E2402, Negative pressure wound therapy electrical pump, stationary or portable
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- A Standard Written Order (SWO) or, where applicable, a signed Written Order Prior to Delivery (WOPD) must be received by the supplier before a claim is submitted or the DMEPOS base item is delivered.
- Medical record must document wound evaluation, care, and measurements by a licensed medical professional prior to and during NPWT.
- Medical record must document application of moist dressings, debridement when indicated, and evaluation/provision of adequate nutrition prior to NPWT.
- For Stage 3/4 pressure ulcers document turning/positioning, use of group 2 or 3 support surface for posterior trunk/pelvis, and moisture/incontinence management prior to NPWT.
Key Coverage Criteria
- For Stage 3 or 4 pressure ulcers, beneficiary must have been appropriately turned and positioned prior to NPWT.
- NPWT pump (E2402) and supplies (A6550, A7000) are covered in the home setting for beneficiaries with a chronic (>=30 days) Stage 3 or 4 pressure ulcer, neuropathic (e.g., diabetic) ulcer, venous or arterial insufficiency ulcer, or a chronic ulcer of mixed etiology.
- Coverage requires that a complete wound therapy program has been tried or considered and ruled out prior to application of NPWT.
- General wound-therapy measures that must be addressed prior to NPWT include documentation of wound evaluation and measurements by a licensed medical professional.
- General wound-therapy measures include application of dressings to maintain a moist wound environment prior to NPWT.
- General wound-therapy measures include debridement of necrotic tissue when present prior to NPWT.
13 Active Policies
HUMANA-NEGATIVE-PRESSURE-WOUND-THERAPY-MA, Negative Pressure Wound Therapy
ANTHEM-CG-DME-48, CG-DME-48 Vacuum Assisted Wound Therapy in the Outpatient Setting
L33821, Negative Pressure Wound Therapy Pumps
UHC-POL-negative-pressure-wound-therapy, Negative Pressure Wound Therapy
AETNA-CPB-0334, Negative Pressure Wound Therapy
Related Codes
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