Clinical UM Guideline |
Subject: Chronic Wound Care in the Home or Outpatient Setting | |
Guideline #: CG-MED-71 | Publish Date: 01/03/2024 |
Status: Revised | Last Review Date: 11/09/2023 |
Description |
This document addresses wound care in the home or outpatient setting (for example, an outpatient wound center or wound clinic) for a variety of chronic wounds, such as ulcers related to pressure sores, venous or arterial insufficiency, or neuropathy.
Note: Please see the following related documents for additional information:
Clinical Indications |
Medically Necessary:
Note: To be eligible for wound care in the home setting, the individual must be confined to the home as defined in CG-MED-23 Home Health.
Initial care for a chronic wound in the home or outpatient setting is considered medically necessary when:
Continued care for a chronic wound in the home or outpatient setting is considered medically necessary when:
Not Medically Necessary:
Care for a chronic wound in the home or outpatient setting is considered not medically necessary when:
Coding |
The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
When services may be Medically Necessary when criteria are met:
CPT |
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99600 | Unlisted home visit service or procedure [when specified as home visit for wound care] |
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HCPCS |
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| For the following services when specified as visit for wound care: |
G0299 | Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes |
G0300 | Direct skilled nursing services of a licensed practical nurse (LPN) in the home health or hospice setting, each 15 minutes |
S9097 | Home visit for wound care |
S9123 | Nursing care in the home; by registered nurse, per hour |
S9124 | Nursing care in the home; by licensed practical nurse, per hour |
T1030 | Nursing care, in the home, by registered nurse, per diem |
T1031 | Nursing care, in the home, by licensed practical nurse, per diem |
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ICD-10 Diagnosis |
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| All diagnoses |
When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for situations designated in the Clinical Indications section as not medically necessary.
Discussion/General Information |
Wound care is a general term for the treatment of a variety of wounds such as ulcers related to pressure sores, venous or arterial insufficiency, or neuropathy, and is often provided in the home or outpatient setting. The treatment of these wounds is determined by a detailed assessment that includes, but is not limited to underlying medical conditions, wound measurements, wound characteristics, and nutritional status. Due to the complexities of the types of wounds, underlying medical conditions, and other factors, treatment strategies typically vary for each individual. The plan of care should be a multimodal approach that includes managing underlying medical conditions. An evaluation of the plan of care should occur at least once a week. Wound healing normally progresses at a sustained, measurable rate. Although there is no specific time frame that clearly differentiates an acute from a chronic wound, a lack of approximately fifty percent reduction of the surface area of the wound over a one-month period may indicate a chronic state (Sheehan, 2006). If the wound shows no measurable improvement within 30 days, the plan of care should be evaluated and changed.
Neuropathic ulcers
Neuropathic ulcers can be caused by various disease processes, including diabetes. The Society for Vascular Surgery published a clinical practice guideline on the management of the diabetic foot, which includes recommendations for diabetic foot ulcers. The guideline recommends off-loading diabetic foot ulcers stating, “most plantar ulcers result from repetitive or high plantar pressures…therefore…such pressures must be ameliorated or reduced to allow healing to occur” (Hingorani, 2016). Regarding wound dressings, the guideline states there is little evidence to support the use of one product over another and recommends basing dressing selection on the characteristics of the wound and ease of use of the product.
Ulcers related to pressure sores
Pressure ulcers, also known as pressure sores or pressure injuries, result from decreased blood supply to the tissue due to friction or prolonged pressure on a part of the body. Both the National Pressure Injury Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance (Haesler, 2019) and the Wound, Ostomy and Continence Nurses Society-Wound Guidelines Task Force (2017) released guidelines on the management of pressure ulcers recommending the use of a multi-faceted approach to meet the individual’s needs that includes strategies to minimize mechanical risk, assess and stage the injury, address factors that impact healing locally and systemically, and monitor the progress of the treatment plan.
Venous or arterial insufficiency
Venous or arterial insufficiency results from impairment of blood flow and can lead to tissue ischemia creating an ulcer. The Society for Vascular Surgery published a clinical practice guideline on the management of venous leg ulcers. Compression therapy is recommended for venous leg ulcers to help increase the healing rate (O’Donnell, 2014). In 2016, the Wound Ostomy and Continence Nurses Society published guidelines on the management of wounds caused by lower-extremity arterial disease (Bonham, 2016). Two treatments that the Wound Ostomy and Continence Nurses Society recommends are compression therapy and offloading foot ulcers.
In 2016, the Wound Healing Society published updates to their 2006 wound care guidelines related to diabetic foot ulcers (Lavery, 2016), pressure ulcers (Gould, 2016), and venous ulcers (Marston, 2016). The authors noted that due to the lack of high-quality data from human clinical studies, they included well-controlled animal studies in their assessment of evidence to demonstrate proof of principle, especially when a clinical series corroborated the results. All three guidelines recommended ongoing and consistent documentation of history, characteristics, and rate of wound healing. The following guidance was also included.
Regarding diabetic foot ulcers (Lavery, 2016):
Guideline 4.5: Patients who fail to show a reduction in ulcer size by 50% or more after 4 weeks of therapy should be reevaluated and other treatments should be considered.
Regarding pressure ulcers (Gould, 2016):
Guideline 2.1: Nutritional assessment should be performed on entry to a new healthcare setting and whenever there is a change in an individual’s condition that may increase the risk of under-nutrition.
Guideline 4.4: Initial debridement is required to remove the obvious necrotic tissue, excessive bacterial burden, and cellular burden of dead and senescent cells. Maintenance debridement is needed to maintain the appearance and readiness of the wound bed for healing. The healthcare provider can choose from a number of debridement methods including sharp, mechanical, enzymatic, and autolytic. More than one debridement method may be appropriate.
Definitions |
Acute Wound: A wound with normal wound physiology anticipated to heal through the normal stages of wound healing; examples include lacerations, minor burns, and postoperative surgical incisions.
Chronic Wound: A wound that is physiologically impaired due to a disruption of the wound healing cycle, such as from impaired angiogenesis, innervation, or cellular migration; examples include nonhealing or infected surgical or traumatic wounds, venous ulcers, pressure ulcers, diabetic foot ulcers, and ischemic ulcers.
Initial wound care in the home setting: The first wound care service provided in the individual’s place of residence.
Neuropathic ulcer: An ulcer resulting from the loss of sensation (for instance, pain, touch, stretch) as well as protective reflexes, due to loss of nerve supply to a body part.
Pressure ulcer (National Pressure Ulcer Advisory Panel, 2016): A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.
Pressure ulcer stages:
Pressure Injury:
A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.
Stage 1 Pressure Injury: Non-blanchable erythema of intact skin
Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.
Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis
Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).
Stage 3 Pressure Injury: Full-thickness skin loss
Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.
Stage 4 Pressure Injury: Full-thickness skin and tissue loss
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.
Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss
Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (for example, dry, adherent, intact without erythema or fluctuance) on an ischemic limb or the heel(s) should not be removed.
Deep Tissue Pressure Injury:
Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.
Medical Device Related Pressure Injury:
This describes an etiology. Medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system.
Mucosal Membrane Pressure Injury:
Mucosal membrane pressure injury is found on mucous membranes with a history of a medical device in use at the location of the injury. Due to the anatomy of the tissue these injuries cannot be staged.
Wound Care Center: An outpatient medical facility that treats wounds that are typically difficult to heal.
References |
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
Index |
Wound Care
History |
Status | Date | Action |
Revised | 11/09/2023 | Medical Policy & Technology Assessment Committee (MPTAC) review. Reformatted Description and Clinical Indications sections. Updated References section. |
Reviewed | 11/10/2022 | MPTAC review. Updated Discussion and References sections. |
Reviewed | 11/11/2021 | MPTAC review. Updated Discussion/General Information and References sections. |
Reviewed | 11/05/2020 | MPTAC review. Updated References section. Reformatted Coding section. |
Revised | 11/07/2019 | MPTAC review. Expanded scope to include outpatient settings. Description, Clinical Indications, Discussion/General Information, Definitions and References sections updates. Coding section updated; added codes 99600, G0299, G0300, S9123, S9124, T1030, T1031. |
Reviewed | 06/06/2019 | MPTAC review. Updated References section. |
Revised | 07/26/2018 | MPTAC review. Revised Description section to clarify setting. Revised medically necessary criteria regarding initial wound care and continued wound care in the Clinical Indications section. Added additional criteria to the not medically necessary statement in the Clinical Indications section. Updated Discussion/General Information and References sections. |
New | 05/03/2018 | MPTAC review. Initial document development. |
Federal and State law, as well as contract language including definitions and specific coverage provisions/exclusions, and Medical Policy take precedence over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Clinical UM Guidelines, which address medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically. Clinical UM guidelines are used when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether or not to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the back of the member's card.
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