Unna Boots versus Multilayered, Sustained, Graduated High Compression Bandage Systems

AMA Recommended 29580 for Unna Boot and Multilayered, Sustained, Graduated High Compression Bandage Systems

    In February 1999, the American Medical Association (AMA) CPT®¹ Editorial Panel voted against issuing a new CPT code for the application of multilayered, sustained, graduated high compression bandage systems.

Instead, the panel recommended that existing code 29580, Application of casts and strapping; lower extremity, strapping — any age, Unna boot, be used with modifier -22, if appropriate, to report this procedure. In the July 1999 edition of CPT Assistant, a physician's question on this topic was answered with this new information. In addition, the CPT Assistant said, “When appending the modifier -22, it may be helpful to include a copy of the procedure report that describes the unusual procedure performed.”

Providers, Manufacturers, Carriers, FIs, and the AMA Recommendations

    Once the wound care providers and manufacturers received this information, they proceeded to use 29580 to bill for the application of both Unna boots and multilayered sustained, graduated high compression bandage systems. Unfortunately, the Medicare Carriers and Fiscal Intermediaries (FIs) did not consistently adopt the AMA CPT Editorial Panel's recommendation.

    Some Carriers conformed. The Medicare Carriers for the states of Arkansas, Louisiana, Missouri (northeastern and southern), New Mexico, and Oklahoma retracted their original directive that 29580 was only for Unna boots. Once the July 1999 edition of the CPT Assistant was brought to their attention, they issued an article that concurred with the AMA recommendation.

    Some Carriers and FIs did not conform. The Medicare Carriers for Alaska, American Samoa, Arizona, Colorado, Connecticut, Florida, Guam, Hawaii, Iowa, Nevada, New York, Northern Marianna Islands, North Dakota, Oregon, South Dakota, Washington, and Wyoming and some Medicare FIs (for the states of Alabama, Florida, Georgia, and North Carolina) specifically designate that 29580 is a paste bandage that consists of gauze impregnated with zinc oxide, gelatin, glycerin, and sometimes calamine. Therefore, the use of the code 29580 for multilayered, sustained, graduated high compression bandage systems is unacceptable for physicians who submit claims to Medicare Carriers and FIs in the states listed above.

    Several Medicare FIs (in Georgia, New Jersey, and Tennessee) further instructed hospital-owned outpatient wound care departments that supplies used to perform a compression wrap are packaged into the clinic visit. A patient visit to a clinic for wound evaluation and care (to include a compression wrap) should be billed utilizing an E&M code reflective of the facility’s resource utilization crosswalk. Some FIs even reminded the facilities that multilayered, sustained, graduated high compression bandage systems should be billed under revenue code 270.

    Some Carriers specified who can apply the Unna boot. Medicare Carriers in New York (Queens and upstate) specify that CPT code 29580 is payable when personally performed or applied by the physician. It is also payable when done by a non-physician provider (under the “incident to” provision). If compression bandaging is performed by nursing staff, it is considered a Medicare Part A service in the hospital inpatient or outpatient settings, where the nurse is employed by the hospital.

    Some Carriers recommended 29799. To confuse matters more, some Medicare Carriers (in Illinois, Michigan, Minnesota, and Wisconsin) say that multilayered compression bandages should be billed using CPT code 29799, unlisted procedure, casting, or strapping. They also advise physicians to place the brand name of the dressing in item 19 of the CMS-1500 claim form or its electronic equivalent. Payment for 29799 will include the application of the dressing and the materials used. The materials should not be billed separately.

    Some Carriers and FIs specify diagnoses that support medical necessity for 29580. Many Carriers and FIs also limit the use of 29580 to patients with certain diagnoses. One Carrier (for Arkansas) only covers Unna boots for ulcers of the lower extremity. The diagnoses that they approve for use of 29580 are 454.0, 454.2, 707.06, 707.07, 707.12, 707.13, and 707.14. Other Carriers and FIs accept a wider variety of diagnosis codes as medical necessity for 29580.

Summary

    All Carriers and FIs appear to accept 29580 for the application of an Unna boot, even though many have written Articles and Local Coverage Decisions that provide guidance to the providers. That is not the case with multilayered, sustained, graduated high compression bandage systems used to manage a high percentage of venous stasis ulcers. Each provider must review the latest Articles and Local Coverage Decisions of their respective Medicare Carriers and FIs. Because these guidance documents can be revised as needed, the Carriers' and FIs' position on this topic can change from one month to the next (NOTE: Advance notice is usually provided by Carriers and FIs). Providers and suppliers should assign someone to monitor revisions (monthly or quarterly) of the Articles and Local Coverage Decisions that pertain to the wound care products, services, and procedures they provide. If you disagree with an Article or Local Coverage Decision, check your Carrier's or FI's website for the proper procedure to request reconsideration. Most of all, do not assume that a paid claim is a correctly paid claim!

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