Indications

Below is a summary of indications to gradient compression stockings. For more information, see “Gradient compressions stockings”, in the section ‘Indications’.

• Chronic venous disease
• • Treat active venous ulcer (VLU)
  • Prevent new or recurrent VLU
  • Spider veins and reticular varices (C1), varicose veins (C2), edema (C3) and skin changes (C4), with heavy, tired legs
  • Post-venous interventions
• Deep vein thrombosis prophylaxis
• Lymphedema
• Superficial thrombophlebitis

Contraindications

Below is a summary of contraindications to compression therapies and gradient compression stockings. For more information see “Compression Therapies for Venous Ulcers”, in section ‘Contraindications’.

General contraindications for compression therapies:

• Severe peripheral arterial disease
• Acute deep venous thrombosis
• Cellulitis
• Unstable cardiac failure

Other contraindications related to compression stockings [2]:

• Allergy to stocking material
• Local skin or soft-tissue condition, including recent skin graft, fragile “tissue paper” skin, gangrene, oozing dermatitis and severe cellulitis
• Extreme deformity of the leg, or unusual leg shape or size preventing correct fit
• Highly exuding VLU is not a contraindication per se, however stockings may need to be washed constantly due to frequent soiling.

Evidence and Recommendations

Please see “Venous ulcers”, section on ‘Compression’ for other recommendations regarding compression therapy, rationales and summary of evidence supporting the recommendations below:

• 1B
  For VLU patients with no contraindications, we recommend compression over no compression therapy to promote wound healing (Grade 1B).
• 2B
  Two-layer gradient compression stockings (HH) that deliver 40 mmHg pressure at the ankle can be considered an effective alternative to multi-component compression systems (4LB) to promote ulcer healing in patients with VLU (Grade 2B).
• 2C
  To decrease risk of ulcer recurrence in patients with a healed VLU, we suggest compression therapy with gradient compression stockings at the highest pressure patients can tolerate (Grade 2C)

Risks and Complications

Most complications due to compression therapy are avoidable if appropriate measures to

mitigate risks are taken. Before application of compression, clinicians should ensure patient does not have any contraindications. If however, the patient is a good candidate and complications still arise, it is important that they be addressed promptly. Complications may include pain, pressure damage, loss of calf muscle and skin problems. Please see more details in “Compression Therapy for Venous Ulcer”, section ‘Risks and Complications’

FDA safety

The following FDA monitored databases do not currently display any findings related to Jobst® Opaque [3] [4] [5]:

• Medical Device Recalls: no findings
• MAUDE - Manufacturer and User Facility Device Experience: no findings
• Post-market Surveillance Studies: no findings

Prescription

Ready-to-wear and over the counter compression garments do not require a prescription when paid out-of-pocket. However, retailers may choose to require a prescription to ensure the product fits the patient’s needs. Prescriptions are needed for Medicare coverage (when product is covered and requirements are met).

Prescriptions for graduated compression stockings need to indicate the type of stocking, length, compression level and number of units (frequency of use, expected duration of need are also needed for Medicare coverage). Measurements are needed for proper fitting (see measuring methods in “Gradient Compression Stockings”, section ‘How to: selection, measurement and application methods’). Stockings should be replaced at least every 3-6 months.

How to: measurement and application (donning) methods

For general information on measurement and application (donning) methods for gradient compression stockings, see “Gradient compression stockings”, section ‘How to: selection, measurement and application(donning) methods’.

The information below relates to Jobst® Opaque Knee-High [1]:

Size chart

Patient Adherence

Compression is only effective if applied constantly, daily. Clinicians should keep in mind the high prevalence of patient adherence issues, which has been reported to be 30%–65% [2].

Among reasons for low adherence to gradient compression stockings are difficulties in putting on and removing the garment, pain, discomfort, sensation of warmth and deterioration of pre-existing pruritus associated with venous eczema, cost and appearance [2] [6]. If problems arise, clinicians should ask their patients why the stockings are not being used. Many of these factors are easily solved by simply changing the stocking material, lowering the degree of compression or providing adequate information and reassurance to patients [2].

PATIENT EDUCATION FOR CLINICIANS

VLU are a chronic, long-term problem, with recurrence rates are as high as 70%. Therefore, long-term maintenance must be addressed even for healed ulcers [6]. See “Venous Ulcers”, section on ‘Patient Education’ for details on patient education for VLU healing, prevention of new VLU and prevention of recurrence.

We recommend sharing our patient education materials with VLU patients (for all materials, see Patient Education Materials).

Jobst Opaque Knee High Patient Education material:

• Compression stockings: Jobst Opaque Knee High (handout)

Related Patient Education materials:

• Basic principles of wound care (handout)
• Chronic ulcers (handout)
• Compression therapy (handout)
• Gradient Compression Stockings for Patients
  
• Debridement (handout)
• Nutrition (handout)
• Showering instructions (handout)
• Smoking cessation (handout)
• Ulcer infection (handout)

CODING, COVERAGE AND REIMBURSEMENT

Below is a summary of coding, coverage and reimbursement for Jobst® Opaque Knee-High with a focus on Medicare references here . For detailed information on coding, documentation, coverage and reimbursement of gradient compression stockings, see “Gradient Compression Stockings”, section ‘Coding, Coverage, Reimbursement’.

* Use modifiers AW (bilateral), and RT/LT (right, left side). Since stockings come in pairs, bill the left and the right stocking on the same claim line using the RT/LT modifiers and 2 units of service

** Benefit covered under Medicare Part B (DMEPOS fee schedule). Not covered if billed in other care settings (home health, acute care, hospital based outpatient clinics, independent physician's office, nursing homes)

Total allowable, patient co-payment (in US$) relates to Medicare part B. Data extracted from the most current Medicare DMEPOS Fee Schedule (2017)  [7] [8]

ICD-10 that support medical necessity

• I83.00-I83.02 Varicose veins of lower extremities with ulcer
• I83.20-I83.22 Varicose veins of lower extremities with both ulcer and inflammation

Medicare Policies & Guidelines (NCDs, LCDs, Articles)

• Local Coverage Determination (LCD) Surgical Dressings (L33831)  [9]
• Local Coverage Article: Surgical Dressings - Policy Article (A54563)  [10]

COST-EFFECTIVENESS

• Gradient compression stockings to promote VLU healing
• • Literature is scarce in studies that analyze cost-effectiveness of gradient compression stockings in VLU healing.

• Gradient compression stockings to prevent VLU
• •  In 2002, a Markov decision analysis model was used for analysis of the cost-effectiveness of a strategy of reimbursement for compression stockings and education (prophylaxis) versus one that does not supply these resources in a 55-year-old patient with prior venous stasis ulceration. Authors concluded that prophylactic compression stockings and education in patients with prior venous stasis ulceration are cost saving, even with the most conservative of assumptions. Insurers should routinely reimburse for these interventions  [11]

CMS QUALITY MEASURES

Below are measures that are directly related to Compression in VLU. For other measures related to VLU see “Venous Ulcers”, section ‘CMS Quality Measures’. For a comprehensive list of wound care related measures, see “Wound Care Quality Measures”.

MIPS currently does not have VLU-specific measures. Listed below are VLU/compression therapy-specific measures issued by the US Wound Registry.

MANUFACTURER

BSN medical Inc.
5825 Carnegie Blvd
Charlotte, NC 28209
Phone: 704-554-9933
BSN.Orders@BSNmedical.com

MANUFACTURER'S PART NUMBERS

The tables below show part numbers of Opaque Knee-High Closed Toe 15-20, 20-30 and 30-40 mmHg. Check manufacturer’s website for part numbers of other styles.