Negative Pressure Wound Therapy

Patient Information

Patient Name

Date of Birth

Address

City

Zip Code

State

Primary Phone Number

Secondary Phone Number

Insurance Provider Information:

Primary:

Name:

Phone Number

Address

City

State

Zip Code

ID Number

Additional Plan Information

Secondary:

Address

City

State

Zip Code

ID Number

Additional Plan Information

Physician Information:

Physician Name:

Phone Number

Address

City

State

Zip Code

NPI number

Order Information:

ICD 9 CODES

ITEM(S) ORDERED

HCPCS CODE(S)

Statement of Ordering Physician

Negative Pressure Wound Therapy System (NPWT) Pump and Supplies

PLEASE PRINT ALL INFORMATION CLEARLY

Patient Name

Order Date

Mdc/Ins #

Date of Birth

Initial

Ongoing

Address

City

State

Zip Code

Product: NPWT Wound Pump

HCPC Code: E2402

Charges

Allowable

Product: Wound Drainage Kits

HCPC Code: A6550

Charges

Allowable

Product: Disposable Canister Set

HCPC Code: A7000

Charges

Allowable

Information in Section A-D may NOT be completed by the supplier of the equipment. PLEASE COMPLETE ALL SECTIONS BELOW.

A. GENERAL HEALTH INFORMATION

Patient Height:

Patient Weight:

Patient Sex:

Male Female

List all patient's diagnoses

Comorbid conditions or complications to healing

Patient's nutritional status:

Good Fair Poor

B. Wound Information

Albumin level

Name and title of person answering questions if other than physician

Wound Type

i.e. pressure, neuropathic, venous, arterial, chronic, traumatic, surgical, flap/graft, other

Onset date of wound

Give brief history of the wound and what treatment has been tried

Wound location

Stage

Dimensions: Length

Width

Depth

Tunneling/Undermining

Yes No

Drainage

Yes No

Infected

Yes No

Is there necrotic tissue present in the wound?

Yes No

Has the patient been on a comprehensive ulcer treatment program prior to application of NPWT?

Yes No

Name and title of person answering question if other than physician

Statement of Ordering Physician
Negative Pressure Therapy System (NPWT) Pump and Supplies

Patient Name

Date of Birth

C. Related Clinical Information

Information for all wounds:

Has a care plan been established by the patient's physician or nurse?

Yes

No

N/A

Regular assessment by a nurse, physician or other licensed healthcare provider?

Yes

No

N/A

Nutritional assessment and interventions consistent with the overall plan of care?

Yes

No

N/A

Appropriate management of moisture/incontinence?

Yes

No

N/A

Moist wound environment maintained?

Yes

No

N/A

If patient has been in an in-patient setting, was NPWT applied in facility?

Yes

No

N/A

Has NPWT utilized prior?

Yes

No

Information for Pressure Ulcer:

Education of the patient and caregiver on the prevention and/or management of pressure ulcers?

Yes No

Appropriate turning, positioning and wound care?

Yes No

For posterior trunk/pelvis pressure ulcers, patient has been on a Group 2 or 3 Support Surface?

Yes No i.e. alternating pressure/low-air-loss mattress

Information for Diabetic Ulcer:

Compression bandages consistently applied

Yes No

Information for Venous Ulcer:

Comprehensive diabetic management program

Yes No

Leg elevation and ambulation have been encouraged?

Yes No

Information for Surgical Wounds:

Date of surgery

Have conventional post-surgical wound treatments been tried?

Yes No

If there is a need for faster wound healing, what conditions warrant this?

Name and title of person answering questions if other than physician

Additional observations/comments relating to wound

If any of the above answers are no, please explain why this is not the case and why the NPWT should be tried in lieu of this?

D. Physician Certification

Estimated length of need in months

4 months maximum

Date patient last seen

Suction setting

i.e. 60 or 80 mmmg

Select one

Constant

Intermittent

Physician name (Print)

NPI #

Physician signature

Date signed

Patient Information

Insurance Provider Information:

Primary:

Secondary:

Physician Information:

Order Information:

Statement of Ordering Physician

Negative Pressure Wound Therapy System (NPWT) Pump and Supplies

PLEASE PRINT ALL INFORMATION CLEARLY

A. GENERAL HEALTH INFORMATION

B. Wound Information

C. Related Clinical Information

Information for all wounds:

D. Physician Certification

Please fill, print and return

Excellent
Service

Progressive
Equipment

Personal
Attention

Positive
Outcomes

Negative Pressure Wound Therapy

Patient Information

Insurance Provider Information:

Primary:

Secondary:

Physician Information:

Order Information:

Statement of Ordering Physician

Negative Pressure Wound Therapy System (NPWT) Pump and Supplies PLEASE PRINT ALL INFORMATION CLEARLY

A. GENERAL HEALTH INFORMATION

B. Wound Information

C. Related Clinical Information

Information for all wounds:

D. Physician Certification

Please fill, print and return

Excellent Service

ProgressiveEquipment

Personal Attention

Positive Outcomes

Negative Pressure Wound Therapy System (NPWT) Pump and Supplies

PLEASE PRINT ALL INFORMATION CLEARLY

Excellent
Service

Progressive
Equipment

Personal
Attention

Positive
Outcomes