Draft MC wound care policy

  1. Check out new MC wound care coverage policy from CAHABA intermediary:

    Evidence of Reasonable and Necessary Wound Care:
    Medicare coverage for wound care on a continuing basis for a given wound in a given patient is contingent upon evidence documented in the patient's record that the wound is improving in response to the wound care being provided. It is neither reasonable nor medically necessary to continue a given type of wound care if evidence of wound improvement cannot be shown. Evidence of improvement includes measurable decreases in the following: drainage, inflammation, swelling, pain and wound dimensions (diameter, depth) or increased granulation tissue. Such evidence must be documented at least weekly. Generally a wound that shows no improvement after 3 weeks of a given type of wound care requires a new approach, including a physician reassessment of underlying metabolic, nutritional, or vascular problems inhibiting wound healing...

    Reasons for Denial
    1. Examples of situations in which visits are non-covered for wound care:
    a. A Stage I pressure ulcer
    b. A first degree burn
    c. Wounds caused by trauma which do not require debridement, or surgical closure (e.g., minor skin tear or abrasion)
    d. A venipuncture or arterial puncture site (e.g., blood sample) other than the site of an indwelling catheter or needle
    2. Therapists performing wound care will not be covered:
    a. If wound care does not fall within the auspice of the state practice act for the therapists, the services may be denied. (see other comments)
    b. When the wound care is performed by a therapy assistant.


    Expect that in the future, if you have a non-healting wound and if you don't try something differrent after three weeks, MC will stop paying for wound care. You just can't keep doing wet-dry drsg daily for 6 months without SOMETHING different tried.
  2. Visit NRSKarenRN profile page

    About NRSKarenRN, BSN, RN Moderator

    Joined: Oct '00; Posts: 27,462; Likes: 13,677
    Utilization Review, prior Intake Mgr Home Care; from PA , US
    Specialty: 40 year(s) of experience in Home Care, Vents, Telemetry, Home infusion


  3. by   gwenith
    Karen - if you wnat to hear something rotten - NONE of our private health insurers pay for wound care porducts - you have to pay yourself out of your own pocket. You can (sometimes) get wound care done at a public hospital but if you have home health care you have to pay. Good system isn't it?
  4. by   NRSKarenRN
    Do they pay for "hard type" DME supplies like walkers, wheelchairs, bedside commodes, prosthesis and "soft disposable" foley catheters and ostomy appliances??
  5. by   gwenith
    Some things they will pay for but others they won't and it is completely arbitary!!! I was in hospital a couple of years ago and the helath care fund I was in, which by the way is the second largest in Aust was happy to pay for me to stay in hospital another week but would not pay one red cent toward wound care or home health visits. A lot of things like crutches and wheelchairs you either pay for or hire from the Red Cross.

    Our goverment and the provate insurers scream about the high cost of hospital care but do less than nothing to support home care. Embarrassing as it is to admit this it is easier to get health insurance that covers "althernative therapies" such as aromatherapy or naturopathy than on that provides cover for the "blue nurses".