ to ‘Patient’.
• Added # 4-7.
To the General Limitations Section:

• This section was newly created, where the content was
restructured as it follows:
1. A licensed health care professional, for the purposes of
this medical policy, may be a physician (MD), 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 patient is
receiving NPWT.
2. When NPWT therapy exceeds 4 months on the most
recent wound and medical coverage ends, individual
consideration for one additional month at a time may be
sought using the appeals process. Information from the
treating physician’s medical record, contemporaneous
with each requested one-month treatment time period
extension, must be submitted with each appeal
explaining the special circumstances necessitating the
extended month of therapy. This medical policy provides
coverage for the use of NPWT limited to initiating healing
of the problem wounds described in the Indications &
Limitations sections, rather than continuation of therapy
to complete healing, since there is no published medical
literature demonstrating evidence of a clinical benefit for
the use of NPWT to complete wound healing. Therefore,
general, vague or nonspecific statements in the medical
record such as “doing well”, “want to continue until
healed”, provide insufficient information to justify the
medical need for extension of treatment. The medical
record must provide specific and detailed information to
explain the continuing problems with the wound, what
additional measures are being undertaken to address
those problems and promote healing and why a switch to
alternative treatments alone is not possible.
3. Suppliers must add a KX modifier to a code only if ALL of
the criteria within the “Indications and Limitations of
Medical Coverage” Sections of this medical policy have
been met.
4. The KX modifier must NOT be used with an NPWT pump
and supplies for wounds if: a. The pump has been used to
treat a single wound and the claim is for the 5th or
subsequent month’s rental, or b. The pump has been
used to treat more than one wound and the claim is for
the 5th or subsequent month’s rental after therapy has
begun on the most recently treated wound. In this
situation, the KX modifier may be billed for more than 4
total months of rental.
5. In all of the situations above describing use of the KX
modifier, if not all of the coverage criteria have been met,
the GA or GZ modifier must be added to a claim line for
the NPWT pump and supplies. When there is an
expectation of a medical necessity denial, suppliers must
enter the GA modifier on the claim line if they have
obtained a properly executed Advance Beneficiary Notice
(ABN) or the GZ modifier if they have not obtained a valid
ABN.
6. For an item addressed in this medical policy to be
covered by MCS, a written signed and dated order must
be received by the supplier prior to delivery of the item.
If the supplier delivers the item prior to receipt of a
written order, it will be denied as non-covered.
7. Disposable wound suction pumps (i.e., HCPCS Code
A9270) and related supplies are NOT covered.
8. NPWT is provided with an integrated system of
components. This system contains a pump (i.e., HCPCS
Code E2402), dressing sets or supplies (i.e., HCPCS Code
A6550), and a separate collection canister (i.e., HCPCS
Code A7000). Wound suction systems that do not
contain all of the required components are NOT classified
as NPWT. The proper components’ specifications are as
follows: A. HCPCS Code E2402 describes a stationary or
portable Negative Pressure Wound Therapy (NPWT)
electrical pump which provides controlled sub-
atmospheric pressure that is designed for use with NPWT
dressings (i.e., HCPCS Code A6550) and canisters (i.e.,
HCPCS Code A7000) to promote wound healing. The
NPWT pump must be capable of being selectively
switched between continuous and intermittent modes of
operation and is controllable to adjust the degree of sub-
atmospheric pressure conveyed to the wound in a range
of 40-80 mm Hg sub-atmospheric pressure. The system
must contain sensors and alarms to monitor pressure
variations and exudate volume in the collection canister.
B. HCPCS Code A6550 describes an allowance for a
dressing set which is used in conjunction with a stationary
or portable NPWT pump (i.e., HCPCS Code E2402). A
single HCPCS Code A6550 is used for each single,
complete dressing change, and contains all necessary
components, including but not limited to any separate,
non-adherent porous dressing(s), drainage tubing, and an
occlusive dressing(s) which creates a seal around the
wound site for maintaining sub-atmospheric pressure at
the wound. C. HCPCS Code A7000 describes a canister set
which is used in conjunction with a stationary or portable
NPWT pump and contains all necessary components,
including but not limited to a container, to collect wound
exudate. Canisters may be various sizes to accommodate
stationary or portable NPWT pumps.
9. Items billed before a signed & dated order has been
received by the supplier, must be submitted with an EY
modifier added to each related HCPCS code.
To the Contraindications/Warnings Section:

• Added to Title: Warnings.
• To #1 revised and modified non-coverage statement to read as it
follows: 1.Negative Pressure Wound Therapy (NPWT) pump and
supplies WILL NOT be considered medically necessary, and
therefore NOT covered for BOTH LOB, if ONE or MORE of the
following are present.
• To #1, added 1-d: Cancer present in the wound.
• To #1, deleted: E. Exposed vital organs (treatment may proceed
after the organ has been covered by vicryl absorbable mesh). F.
Inadequate debrided wounds; granulation tissue that will not
form over necrotic tissue. G. Presence of untreated
coagulopathy. H. Malignancy in the wound (negative pressure
therapy may lead to cellular proliferation). I. Allergy to any
component required for the procedure. J.NPWT should be used
cautiously when there is active bleeding, when the patient is on
anticoagulants, when there is difficult wound homeostasis, or
when placing dressing in proximity to blood vessels.
• Separated from Contraindications and corrected to be as
Warning: NPWT should be used cautiously when there is active
bleeding, when the patient is on anticoagulants, when there is
difficult wound homeostasis, or when placing dressing in
proximity to blood vessels.
To the Coding Information:

