Urgent update on multilayer wrap reimbursement and billing codes.

Noridian is the fiscal intermediary for most states west of the Mississippi River. Effective Feb 21, 2007 they published a clarification stating that multilayer compression wraps were not to be billed using the CPT Code for Unna Boots because, in their opinion, these multilayer wraps could be applied independently by patients and families.

The actual ruling can be read in its entirety by going to: www.noridianmedicare.com

Obviously, most WOC nurses who actually use these products would disagree with this rationale. There is concern that this ruling clarification will be adopted by other fiscal intermediaries as well.

We are asking members to respond to Noridian and ask them to reconsider this ruling. Following is a sample letter with talking points that members can use to draft their response.

Thanks to all members in advance who take the time and effort to respond to Noridian on behalf of your patients.

Lee Ann Krapfl, RN, CWOCN

Chair, WOCN Public Policy Committee

Noridian Administrative Services
Medicare B
P.O. Box 6711
Fargo, N.D.  58108-6711

To Whom It May Concern:

I am writing in response to your recent billing clarification regarding high compression bandage systems. I am a certified wound nurse and have clinical experience with these multiplayer wraps. From my personal experience in caring for patients with venous stasis leg ulcers, the suggestion that the patient and/or caregiver can safely apply these products independently is simply unfounded.

Sustained, graduated compression delivered by the multiplayer wraps is more therapeutic. The disadvantage is that the application of them is actually more complex than an Unna boot and requires advanced skill, training and experience of a health care professional. My rationale is as follows:

An Unna boot delivers a pressure range between 12-18 mmHg. When applied to a leg with a venous ulcer, the main function is the protection of the wound with the application of minimal compression.

Ideally, the most effective therapeutic compression to treat venous ulcers requires 25-45 mmHg at the ankle reducing to 15-20 mmHg at the knee.

Sustained, graduated compression delivered by a multiplayer-wrap is a more complex procedure than the application of an Unna boot. There is an application of multiple layers, usually 3-4 layers. Each layer is applied with a different technique and pressure such as spiral or figure-eight. Additionally, each layer must be applied in a specific order as instructed per the manufacturer's recommendations. Evidence has shown that the effectiveness of these wraps is dependent upon the training, skill and experience of the health care professional applying the compression. Application of this system requires more time, skill and training when compared to the application of an Unna boot.

Because the sustained, graduated compression wrap delivers a high amount of pressure, confirmation of adequate circulation is required before and after application. This is more critical than with the Unna boot application and requires more advanced assessment skills of a health care practitioner.

Because venous insufficiency can result in very delicate skin, maceration and dermatitis, additional skin preparation is usually needed with emollient lotions, steroid creams or barrier ointments prior to the application of a sustained, graduated compression wrap. The clinical judgments of the health care professional in this regard are necessary to prevent further skin injury.

The decision by Noridian to deny reimbursement for these wraps as not medically reasonable and necessary because patients and/ or their caregivers can independently apply them is not based in fact. I am asking for a reconsideration of this ruling.

Marilyn Magoffin RN, CWOCN