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Update: New Novitas Wound Care LCD L35125

10/06/2017 9:13 AM | Anonymous

Novitas Solutions, Inc. is the Medicare contractor (MAC) for the following states and district:

District of Columbia
New Jersey
New Mexico

In January 2017, Novitas published a proposed rule for payment of wound care treatments to their beneficiaries which we thought was filled with many inconsistencies and confusion with aspects that did not seem to be based on the current state of wound care delivery by the wound care industry (many of whom are members of the APWCA). This proposed rule was subject to a 60 day comment period. APWCA, in conjunction with the Alliance of Wound Care Stakeholders, spoke on behalf of its Novitas members and submitted comments. Our voice was heard!

Novitas has just published their recently finalized LCD (Local Coverage Determination) L35125 entitled "Wound Care" which is due to go into effect on November 11, 2017. A copy of the entire LCD L35125 is available here. This update to membership is meant to review key points of the finalized LCD.

  1. Surgical/excisional debridement of dermis, subcutaneous tissues, and fascia: There is no limit to the number of surgical debridements a patient may receive in a 360 day time frame. However, Novitas feels that greater than 8 debridements at any depth is "excessive". Therefore, the LCD states that should the patient require greater than 8 total debridements, "meticulous" documentation is necessary to explain why this "excessive" amount of debridement is indicated. Please keep in mind that providers should already be documenting medical necessity with each and every debridement. Please take this opportunity to review your documentation habits.
  2. Surgical/excisional Muscle/fascia and bone debridement: Novitas feels that more than 5 total debridements that include muscle/fascia or bone in a 360 day period is "excessive" but will not place an "a priori" limit. Instead the LCD requires that more than 5 total debridements that include muscle/fascia or bone in a 360 day period be accompanied by "meticulous" documentation illustrating that the service is both medically reasonable and necessary.
  3. Non-contact non-thermal Ultrasound for wound treatment (MIST): The LCD states it should be offered a minimum of 2-3 times per week. But, if no observable wound improvement is noted after 2 weeks (4-6 treatments), then this wound treatment is not reasonable or necessary. Furthermore, no more than 18 treatments in a 6 week period will be considered reasonable or necessary.
  4. Negative Pressure Wound Therapy (NPWT): Two types are considered: a) that done with DME, and b) that done with disposable systems as an outpatient or homecare patient. Both are covered given proper indications and usage. The LCD states, "…the beneficiaries who undergo treatment utilizing negative pressure wound therapy, only a minority appears to require more than 6 NPWT services in a 120 day period to accomplish the desired objective of the treatment plan of the wound. Only when medical necessity continues to be met and there is documented evidence of clear benefit from the NPWT treatment already provided, should NPWT services be continued beyond this frequency or time frame."

There were numerous changes from the proposed LCD to the final LCD which was just published. The changes relevant to our comments include:

  1. No frequency limit on total number of debridements in a year
  2. No frequency limit on the total number of debridements including muscle / fascia and bone in a year
  3. Disposable NPWT coverage was not removed as was proposed
  4. Wound photography not required as proposed (but it is suggested especially when more than 8 total debridements or 5 debridements including muscle / fascia and bone are performed in a year)
  5. Palliative wound care is covered
  6. The statement in the proposed LCD that a wound needs to show a documented improvement of 10% per month or granulation tissue progression of 1 mm per month was removed
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