• Deleted HCPCS Codes NOT covered: Codes G0456 & G0457.
• Added to HCPCS Codes NOT covered: Code A9270.
• Added the following ICD-9 Codes: 682.0, 682.1, 682.2, 682.3,
682.4, 682.5, 682.6, 682.7, 682.8, 868.10, 868.11, 868.12,
868.13, 868.14, 868.19, 880.10, 880.11, 880.12, 880.13, 880.19,
881.10, 881.11, 881.12, 884.1, 891.1, 892.1, 959.12, 998.31, &
998.59.
To Appendix A:
• Revised and modified staging of pressure ulcers to read as
follows: The staging of pressure ulcers used in this medical
policy, according to the National Pressure Ulcer Advisory Panel
(NPUAP), is as follows.
• Revised and modified order staging of pressure ulcers, from
Stage I to IV, then Unstageable/Unclassified & Suspected Deep
Tissue Injury.
• To Stage I, added the sub-title: Non-blanchable Erythema. To its
content added: Category I may be difficult to detect in
individuals with dark skin tones. May indicate “at risk” persons.
• To Stage II, added the sub-title: Partial Thickness. To its content
added: Presents as a shiny or dry shallow ulcer without slough
or bruising. Bruising indicates deep tissue injury. This stage
should not be used to describe skin tears, tape burns,
incontinence associated dermatitis, maceration or excoriation.
• To Stage III, added the sub-title: Full Thickness Skin Loss. To its
content added: The depth of a Stage III pressure ulcer varies by
anatomical location. The bridge of the nose, ear, occiput and
malleolus do not have (adipose) subcutaneous tissue and Stage
III ulcers can be shallow. In contrast, areas of significant
adiposity can develop extremely deep Stage III pressure ulcers.
Bone/tendon is not visible or directly palpable.
• To Stage IV, added the sub-title: Full Thickness Tissue Loss. To
its content added: The depth of a Stage IV pressure ulcer also
varies by anatomical location. The bridge of the nose, ear,
occiput and malleolus do not have (adipose) subcutaneous
tissue and these ulcers can be shallow. Stage IV ulcers can
extend into muscle and/or supporting structures (e.g., fascia,
tendon or joint capsule) making osteomyelitis or osteitis likely to
occur. Exposed bone/muscle is visible or directly palpable.
• To Unstageable Stage added to subtitle: Unclassified – Full
Thickness Skin or Tissue Loss – Depth Unknown. To its content
added: Until enough slough and/or eschar are removed to
expose the base of the wound, the true depth cannot be
determined; but it will be either a Stage III or IV. Stable (dry,
adherent, intact without erythema or fluctuance) eschar on the
heels serves as “the body’s natural (biological) cover” and
should not be removed.
• To Suspected Deep Tissue Injury Stage added to subtitle: Depth
Unknown. To its content added: Deep tissue injury may be
difficult to detect in individuals with dark skin tones. Evolution
may include a thin blister over a dark wound bed. The wound
may further evolve and become covered by thin eschar.
Evolution may be rapid exposing additional layers of tissue even
with optimal treatment.
• Reformatted all of this Appendix’s content into a table.
To Appendix B:
• To Group 1 Support Surfaces added: For further details of
medical coverage, please access the Medicare Local Coverage
Determination (LCD) for Pressure Reducing Support Surfaces –
Group 1 (L11563).
Group 2 (L11564).
Group 3 (L11565).
October 14, 2014 Revised The MCS Medical Advisory Committee (MAC) evaluated and approved the
implemented changes from September 18, 2014, on October 14, 2014.
MAC also determined that the MCS medical policy will be the predominant
source to evaluate medical necessity for NPWT, and that laboratory test
results (e.g., albumin and pre-albumin), used for decades as biomarkers of
malnutrition, are not included as characteristics of malnutrition due to lack
of evidence-based research, and since the literature is inconclusive on the
relationship between the changes in albumin and pre-albumin (as well as
other laboratory tests) as predictors of changes in nutrition status.
November 23, 2015 Revised To the coding section:
• Eliminate ICD-9 codes since they are no longer valid for
diagnosis classification.
• Add new section of ICD-10 codes which are the valid diagnosis
classification system since October 1, 2015.
February 03, 2016 Revised References updated.

Example in the #7 was corrected by the Instruction in the LCA (A52511):
Disposable wound suction system pumps and related supplies must be
coded A9272 (WOUND SUCTION, DISPOSABLE, INCLUDES DRESSING, ALL
ACCESSORIES AND COMPONENTS, ANY TYPE, EACH).
To the References Section:

• Reference #1 was deleted. This reference is duplicate in the
document Reference #17.
• Also references #18 and 24 were deleted from the Policy.
May 22, 2017 Revised References Updated. Deleted #15 & 16. Added #2 & #14.
To the Indications Section:

• To indication set IV: Added #3: When billing for quantities of
canisters greater than those described in the policy as the usual
maximum amounts, there must be clear and explicit information
in the medical record that justifies the additional quantities.

• To #9: Deleted: Items billed before a signed & dated order has
been received by the supplier, must be submitted with an EY
modifier added to each related HCPCS code. Added: An order
for each item billed must be signed and dated by the prescribing
physician. Items dispensed and/or billed that do not meet these
prescription requirements and those below must be submitted
with an EY modifier added to each affected HCPCS code.
To the Coding Section:

• Deleted ICD-10 codes: I70.331, I70.332, I70.333, I70.334,
I70.335, I70.338, I70.339, I70.341, I70.342, I70.343, I70.344,
I70.345, I70.348, I70.349, I70.35, I70.431, I70.432, I70.433,
I70.434, I70.435, I70.438, I70.439, I70.441, I70.442, I70.443,
I70.444, I70.445, I70.448, I70.449, I70.45, I70.531, I70.532,
I70.533, I70.534, I70.535, I70.538, I70.539, I70.541, I70.542,
I70.543, I70.544, I70.545, I70.548, I70.549, I70.55, I70.631
I70.632, I70.633, I70.634, I70.635, I70.638, I70.639, I70.641,
I70.642, I70.643, I70.644, I70.645, I70.648, I70.649, I70.65,
I70.731, I70.732, I70.733, I70.734, I70.735, I70.738, I70.739,
I70.741, I70.742, I70.744, I70.745, I70.748, I70.749, I70.75,
L89.000, L89.000, L89.001, L89.002, L89.009, L89.010, L89.011,
L89.012, L89.019, L89.020, L89.021, L89.022, L89.029, L89.100,
L89.101, L89.102, L89.109, L89.110, L89.111, L89.112, L89.119,
L89.120, L89.121, L89.122, L89.129, L89.130, L89.131, L89.132,
L89.139, L89.140, L89.141, L89.142, L89.149, L89.150, L89.151,
L89.152, L89.159, L89.200, L89.201, L89.202, L89.209, L89.210,
L89.211, L89.212, L89.219, L89.220, L89.221, L89.222, L89.229,
L89.300, L89.301, L89.302, L89.309, L89.310, L89.311, L89.312,
L89.319, L89.320, L89.321 L89.322 L89.329 L89.40, L89.41
L89.42, L89.45, L89.500, L89.501, L89.502, L89.509, L89.510,
L89.511, L89.512, L89.519, L89.520, L89.521, L89.522, L89.529,
L89.600, L89.601, L89.602, L89.609, L89.610, L89.611, L89.612,
L89.619, L89.620, L89.621, L89.622, L89.629, L89.810, L89.811,
L89.812, L89.819, L89.890, L89.891, L89.892, L89.95, L97.101,
L97.102, L97.103, L97.104, L97.109, L97.111, L97.112, L97.113,
L97.114, L97.119, L97.121, L97.122, L97.123, L97.124, L97.129,
L97.201, L97.202, L97.203, L97.204, L97.209, L97.211, L97.212,
L97.213, L97.214, L97.219, L97.221, L97.222, L97.223, L97.224,
L97.229, L97.301, L97.302, L97.303, L97.304, L97.309, L97.311,
L97.312, L97.313, L97.314, L97.319, L97.321, L97.322, L97.323,
L97.324, L97.329, L97.401, L97.402, L97.403, L97.404, L97.409,
L97.411, L97.412, L97.413, L97.414, L97.419, L97.421, L97.422,
L97.423, L97.424, L97.429, L97.501, L97.502, L97.503, L97.504,
L97.509, L97.511, L97.512, L97.513, L97.514, L97.519, L97.521,
L97.522, L97.523, L97.524, L97.529, L97.801, L97.802, L97.803,
L97.804, L97.809, L97.811, L97.812, L97.813, L97.814, L97.819,
L97.821, L97.822, L97.823, L97.824, L97.829, L97.901, L97.902,
L97.903, L97.904, L97.909, L97.911, L97.912, L97.913, L97.914,
L97.919, L97.921, L97.922, L97.923, L97.924, L97.929, L98.411,
L98.412, L98.413, L98.414, L98.419, L98.421, L98.422, L98.423,
L98.424, L98.429, L98.491, L98.492, L98.493, L98.494, L98.499.
• Added new ICD-10 codes: S21.021D, S21.021S, S21.022D,
S21.022S, S21.029D, S21.029S, S21.041D, S21.041S, S21.042D,
S21.042S, S21.049D, S21.049S, S21.121D S21.121S, S21.122D,
S21.122S, S21.129D, S21.129S, S21.141D, S21.141S, S21.142D,
S21.142S, S21.149D, S21.149S, S21.92XD, S21.92XS, S21.94XD,
S21.94XS, S31.001D, S31.001S, S31.011D, S31.011S, S31.020D,
S31.020S, S31.021D, S31.021S, S31.031D,S31.031S, S31.040D,
S31.040S, S31.041D, S31.041S, S31.051D, S31.051S, S31.120D,
S31.120S, S31.121D, S31.121S, S31.122D, S31.122S, S31.123D,
S31.123S, S31.124D, S31.124S, S31.125D, S31.125S, S31.129D,
S31.129S, S31.140D, S31.140S, S31.141D, S31.141S, S31.142D,
S31.142S, S31.143D, S31.143S, S31.144D, S31.144S, S31.145D,
S31.145S, S31.149D, S31.149S, S31.600D, S31.600S, S31.601D,
S31.601S, S31.602D, S31.602S, S31.603D, S31.603S, S31.604D,
S31.604S, S31.605D, S31.605S, S31.610D, S31.610S, S31.611D,
S31.611S, S31.612D, S31.612S, S31.613D, S31.613S, S31.614D,
S31.614S, S31.615D, S31.615S, S31.619D, S31.619S, S31.620D,
S31.620S, S31.621D, S31.621S, S31.622D, S31.622S, S31.623D,
S31.623S, S31.624D, S31.624S, S31.625D, S31.625S, S31.640D,
S31.640S, S31.641D, S31.641S, S31.642D, S31.642S, S31.643D,
S31.643S, S31.644D, S31.644S, S31.645D, S31.645S, S31.649D,
S31.649S, S31.650D, S31.650S, S31.651D, S31.651S, S31.652D,
S31.652S, S31.653D, S31.653S, S31.654D, S31.654S, S31.659D,
S31.659S, S31.802D, S31.802S,S31.804D, S31.804S, S31.812D,
S31.812S, S31.814D, S31.814S, S31.822D, S31.822S, S31.832D,
S31.832S, S31.834D, S31.834S, S36.129D, S36.129S, S36.13XD,
S36.13XS, S36.81XD, S36.81XS, S36.899D, S36.899S, S37.819D,
S37.819S, S37.819D, S37.819S, S37.819D, S37.819S, S39.091D,
S39.091S, S39.81XD, S39.81XS, S39.91XD, S39.91XS, S41.021D,
S41.021S, S41.022D, S41.022S, S41.029D, S41.029S, S41.041D,
S41.041S, S41.042D, S41.042S, S41.049D, S41.049S, S41.121D,
S41.121S, S41.122D, S41.122S, S41.129D, S41.129S, S41.141D
S41.141S, S41.142D, S41.142S, S41.149D, S41.149S, S51.021D,
S51.021S, S51.022D, S51.022S, S51.029D, S51.029S, S51.041D,
S51.041S, S51.042D, S51.042S, S51.049D, S51.049S, S51.821D,
S51.821S, S51.822A, S51.822D, S51.822S, S51.841A, S51.841D,
S51.841S, S51.842A, S51.842D, S51.842S, S61.021A, S61.021D,
S61.021S, S61.041A, S61.041D, S61.041S, S61.121A, S61.121D,
S61.121S, S61.122A, S61.122A, S61.122A, S61.141A, S61.141D,
S61.141S, S61.220A, S61.220D, S61.220S, S61.229A, S61.229D,
S61.229S, S61.240A, S61.240D, S61.240S, S61.320A, S61.320D,
S61.320S, S61.329A, S61.329D, S61.329S, S61.340A, S61.340D,
S61.340S, S61.341A, S61.341D, S61.341S, S61.421A, S61.421D,
S61.421S, S61.422A, S61.422D, S61.422S, S61.441A, S61.441D,
S61.441S, S61.521D, S61.521S, S61.522D, S61.522S, S61.529D,
S61.529S, S61.541D, S61.541S, S61.542D, S61.542S, S61.549D,
S61.549S, S71.021D, S71.021S, S71.022D, S71.022S, S71.029D,
S71.029S, S71.041D, S71.041S, S71.042D, S71.042S, S71.049D,
S71.049S, S71.121D, S71.121S, S71.122D, S71.122S, S71.122D,
S71.122S, S71.129D, S71.129S, S71.141D, S71.141S, S71.142D,
S71.142S, S71.149D, S71.149S, S81.021D, S81.021S, S81.022D,
S81.022S, S81.029D, S81.029S, S81.041D, S81.041S, S81.042D,
S81.042S, S81.049D, S81.049S, S81.821D, S81.821S, S81.822D,
S81.822S, S81.829D, S81.829S, S81.841D, S81.841S, S81.842D,
S81.842S, S81.849D, S81.849S, S91.021D, S91.021S, S91.022D,
S91.022S, S91.029D, S91.029S, S91.041D, S91.041S, S91.041D,
S91.041S, S91.042D, S91.042S, S91.042D, S91.042S, S91.049D,
S91.049S, S91.321D, S91.321S, S91.322D, S91.322S, S91.329D,
S91.329S, S91.341D, S91.341S, S91.341D, S91.341S, S91.342D,
S91.342S, S91.349D, S91.349S, T81.31XD, T81.31XS, T81.4XXD,
T81.4XXS, T81.89XD, T81.89XS.
August 21, 2018 Revised To the Prescription (order) Requirements Section:
• Word “produce” was deleted and replaced by word “Complete”
in the #1.
• New Information was added to #5: “and/or a HCPCS code, the
long description of a HCPCS code”.
• Letters “B, C, and E” were deleted from #2.

• Information in #6 was deleted when reviewed with the
Information contained in the following document:
LCA NPWT Pumps - Policy Article (A52511)
WRITTEN ORDER PRIOR TO DELIVERY (WOPD)
Effective for claims with dates of service on or after 05/25/2017,
a WOPD is no longer required.
To the Contraindications/Warnings Section:

New Phrase “An Open” was added to the Letter “c” from the LCD Negative
Pressure Wound Therapy Pumps L33821.
To the Coding Section:
• To the ICD-10 Codes Section:
The following Codes were added to the Policy:
E10.42, E10.641, E11.42, E11.641, E13.29, E13.311, E13.319,
E13.3211, E13.3212, E13.3213, E13.3219, E13.3291, E13.3292,
E13.3293, E13.3299, E13.3311, E13.3312, E13.3313, E13.3319,
E13.3391, E13.3392, E13.3393, E13.3399, E13.3411, E13.3412,
E13.3413, E13.3419, E13.3491, E13.3492, E13.3493, E13.3499,
E13.3511, E13.3512, E13.3513, E13.3519, E13.3521, E13.3522,
E13.3523, E13.3529, E13.3531, E13.3532, E13.3533, E13.3539,
E13.3541, E13.3542, E13.3543, E13.3549, E13.3551, E13.3552,
E13.3553, E13.3559, E13.3591, E13.3592, E13.3593, E13.3599,
E13.36, E13.37X1, E13.37X2, E13.37X3, E13.37X9, E13.39,
E13.40, E13.59, E13.620, E13.621, E13.622, E13.628, E13.638,
E13.641, E13.649, E13.65, E13.69, L02.02, L02.03, L02.12,
L02.13, L02.221, L02.222, L02.223, L02.224, L02.225, L02.226,
L02.229, L02.231, L02.232, L02.233, L02.234, L02.235, L02.236,
L02.239, L02.32, L02.33, L02.42, L02.421, L02.422, L02.423,
L02.424, L02.425, L02.426, L02.429, L02.431, L02.432, L02.433,
L02.434, L02.435, L02.436, L02.439, L02.521, L02.522, L02.529,
L02.531, L02.532, L02.539, L02.621, L02.622, L02.629, L02.631,
L02.632, L02.639, L02.821, L02.828, L02.831, L02.838, L02.91,
L02.92, L02.93, L03.011, L03.012, L03.019, L03.021, L03.022,
L03.029, L03.031, L03.032, L03.039, L03.041, L03.042, L03.049,
L03.213, L03.90, S31.100A, S31.100D, S31.100S, S31.101A,
S31.101D, S31.101S, S31.102A, S31.102D, S31.102S, S31.103A,
S31.103D, S31.103S, S31.104A, S31.104D, S31.104S, S31.105A,
S31.105D, S31.105S, S31.109A, S31.109D, S31.109S, S31.110A,
S31.110D, S31.110S, S31.111A, S31.111D, S31.111S, S31.112A,
S31.112D, S31.112S, S31.113A, S31.113D, S31.113S, S31.114A,
S31.114D, S31.114S, S31.115A, S31.115D, S31.115S, S31.119A,
S31.119D, S31.119S, S31.122S, S31.130A, S31.130D, S31.130S,
S31.131A, S31.131D, S31.131S, S31.132A, S31.132D, S31.132S,
S31.133A, S31.133D, S31.133S, S31.134A, S31.134D, S31.134S,
S31.135A, S31.135D, S31.135S, S31.139A, S31.139D, S31.139S,
S31.150A, S31.150D, S31.150S, S31.151A, S31.151D, S31.151S,
S31.152A, S31.152D, S31.152S, S31.153A, S31.153D, S31.153S,
S31.154A, S31.154D, S31.154S, S31.155A, S31.155D, S31.155S,
S31.159A, S31.159D, S31.159S, S31.609A, S31.609D, S31.609S,
S31.629A, S31.629D, S31.629S, S31.630A, S31.630D, S31.630S,
S31.631A, S31.631D, S31.631S, S31.632A, S31.632D, S31.632S,
S31.633A, S31.633D, S31.633S, S31.634A, S31.634D, S31.634S,
S31.635A, S31.635D, S31.635S, S31.639A, S31.639D, S31.639S,
S39.001A, S39.001D, S39.001S, S39.021A, S39.021D, S39.021S,
S51.851A, S51.851D, S51.851S, S51.852A, S51.852D, S51.852S,
S61.022A, S61.022D, S61.022S, S61.042A, S61.042D, S61.042S,
S61.142A, S61.142D, S61.142S, S61.221A, S61.221D, S61.221S,
S61.222A, S61.222D, S61.222S, S61.223A, S61.223D, S61.223S,
S61.224A, S61.224D, S61.224S, S61.225A, S61.225D, S61.225S,
S61.226A, S61.226D, S61.226S, S61.227A, S61.227D, S61.227S,
S61.228A, S61.228D, S61.228S, S61.241A, S61.241D, S61.241S,
S61.242A, S61.242D, S61.242S, S61.243A, S61.243D, S61.243S,
S61.244A, S61.244D, S61.244S, S61.245A, S61.245D, S61.245S,
S61.246A, S61.246D, S61.246S, S61.247A, S61.247D, S61.247S,
S61.248A, S61.248D, S61.248S, S61.321A, S61.321D, S61.321S,
S61.322A, S61.322D, S61.322S, S61.323A, S61.323D, S61.323S,
S61.324A, S61.324D, S61.324S, S61.325A, S61.325D, S61.325S,
S61.326A, S61.326D, S61.326S, S61.327A, S61.327D, S61.327S,
S61.328A, S61.328D, S61.328S, S61.342A, S61.342D, S61.342S,
S61.343A, S61.343D, S61.343S, S61.344A, S61.344D, S61.344S,
S61.345A, S61.345D, S61.345S, S61.346A, S61.346D, S61.346S,
S61.347A, S61.347D, S61.347S, S61.348A, S61.348D, S61.348S,
S61.442A, S61.442D, and S61.442S.

The following References were deleted from this Policy: #1, 12, and 19.
June 28, 2019 Revised Prescription (order) requirements Section was deleted from this Policy.
To the contraindications/warnings Section:

• New Note#1 was added to the Policy:
NPWT systems, pumps and their associated supplies, that have
not been specifically designated as being qualified to use HCPCS
codes E2402 via written instructions from the Pricing, Data
Analysis and Coding (PDAC) Contractor will be denied as not
reasonable and necessary.
To the Coding Information Section:

• To the HCPCS Codes Section:
New HCPCS code A9272 was added to the Policy.
To the ICD-10 Codes Section:

