Submitter Name E-Mail Phone

For all ulcers or wounds, the wound therapy program must include a minimum of all the following general measures, which should either be addressed, applied, or considered and ruled out prior to application of NPWT. Please submit the following documentation to support medical necessity:

Current evalutation, care and wound measurements by a licensed medical professional, and
Past evaluation, care and wound measurements by a licensed medical professional, and
Application of dressings to maintain a moist wound environment, and
Debridement of necrotic tissue if present, and
Evaluation of and provision for adequate nutritional status, and
Other less expensive therapies tried, considered and ruled out, and
Pre- and post-operative reports, if applicable, and

If the wound or ulcer is any of the following, the additional supportive documentation listed will be required: Medicare denies NPWT as not medically necessary when there is:
What HHA will be following this patient? Phone

Section A - Patient Information Patient's Name Social Security Number Date of Birth
Section B - Wound History ( Negative Pressure Wound Therapy ) 1. Has patient been on NPWT in the past 30-60 days? Yes No Date Initiated
2. NPWT initiated in inpatient history? Yes No Facility Name
Other Treatments
1. Has patient had a flap or graft? Yes No If yes, location Date
2. Is wound infected? Yes No If yes, type/treatment plan
3. Does patient have osteomyelitis? Yes No If yes, treatment
Nutrition
1. Does the patient have adequate nutrition? Yes No Regular Special Diet
2. Albumin Level Date Height Weight
Previous Wound Dressings
1. What type of wound dressings were previously used?
2. Frequency of change:
Section C - Wound Type (Select Appropriate Wound Type) Pressure Ulcer
1. Has patient been on a Group2/Group 3 Surface/Bed? Yes No From To
2. Is the patient being turned every 2 hours? Yes No
3. Is incontinence being managed/controlled? Yes No
Specify: Bowel Bladder
Diabetic/Neuropathic Ulcer
1. Has foot pressure been reduced? Yes No
2. Is patient on diabetic management program? Yes No
Venous Insufficiency
1. Are compression bandages being used? Yes No
2. Is elevation/ambulation of lower extremitiies permitted? Yes No
Chronic Ulcer
1. Has pressure been relieved? Yes No
2. Is incontinence being managed/controlled? Yes No
Specify: Bowel Bladder
Traumatic
Surgical
Dehisced
Date of Occurrence
Section D - Current Wound Description(s) Location 1
Stage
Size (cm) Length Width Depth
Undermining Yes No @
Tunneling/Sinus Yes No @
Wound Bed:
Granulation % Slough %
Other
Drainage Amount:
Dry Minimal Moderate Heavy
Color:
Serosanguinous Serous Sanguinous Purulent
Debridement Date:
Within the vicinity of the wound, is there:
Untreated osteomyelitis? Yes No
Cancer present in the wound? Yes No
A fistula to an organ or body cavity? Yes No

Location 2
Stage
Size (cm) Length Width Depth
Undermining Yes No @
Tunneling/Sinus Yes No @
Wound Bed:
Granulation % Slough %
Other
Drainage Amount:
Dry Minimal Moderate Heavy
Color:
Serosanguinous Serous Sanguinous Purulent
Debridement Date:
Within the vicinity of the wound, is there:
Untreated osteomyelitis? Yes No
Cancer present in the wound? Yes No
A fistula to an organ or body cavity? Yes No
Section E - Ordering Physician Information Physician Name: NPI: Phone:

I prescribe negative pressure therapy pump (NPWT) E2402 as medically necessary and certify that all other treatment modalities have been utilized and evaluated. I certify that I am the treating physician identified in Section E of this form.
I hereby understand the principles of NPWT and the product information regarding the Smith & Nephew NPWT.

Items Ordered:
Therapy initial date Length of Need for the ICD9 code(s)


Physician Signature: