Unless otherwise specified, the staging of pressure ulcers used in this rule is as follows:
(1) Suspected deep tissue injury: Purple or maroon localized area of discolored 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, mushy, boggy, warmer or cooler as compared to adjacent tissue.
(2) Stage 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 differ from the surrounding area.
(3) Stage 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-filled blister.
(4) Stage III: Full thickness loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
(5) Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.
(6) Unstageable: 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.
(B) Coverage determination
(1) Surgical dressings are covered for as long as medical necessity exists. Dressings over a percutaneous catheter or tube (e.g., intravascular, epidural, nephrostomy, etc.) are covered as long as the catheter or tube remains in place and after removal until the wound heals.
(2) Any prescription for surgical dressings and related supplies must be prescribed by a prescriber actively involved in managing the consumer's medical condition as indicated in paragraph (A)(2) of rule 5101:3-10-05 of the Administrative Code. The prescriber should be treating the consumer under a comprehensive plan of care which addresses the underlying medical need for any supplies referenced in this rule.
(3) When a wound cover with an adhesive border is being used, no other dressing is needed on top of it and additional tape is usually not required. Reasons for use of additional tape must be documented by the provider. An adhesive border is usually more binding than that obtained with separate taping and is therefore indicated for use with wounds requiring less frequent dressing changes.
(4) Use of more than one type of wound filler or more than one type of wound cover in a single wound is rarely medically necessary. The reasons for use of more than one type of wound filler or wound cover must be well documented by the provider. An exception is an alginate or other fiber gelling dressing or a saline, water, or hydrogel impregnated gauze dressing which might need an additional wound cover.
(5) It may not be appropriate to use some combinations of a hydrating dressing on the same wound at the same time as an absorptive dressing (e.g., hydrogel and alginate).
(6) When used as a secondary dressing, composite dressings, foam and hydrocolloid wound covers, and transparent film are meant to be changed at frequencies less than daily and appropriate clinical judgment must be used to avoid their use with primary dressings which require more frequent dressing changes. When claims are submitted for these dressing for changes greater than once every other day, the quantity in excess of that amount will not be reimbursable by the department for a period not to exceed thirty days during the initial treatment. While a highly exudative wound might require such a combination initially, with continued proper management the wound usually progresses to a point where the appropriate selection of these products results in the less frequent dressing changes which they are designed to allow. An example of an inappropriate combination is the use of a specialty absorptive dressing on top of non-impregnated gauze being used as a primary dressing.
(7) Dressing size must be based on and appropriate to the size of the wound. For wound covers, the pad size is usually about two inches greater than the dimensions of the wound.
(8) The quantity and type of dressings dispensed at any one time must take into account the current status of the wound(s), the likelihood of change, and the recent use of dressings.
(9) Dressing needs may change frequently (e.g.,weekly) in the early phases of wound treatment and/or with heavily draining wounds. Providers are expected to have a mechanism for determining the quantity of dressings that the consumer is actually using and to adjust their provision of dressings accordingly. No more than one month's supply of dressings may be provided at one time. The stockpiling of surgical dressings and related supplies by a consumer is not allowed.
(10) Providers are responsible for determining whether additional surgical dressings and related supplies have been acquired by the consumer from a different provider during any given month. Surgical dressings and related supplies dispensed over and above the stated maximum allowables as listed in appendix A to rule 5101:3-10-03 of the Administrative Code will be not be reimbursed without prior authorization.
(11) Surgical dressings must be tailored to the specific needs of an individual consumer. When surgical dressings are provided in kits, only those components of the kit that meet the definition of a surgical dressing and are specifically ordered by a prescriber and are medically necessary are covered. Components included in a kit such as scissors and/or tape may not be billed separately to the department.
(C) Alginate or other fiber gelling dressing
Alginate or other fiber gelling dressing covers are covered for moderately to highly exudative full thickness wounds (e.g., stage III or IV ulcers), and alginate or other fiber gelling dressing fillers for moderately to highly exudative full thickness wound cavities (e.g., state III or IV ulcers). They are not medically necessary on dry wounds or wounds covered with eschar. Usual dressing change is up to once per day. One wound cover sheet of the approximate size of the wound or up to two units of wound filler (one unit equals six inches of alginate or other fiber gelling dressing rope) is usually used at each dressing change. It is usually inappropriate to use alginates or other fiber gelling dressings in combination with hydrogels.
(D) Composite dressing
Usual composite dressing change is up to three times per week, one wound cover per dressing change.
(E) Contact layer dressing
Contact layer dressings are used to line the entire wound and are not intended to be changed with each dressing change. Usual dressing change is up to once per week.
(F) Foam dressing
Foam dressings are covered when used on full thickness wounds (e.g., stage III or IV ulcers) with moderate to heavy exudate. Usual dressing changes for a foam wound cover used as a primary dressing is up to three times per week. When a foam wound cover is used as a secondary dressing for wounds with a very heavy exudate, dressing change may be up to three time per week. Usual dressing change for foam wound fillers is up to once per day.
(G) Gauze, non-impregnated dressing
Usual non-impregnated gauze dressing change is up to three times per day for a dressing without a border and once per day for a dressing with a border. It is usually not necessary to stack more than two gauze pads on top of each other in any one area.
