Orthopedic Coding Alert

Question: I-ve heard that we can now collect from Medicare for VAC therapy (as of 2006). Under what circumstances will Medicare reimburse this procedure?

Florida Subscriber

Answer: Yes, Medicare payers may now reimburse you for vacuum-assisted collection (VAC) codes 97605 (Negative pressure wound therapy [e.g., vacuum-assisted drainage collection], 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) and 97606 (... total wound[s] surface area greater than 50 square cm).
 
Prior to 2006, the Medicare fee schedule assigned zero relative value units to 97605 and 97606, and labeled the codes as -status B,- or carrier-priced. In practice, this meant that although many payers agreed that VAC procedures could be medically necessary for certain diagnoses, they would not separately reimburse for the procedures under any circumstances.
 
For 2006, Medicare provides RVUs for 97605 and 97606, thereby mandating payment for the services when medically necessary -- although payment to the physician will still equal less than $20 in most areas.
 
Local Part B payers vary in the exact diagnoses they will allow to support a claim of 97605 or 97606, but a typical policy makes clear that VAC will be covered -as an adjunct to standard treatment in carefully selected patients who have failed all other forms of treatment.- Generally accepted indications include (but are not limited to):
 
- chronic stage III or IV pressure ulcers
 
- neuropathic ulcers
 
- venous or arterial insufficiency ulcers
 
- chronic ulcers of mixed etiology present for at least 30 days
 
- dehisced wounds or wounds with exposed orthopedic hardware or bone
 
- acute wounds.
 
Contraindications for coverage of 97605-97606 typically include (but are not limited to):
  
- necrotic tissue with eschar in the wound, if debridement is not attempted
 
- untreated osteomyelitis within the vicinity of the wound
 
- cancer in the wound
 
- a fistula to an organ or body cavity within the vicinity of the wound.
 
Tip: Contact your local carrier for a complete list of covered ICD-9 codes. Remember, you must report a diagnosis supported by clinical evidence. You should not select a diagnosis merely to obtain coverage.
 
Most payers will continue to provide coverage for up to four months, until adequate wound healing has occurred or when documentation shows that a measurable degree of wound healing has failed to occur over the prior month (whichever comes first).

 -- Reader Questions were reviewed by Heidi Stout, CPC, CCS-P, coding and reimbursement manager at UMDNJ-RWJ University Orthopaedic Group in New Brunswick, N.J.; and Bill Mallon, MD, orthopedic surgeon and medical director at Triangle Orthopaedic Associates in Durham, N.C.