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Date Printed: October 23, 2017: 07:19 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

09-E0000-43

Original Effective Date: 08/15/03

Reviewed: 05/28/09

Revised: 11/01/15

Subject: Electric and Electromagnetic Stimulation and Ultrasound for Wound Healing

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Electric stimulation comes in many forms. It can encompass interferential therapy (low frequency, alternating electric current), direct current, pulsed current, alternating current, high voltage pulsed current (HVPC) and transcutaneous electrical nerve stimulation (TENS - considered alternating current). Some believe that electric stimulation applied to the skin through electrodes can increase or accelerate the biologic activities involved in healing. Examples of these activities are adenosine triphosphate (ATP) concentrations in tissues and DNA synthesis (which causes epithelial cells and fibroblasts to migrate into wound sites), as well as processes involved with damaged neural tissue recovery, edema reduction and growth inhibition of some pathogens. There is currently no FDA-approved electrical stimulation device for treating wounds.

Diathermy causes heating of body tissues because of their resistance to the passage of electromagnetic energy or ultrasound. The tissues are warmed, but not damaged. Pulsing these energies produces a non-thermal effect. Another form of diathermy is used during surgery (electrocoagulation), during which tissue is destroyed.

Electromagnetic therapy is a related but distinct form of treatment that applies electromagnetic fields rather than direct electrical current.

Chronic wounds can be grouped into three categories: decubitus (or pressure), venous and arterial (or ischemic). Venous ulcers may develop slowly over years, may be painless and can result from thrombosis, varicosities or hemorrhage. Arterial ulcers result from inadequate blood flow and can be the result of arteriosclerosis obliterans, rheumatoid arthritis or diabetes mellitus. They are quite painful.

Standard wound care consists of debridement, cleansing and dressings. Depending on the ulcer type, it may also include frequent repositioning, use of a compression system for venous ulcers and, if infection is present, treatment with antibiotics. Maintaining a good nutritional status is important for healing.

Stage III ulcers are defined as full-thickness skin loss with damage to or necrosis of subcutaneous tissue; may extend down to fascia; deep crater, with or without undermining of tissue.

Stage IV ulcers involve full-thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures (tendon, joint); undermining and sinus tracts may be present.

POSITION STATEMENT:

The use of any device for the application of electrical or electromagnetic stimulation to promote healing of Stage III and IV chronic pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers meets the definition of medical necessity.

Home use of electric or electromagnetic stimulation does not meet the definition of medical necessity. The standard practice for the use of electric or electromagnetic stimulation includes that the therapy must be administered and supervised by a physician or physical therapist or be incidental to a physician service. Evaluation of the wound is an integral part of wound therapy.

The use of ultrasound therapy is considered experimental or investigational, as there is insufficient clinical evidence to support the use of ultrasound therapy for wound healing and specifically for Stage lll and lV chronic pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers. There is insufficient data available from well-controlled clinical trials to permit conclusions on net health outcome.

BILLING/CODING INFORMATION:

CPT Coding:

There is no specific CPT code that describes these procedures.

HCPCS Coding:

G0281

Electrical stimulation, (unattended), to one or more areas, for chronic Stage III and Stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care

G0282

Electrical stimulation, (unattended), to one or more areas, for wound care other than described in G0281 (investigational)

G0295

Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses (investigational)

G0329

Electromagnetic therapy, to one or more areas for chronic Stage III or Stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care

E0761

Non-thermal pulsed high frequency radiowaves, high peak power electromagnetic energy treatment device (investigational)

E0769

Electrical stimulation or electromagnetic wound treatment device, not otherwise classified

ICD-10 Diagnoses Codes That Support Medical Necessity: (Effective 10/01/15)

L89.013 – L89.014

Pressure ulcer of right elbow

L89.023 – L89.024

Pressure ulcer of left elbow

L89.113 – L89.114

Pressure ulcer of right upper back

L89.123 – L89.124

Pressure ulcer of left upper back

L89.133 – L89.134

Pressure ulcer of right lower back

L89.143 – L89.144

Pressure ulcer of left lower back

L89.153 – L89.154

Pressure ulcer of sacral region

L89.213 – L89.214

Pressure ulcer of right hip

L89.223 – L89.224

Pressure ulcer of left hip

L89.313 – L89.314

Pressure ulcer of right buttock

L89.323 – L89.324

Pressure ulcer of left buttock

L89.43 – L89.44

Pressure ulcer of contiguous site of back, buttock and hip

L89.513 – L89.514

Pressure ulcer of right ankle

L89.523 – L89.524

Pressure ulcer of left ankle

L89.613 – L89.614

Pressure ulcer of right heel

L89.623 – L89.624

Pressure ulcer of left heel

L89.813 – L89.814

Pressure ulcer of other site, head

L89.893 – L89.894

Pressure ulcer of other site

L89.90, L89.93 – L89.95

Pressure ulcer of unspecific site

L97.101 – L97.929

Non-pressure chronic ulcer of lower limb, not elsewhere classified

L98.411 – L98.499

Non-pressure chronic ulcer of skin, not elsewhere classified

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds (270.1) located at cms.gov.

DEFINITIONS:

Diathermy: heating of body tissues due to their resistance to the passage of high frequency electromagnetic radiation, electric currents or ultrasonic waves.

RELATED GUIDELINES:

Physical Therapy (Physical Medicine), 01-97000-01 – for appropriate application of ultrasound and diathermy as modalities.

OTHER:

None applicable.