(H) Gauze dressing, impregnated, with other than water, normal saline, hydrogel, or zinc paste
Usual dressing change for this type of dressing is up to once per day.
(I) Hydrocolloid dressing
Hydrocolloid dressings are covered for use on wounds with light to moderate exudate. Usual dressing change for hydrocolloid wound covers or hydrocolloid wound fillers is up to three times per week.
(J) Hydrogel dressing
Hydrogel dressings are covered when used on full thickness wounds with minimal or no exudate (e.g., stage III or IV ulcers). Hydrogel dressings are not usually medically necessary for stage II ulcers. Documentation must substantiate the medical necessity for use of hydrogel dressing for stage II ulcers (e.g., location of ulcer in sacrococcygeal area). Usual dressing change for hydrogel wound covers without adhesive border or hydrogel wound fillers is up to once per day. Usual dressing change for hydrogel wound covers with adhesive border is up to three times per week.
The quantity of hydrogel filler used for each wound must not exceed the amount needed to line the surface of the wound. Additional amounts used to fill a cavity are not medically necessary. Provider documentation must substantiate the medical necessity for this product billed in excess of three units (fluid ounces) per wound in thirty days.
Use of more than one type of hydrogel dressing (filler, cover, or impregnated gauze) on the same wound at the same time is not medically necessary.
(K) Specialty absorptive dressing
Specialty absorptive dressings are covered when used for moderately or highly exudative wounds (e.g., stage III or IV ulcers). Usual specialty absorptive dressing change is up to once per day for a dressing without an adhesive border and up to every other day for a dressing with a border.
(L) Transparent film dressing
Transparent film dressings are covered when used on open partial thickness wounds with minimal exudate or closed wounds. Usual dressing changes is up to three times per week.
(M) Wound filler, not elsewhere classified
Usual dressing change is up to once per day. (N) Wound pouch Usual dressing change is up to three time per week.
Tape is covered when needed to secure a wound cover, elastic roll gauze or non-elastic roll gauze. Tape is usually not required when a wound cover with an adhesive border is used. The medical necessity for tape in these situations must be documented by the provider. Tape change is determined by the frequency of change of the wound cover. Quantities of tape must reasonably reflect the size of the wound cover being secured. Usual use for wound covers measuring sixteen square inches or less is up to two units per dressing change; for wounds covers measuring sixteen to forty-eight square inches, up to three units per dressing change; for wound covers measuring greater that forty-eight square inches, up to four units per dressing change.
(P) Light compression bandage, moderate/high compression bandage, self-adherent bandage, conforming bandage, padding bandage
Most compression bandages are reusable. Usual frequency of replacement would be no more than one per week unless they are a part of a multi-layer compression bandage system.
Conforming bandage dressing change is determined by the frequency of change of the selected underlying dressing.
(Q) Non-coverage determination
(1) Surgical dressings are not separately reimbursable for consumers in long term care facilities (LTCFs) as these supplies are included the facility's cost report.
(2) Gauze, impregnated, water or normal saline
There is no medical necessity for these dressings compared to non-impregnated gauze moistened with bulk saline or sterile water. These dressings are not separately reimbursed by the department.
(3) Providers can not bill the department for any surgical dressing or a related supply item past the date of medical necessity.
(1) A fully completed and legible prescription signed by an eligible prescriber must be kept on file by the provider and made available for review upon request by the department and sent to the department for review as a part of a prior authorization request for surgical dressings or supplies.
(2) The prescription must specify the type of dressing being prescribed, the size of the dressing being prescribed, the number/amount to be used at one time (if more than one), the frequency of dressing change, and the expected duration of need for the surgical dressings and related supplies.
(3) A new prescription is needed if any new dressing is added or if the quantity used of an existing dressing is increased. A new prescription is not needed if the quantity of dressings used is decreased. However, a new prescription is required at least every three months for each dressing being used even if the quantity used has remained the same or decreased.
(4) The prescription for the dressing must identify the number of wounds being treated and the reasons for the dressing (e.g., a primary or secondary dressing to cover a surgical or debrided wound, or for wound cleansing). Dressing use or the use of a related supply item must be documented in the provider's records and include the date and source of this information (e.g., prescriber or home care nurse).
(5) The prescription must contain clinical information not more than one year old supporting the necessity of the type and quantity of surgical dressings provided and must be maintained in the consumer's medical records. An evaluation of the consumer's wound (s) must be performed at least on a monthly basis by a qualified health care provider unless there is documentation in the consumer's medical record which justifies why an evaluation could not be done within this timeframe and what other monitoring methods were used to evaluate the continuing need for dressings. Evaluation is expected on a more frequent basis (e.g., weekly) if a consumer has a heavily draining or infected wound. The wound evaluation must include the type of each wound (e.g., surgical wound, pressure ulcer, burn, etc.), its location, size (length and width in centimeters) and depth, the amount of drainage, and any other relevant clinical information. This information must be available for review upon department request.
Surgical dressings and related supplies are reimbursed at the lesser of the department's fee schedule contained in appendix DD to rule 5101:3-1-60 of the Administrative Code or the provider's usual and customary charge.