• The following ICD-10 Codes were deleted from this Policy:
I87.2, L02.42, K12.2, S21.021A, S21.021D, S21.021S, S21.022A,
S21.022A, S21.022A, S21.029A, S21.029D, S21.029S, S21.041A,
S21.041D, S21.041S, S21.042A, S21.042D, S21.042S, S21.049A,
S21.049D, S21.049S, S21.121A, S21.121D, S21.121S, S21.122A,
S21.122D, S21.122S, S21.129A, S21.129D, S21.129S, S21.141A,
S21.141D, S21.141S, S21.142A, S21.142A, S21.142A, S21.149A,
S21.149D, S21.149S, S21.92XA, S21.92XD, S21.92XS, S21.94XA,
S21.94XD, S21.94XS, S31.020A, S31.020D, S31.020S, S31.021A,
S31.021D, S31.021S, S31.031A, S31.031D, S31.031S, S31.040A,
S31.040D, S31.040S, S31.041A, S31.041D, S31.041S, S31.051A,
S31.051D, S31.051S, S31.802A, S31.802D, S31.802S, S31.804A,
S31.804D, S31.804S, S31.812A, S31.812D, S31.812S, S31.814A,
S31.814D, S31.814S, S31.822A, S31.822D, S31.822S, S31.824A,
S31.822D, S31.822S, S31.832A, S31.822D, S31.822S, S31.834A,
S31.834D, S31.834S, S36.129A, S36.129D, S36.129S, S36.13XA,
S36.13XD, S36.13XS, S36.81XA, S36.81XD, S36.81XS, S36.899A,
S36.899D, S36.899S, S37.819A, S37.819D, S37.819S, S39.001A,
S37.819D, and S37.819S.

• The Following References were added to this Policy:
#20.
• The following References were deleted from this Policy:
#10, and 18.
June 11, 2020 Revised To the Limitations Section:
• New Sentence was added to Limitation #8: This written
order/prescription is referred to as the Standard Written Order
(SWO).
To the Coding Information Section:

• The following ICD-10 Codes were added to the Policy:
S51.829ª, S51.829D, S51.829S, S51.859A, S51.859D, S51.859S,
S61.029A, S61.029D, S61.029S, S61.049A, S61.049D, S61.049S,
S61.129A, S61.129D, S61.129S, S61.131A, S61.131D, S61.131S,
S61.132A, S61.132D, S61.132S, S61.139A, S61.139D, S61.139S,
S61.149A, S61.149D, S61.149S, S61.249A, S61.249D, S61.249S,
S61.349A, S61.349D, S61.349S, S61.429A, S61.429D, S61.429S,
S61.449A, S61.449D, S61.449S, T79.A0XA, T79.A0XD, T79.A0XS,
T79.A11A, T79.A11D, T79.A11S, T79.A12A, T79.A12D, T79.A12S,
T79.A3XA, T79.A3XD, T79.A3XS, T79.A9XA, T79.A9XD, T79.A9XS,
T81.41XA, T81.41XD, T81.41XS, T81.42XA, T81.42XD, T81.42XS,
T81.43XA, T81.43XD, T81.43XS, T81.44XA, T81.44XD, T81.44XS,
T81.49XA, T81.49XD, AND T81.49XS.
K68.11, L89.93, L89.94, S31.001A, S31.001D, S31.001S,
S31.011A, S31.011D, S31.011S, S61.541A, S61.541D, S61.541S,
S61.542A, S61.542D, S61.542S, S61.549A, S61.549D, S61.549S,
S91.021A, S91.021D, S91.021S, S91.022A, S91.022D, S91.022S,
S91.029A, S91.029D, S91.029S, S91.041A, S91.041D, S91.041S,
S91.042A, S91.042D, S91.042S, S91.049A, S91.049D, S91.049S,
S91.321A, S91.321D, S91.321S, S91.322A, S91.322D, S91.322S,
S91.329A, S91.329D, S91.329S, S91.341A, S91.341D, S91.341S,
S91.342A, S91.342D, S91.342S, S91.349A, S91.349D, AND
S91.349S.

• The Following References were added to this Policy:
#4.
June 15, 2021 Revised To the Coverage Statement:
Link was added to the order requirements and the word “New”.

• New Information was added to the Limitation #5: Claim lines
billed without a KX, GA or GZ modifier will be rejected as missing
information.
• New Sentence was added to the Limitation #8: For more
information make reference to the LCA Standard
Documentation Requirements for All Claims Submitted to DME
MACs (A55426).

• The Following References were deleted from this Policy:
#6 and 15.
To the Appendix A:
To the II Partial Thickness: Some Information was deleted and New was
added in Substitution: 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) from the LCD L33821.
To the III Full Thickness Skin Loss: Some Information was deleted and New
was added in Substitution from the LCD L33821: Some Information was
deleted and New was added in Substitution from the LCD L33821: 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.
Suspected Deep Tissue Injury Depth Unknown: Some New Information

was added from the LCD L33821: 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.
June 30, 2022 Revised References updated. Deleted references 11 & 15.
To the Coverage Section:

• Reversed order of link name to New Order (Prescription)
Requirements and updated link address.
To the Description Section:

• To first sentence: Updated citation date.
To the Limitations for Medical Coverage for NWPT Supplies Section:

• To #6: Replaced term “ordering physicians” with term “treating
practitioner”

• To #1, 2nd sentence: Added term “treating”.
• To #2: replaced term “physicians” with term “practitioner’s”.
• To #8: replaced term “prescribing physician” with term “treating
practitioner”
• To #8, 2nd sentence: Added term “order”.
• Updated link address for Standard Documentation
Requirements for All Claims Submitted to DME MACs (A55426).
June 27, 2023 Revised To the Coding Information Section:
• The following ICD-10 Codes were added to the Policy: N/A.