REFERENCES:

  1. Agency for Health Care Policy & Research (AHCPR). U.S. Department of Health and Human Services. Clinical Practice Guideline: Number 15. (1994). “Treatment of pressure ulcers.” (AHCPR Pub No. 95-0652), accessed at ncbi.nlm.nih.gov on 05/01/08.
  2. American College of Physicians, Local Wound Management of the Diabetic Foot, 04/07/06.
  3. Baba-Akbari SA, Flemming K, Cullum NA, Wollina U, Therapeutic Ultrasound for Pressure Ulcers, Cochrane Database of systematic Reviews 2000, Issue 4, updated 05/15/06.
  4. Blue Cross Blue Shield Association Medical Policy Reference Manual – “Electrostimulation and Electromagnetic Therapy for the Treatment of Chronic Wounds” 2.01.57 (05/08).
  5. Blue Cross Blue Shield Association Technology Evaluation Center (TEC) – “Electrical Stimulation or Electromagnetic Therapy as Adjunctive Treatments for Chronic Skin Wounds.” Vol 20, #2, April 2005.
  6. Center for Medicare and Medicaid Services (CMS). “NCD for Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds (35-102). Effective 07/01/04.
  7. Center for Medicare and Medicaid Services (CMS). Transcript of Executive Committee Meeting on Feb 22, 2001 addressing electrostimulation for wounds.
  8. Centers for Medicare and Medicaid Services (CMS) – “NCD for Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds,” Pub 100-3, #270.1 (7/04).
  9. Clegg JP, Guest JF, Modelling the Cost-Utility of Bio-Electric Stimulation Therapy Compared to Standard Care in the Treatment of Elderly Patients with Chronic Non-Healing Wounds in the UK, Curr Med Res Opin. 2007 Apr; 23(4): 871-83.
  10. Connolly, J. B., P.T., Sr VP for Health Policy, Amer Phys Ther Assoc (APTA). (April 1999). Ltr to John Whyte, M.D., M.P.H., HCFA, re: APTA response to ECRI Jan 1998 letter and Oct 1998 memo from Dr. Kamerow (AHCPR).
  11. Cullum, N., Nelson, E. A., Flemming, K., & Sheldon, T. (2001). Systematic reviews of wound care management: (5) beds; (6) compression; (7) laser therapy, therapeutic ultrasound, electrotherapy and electromagnetic therapy. Health Technology Assessment (HTA) 2001, 5(9). Department of Health Studies, University of York, UK. (Accessed June 06, 2003).
  12. ECRI Executive Briefing. (April 1996). Electrical stimulation for the treatment of chronic wounds: Part I (#47).
  13. ECRI Executive Briefing. (May 1996). Electrical stimulation for the treatment of chronic wounds: Part II (#48).
  14. ECRI Hotline Response “Electrical Stimulation and Electromagnetic Therapy for the Treatment of Chronic Wounds” (06/04), updated 08/13/07.
  15. Flemming K, Cullum N. Electromagnetic therapy for treating pressure sores. The Cochrane Database of Systematic Reviews 2001, Issue 1.
  16. Flemming K, Cullum N. Electromagnetic therapy for treating venous leg ulcers. The Cochrane Database of Systematic Reviews 2001, Issue 1.
  17. Flemming K, Cullum N. Therapeutic ultrasound for pressure sores. The Cochrane Database of Systematic Reviews 2000, Issue 4.
  18. Flemming K, Cullum N. Therapeutic ultrasound for venous leg ulcers. The Cochrane Database of Systematic Reviews 2000, Issue 4.
  19. HAYES Medical Technology Directory. (August 2003). “Electrical stimulation for treatment of chronic nonhealing dermal ulcers” (ELEC0101.28). (10/07 update).
  20. HAYES Medical Technology Directory. (January 1997). “Diathermy, pulsed electromagnetic energy and pulsed ultrasound therapy” (DIAT1001.04). Archived.
  21. HAYES Technology Assessment Brief. (May 2004). “Pulsed high-frequency electromagnetic energy for the treatment of chronic wounds and soft tissue injuries”.
  22. Kamerow, D. B., M.D., Dir., Cen for Practice and Technology Assessment, Dept of Health and Human Services. (Oct 1998). Ltr to Dir, Cov and Analysis Grp, HCFA, re: Request for review and opinion of the ECRI evaluation of the U.S. District Court decision regarding electrical stimulation of chronic wounds.
  23. Lerner, J. C., VP for Strategic Planning, ECRI. (Jan 1998). Ltr to Betty Burrier, Health Insurance Specialist, Coverage and Analysis Grp, HCFA, re: Response to U.S. District Court opinion for HFCA national coverage decision not to reimburse for use of electrical stimulation for wound healing, based on ECRI technology assessment “Electrical stimulation for the treatment of chronic wounds”.
  24. Wound, Ostomy, Continence Nurses (WOCN) Pressure Ulcer Panel, Guideline for Prevention and Management of Pressure Ulcers, National Guideline Clearinghouse, 2004, accessed at guideline.gov on 05/01/09.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 05/28/09.

GUIDELINE UPDATE INFORMATION:

08/15/03

New Medical Coverage Guideline.

07/15/04

Scheduled review; new code G0329 added; G0295 revised; coverage extended to electromagnetic, in addition to electric; ultrasound maintained investigational.

10/01/04

Change to description of G0329 per HCPCS update.

01/01/05

Code E0769 added & revision to G0295 per HCPCS update.

08/15/05

Scheduled review; current coverage criteria maintained.

08/15/06

Annual review; current coverage maintained; ultrasound maintained investigational.

07/15/07

Scheduled review; current coverage and limitations maintained, reformatted guideline, references updated.

07/15/08

Annual review: position statements maintained and references updated.

06/15/09

Annual review: position statements maintained and references updated.

10/15/10

Revision; related ICD-10 codes added.

05/11/14

Revision: Program Exceptions section updated.

10/01/15

Revision; ICD9 and ICD10 coding sections updated.

11/01/15

Revision: ICD-9 Codes deleted.

Date Printed: October 23, 2017: 07:19 AM