L02.01, L02.02, L02.03, L02.11, L02.12, L02.13, L02.211, L02.212,
L02.213, L02.214, L02.215, L02.216, L02.219, L02.221, L02.222,
L02.223, L02.224, L02.225, L02.226, L02.229, L02.231, L02.232,
L02.233, L02.234, L02.235, L02.236, L02.239, L02.31, L02.32,
L02.33, L02.411, L02.412, L02.413, L02.414, L02.415, L02.416,
L02.419, L02.421, L02.422, L02.423, L02.424, L02.425, L02.426,
L02.429, L02.431, L02.432, L02.433, L02.434, L02.435, L02.436,
L02.439, L02.511, L02.512, L02.519, L02.521, L02.522, L02.529,
L02.531, L02.532, L02.539, L02.611, L02.612, L02.619, L02.621,
L02.622, L02.629, L02.631, L02.632, L02.639, L02.811, L02.818,
L02.821, L02.828, L02.831, L02.838, L02.91, L02.92, L02.93,
L03.011, L03.012, L03.019, L03.021, L03.022, L03.029, L03.031,
L03.032, L03.039, L03.041, L03.042, L03.049, L03.111, L03.112,
L03.113, L03.114, L03.115, L03.116, L03.119, L03.121, L03.122,
L03.123, L03.124, L03.125, L03.126, L03.129, L03.211, L03.212,
L03.213, L03.221, L03.222, L03.311, L03.312, L03.313, L03.314,
L03.315, L03.316, L03.317, L03.319, L03.321, L03.322, L03.323,
L03.324, L03.325, L03.326, L03.327, L03.329, L03.811, L03.818,
L03.891, L03.898, L03.90, S61.021A, S61.021D, S61.021S,
S61.022A, S61.022D, S61.022S, S61.029A, S61.029D, S61.029S,
S61.041A, S61.041D, S61.041S, S61.042A, S61.042D, S61.042S,
S61.049A, S61.049D, S61.049S, S61.121A, S61.121D, S61.121S,
S61.122A, S61.122D, S61.122S, S61.129A, S61.129D, S61.129S,
S61.131A, S61.131D, S61.131S, S61.132A, S61.132D, S61.132S,
S61.139A, S61.139D, S61.139S, S61.141A, S61.141D, S61.141S,
S61.142A, S61.142D, S61.142S, S61.149A, S61.149D, S61.149S,
S61.220A, S61.220D, S61.220S, S61.221A, S61.221D, S61.221S,
S61.222A, S61.222D, S61.222S, S61.223A, S61.223D, S61.223S,
S61.224A, S61.224D, S61.224S, S61.225A, S61.225D, S61.225S,
S61.226A, S61.226D, S61.226S, S61.227A, S61.227D, S61.227S,
S61.228A, S61.228D, S61.228S, S61.229A, S61.229D, S61.229S,
S61.240A, S61.240D, S61.240S, S61.241A, S61.241D, S61.241S,
S61.242A, S61.242D, S61.242S, S61.243A, S61.243D, S61.243S,
S61.244A, S61.244D, S61.244S, S61.245A, S61.245D, S61.245S,
S61.246A, S61.246D, S61.246S, S61.247A, S61.247D, S61.247S,
S61.248A, S61.248D, S61.248S, S61.249A, S61.249D, S61.249S,
S61.320A, S61.320D, S61.320S, S61.321A, S61.321D, S61.321S,
S61.322A, S61.322D, S61.322S, S61.323A, S61.323D, S61.323S,
S61.324A, S61.324D, S61.324S, S61.325A, S61.325D, S61.325S,
S61.326A, S61.326D, S61.326S, S61.327A, S61.327D, S61.327S,
S61.328A, S61.328D, S61.328S, S61.329A, S61.329D, S61.329S,
S61.340A, S61.340D, S61.340S, S61.341A, S61.341D, S61.341S,
S61.342A, S61.342D, S61.342S, S61.343A, S61.343D, S61.343S,
S61.344A, S61.344D, S61.344S, S61.345A, S61.345D, S61.345S,
S61.346A, S61.346D, S61.346S, S61.347A, S61.347D, S61.347S,
S61.348A, S61.348D, S61.348S, S61.349A, S61.349D, S61.349S,
S61.421A, S61.421D, S61.421S, S61.422A, S61.422D, S61.422S,
S61.429A, S61.429D, S61.429S, S61.441A, S61.441D, S61.441S,
S61.442A, S61.442D, S61.442S, S61.449A, S61.449D, S61.449S,
S61.521A, S61.521D, S61.521S, S61.522A, S61.522D, S61.522S,
S61.529A, S61.529D, and S61.529S.

• The Following References were deleted from this Policy: #2 and
10.
To the Appendix Section:

To the Appendix A:
• To the IV Full Thickness Skin and Tissue Loss Category: Words
“Ligament and Cartilage” were added to the stage IV Category.
• To the Suspected Deep Tissue Injury Depth Unknown Category:

Phrase “Persistent non-blanchable deep red” was added to the
Suspected Deep Tissue Injury Depth Unknown Stage/Category.
April 11, 2024 UMC Approval
This document is for informational purposes only. It is not an authorization, certification, explanation of benefits, or contract. Receipt of
benefits is subject to satisfaction of all terms and conditions of coverage. Eligibility and benefit coverage are determined in accordance with
the terms of the member’s plan in effect as of the date services are rendered. Medical Card System, Inc., (MCS) medical policies are
developed with the assistance of medical professionals and are based upon a review of published and unpublished information including, but
not limited to, current medical literature, guidelines published by public health and health research agencies, and community medical
practices in the treatment and diagnosis of disease. Because medical practice, information, and technology are constantly changing, Medical
Card System, Inc., (MCS) reserves the right to review and update its medical policies at its discretion. Medical Card System, Inc., (MCS)
medical policies are intended to serve as a resource to the plan. They are not intended to limit the plan’s ability to interpret plan language as
deemed appropriate. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type,
quality, and levels of care and treatment they choose to provide.
APPENDIX A
❖ The staging of pressure ulcers used in this medical policy: According to the National Pressure
Ulcer Advisory Panel 2008 Revision (NPUAP), is as follows:
Stage/Category Description
I Intact skin with non-blanchable redness of a localized area usually over a bony
prominence. Darkly pigmented skin may not have visible blanching; its color may
Non-blanchable differ from the surrounding area. Category I may be difficult to detect in individuals
Erythema of intact skin with dark skin tones. May indicate “at risk” persons.
II Partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink
wound bed, without slough. May also present as an intact or open/ruptured serum-
Partial Thickness filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.
Bruising indicates deep tissue injury. 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).
III 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
Full Thickness Skin Loss 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.
IV Full thickness tissue loss with exposed bone, tendon, ligament, cartilage or muscle.
Slough or eschar may be present on some parts of the wound bed. Often include
Full Thickness Skin and undermining and tunneling. The depth of a Stage IV pressure ulcer also varies by
Tissue Loss anatomical location. The bridge of the nose, ear, occiput and malleolus do not have
(adipose) subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can
extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule)
making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or
directly palpable.
Unstagable/Unclassified Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow,
tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.
Full Thickness Skin or Until enough slough and/or eschar are removed to expose the base of the wound, the
Tissue Loss – Depth true depth cannot be determined; but it will be either a Stage III or IV. Stable (dry,
Unknown adherent, intact without erythema or fluctuance) eschar on the heels serves as “the
body’s natural (biological) cover” and should not be removed.
Suspected Deep Tissue Persistent non-blanchable deep red, Purple or maroon localized area of discolored
Injury intact skin or blood-filled blister due to damage of underlying soft tissue from
pressure and/or shear. The area may be preceded by tissue that is painful, firm,
Depth Unknown mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury
may be difficult to detect in individuals with dark skin tones. Evolution may include a
thin blister over a dark wound bed. The wound may further evolve and become
covered by thin eschar. Evolution may be rapid exposing additional layers of tissue
even with optimal treatment. 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.
APPENDIX B
❖ Support Surface Categories
The three support surface groups have varying characteristics and include the following:
• Group 1 Support Surfaces are generally designed to either replace a standard hospital or home
mattress or as an overlay placed on top of a standard hospital or home mattress. Products in
this category include mattresses, pressure pads and mattress overlays (foam, air, water or gel).
For further details of medical coverage, please access the Medicare Local Coverage
Determination (LCD) for Pressure Reducing Support Surfaces - Group 1 (L33830).
• Group 2 Support Surfaces are generally designed to either replace a standard hospital or home
mattress or as an overlay placed on top of a standard hospital or home mattress. Products in
this category include air flotation beds, powered pressure reducing air mattresses, and non-
powered advanced pressure reducing mattresses. For further details of medical coverage,
please access the Medicare Local Coverage Determination (LCD) for Pressure Reducing Support
Surfaces - Group 2 (L33642).
• Group 3 Support Surfaces are complete bed systems, known as air-fluidized beds, which use the
circulation of filtered air through silicone beads. For further details of medical coverage, please
access the Medicare Local Coverage Determination (LCD) for Pressure Reducing Support
Surfaces - Group 3 (L33692).

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Clinical Medical Policy Department

Clinical Affairs Division

Negative Pressure Wound Therapy (NPWT)

Medical Policy: MP-DME-03-09

a. Documentation in the patient’s medical record of evaluation, care, and wound

b. Application of dressings to maintain a moist wound environment; and

c. Debridement of necrotic tissue if present; and

d. Evaluation of and provision for adequate nutritional status.

2. For Stage III or IV pressure ulcers:

a. The patient has been appropriately turned and positioned, and

c. The patient’s moisture and incontinence have been appropriately managed.

3. For neuropathic ulcers (for example, diabetic):

a. The patient has been on a comprehensive diabetic management program, and

b. Reduction in pressure on a foot ulcer has been accomplished with appropriate

4. For venous insufficiency ulcers:

a. Compression bandages and/or garments have been consistently applied, and

B. Ulcers and Wounds Encountered in an Inpatient Setting:

• Limitations for Ulcers and Wounds Encountered in an Inpatient Setting:

b. Supervise or directly perform the NPWT dressing changes; and

2. On at least a monthly basis, document changes in the ulcer’s dimensions and

• Limitations for Continued Medical Coverage for NPWT:

• Limitations for Medical Coverage for NPWT Supplies:

6. Suppliers must not dispense a quantity of supplies exceeding a patient’s expected

d. Cancer present in the wound.

HCPCS Codes (List may not be all inclusive)

HCPCS Modifiers (List may not be all inclusive)

ICD-10 Codes (List may not be all inclusive)

Contraindication / Limitation # 2 was revised and modified.

To Coding Information: Added new section of HCPCS Codes Not Covered:

Appendix A was revised & updated.

Appendix B was revised & updated.

New Prescription (Order) Requirements Section was added:

Added new ICD-9 Codes 707.20 – 707.25.

To the Description Section:

To the Coverage Statement:

To the Indications Section:

To the Prescription (Order) Requirements Section:

To the General Limitations Section:

To the Contraindications/Warnings Section:

To the Coding Information:

To the General Limitations Section:

To the References Section:

To the Indications Section:

To the General Limitations Section:

To the Coding Section:

To the General Limitations Section:

To the Contraindications/Warnings Section:

To the References Section:

To the contraindications/warnings Section:

To the Coding Information Section:

To the ICD-10 Codes Section:

To the References Section:

To the Coding Information Section:

To the References Section:

To the General Limitations Section:

To the References Section:

Suspected Deep Tissue Injury Depth Unknown: Some New Information

To the Coverage Section:

To the Description Section:

To the Limitations for Medical Coverage for NWPT Supplies Section: