Published Apr 22, 2002
here is a link for what medicare will pay re wound care supplies ---most hmo's follow same wound practices :
regional a medical review policies (rmrps)
17.01 surgical dressings
cahaba (iowa medicare intermediary)
medicare reference guide: home health coverage guidelines updated 11/6 /08
patients open to home care under medicare have the cost of wound supplies bundled into their visit cost. if a patient is discharged with an open surgical wound because they can independently care for it, you need to notify the dme company of the discharge in order for them to be able to bill for client.
section 1833(e) of the social security act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider" (42 u.s.c. 1395l(e)). it is expected that the patient's medical records will reflect the need for the care provided. the patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. this documentation must be available to the dmerc upon request.
an order for surgical dressings must be signed and dated by the treating physician. this order must be kept on file by the supplier.
the order must specify (a) the type of dressing (e.g., hydrocolloid wound cover, hydrogel wound filler, etc.), (b) the size of the dressing (if appropriate), © the number/amount to be used at one time (if more than one), (d) the frequency of dressing change, and (e) the expected duration of need.
a new order is needed if a new dressing is added or if the quantity of an existing dressing to be used is increased. a new order is not routinely needed if the quantity of dressings used is decreased. however a new order is required at least every 3 months for each dressing being used even if the quantity used has remained the same or decreased.
information defining the number of surgical/debrided wounds being treated with a dressing, the reason for dressing use (e.g., surgical wound, debrided wound, etc.), and whether the dressing is being used as a primary or secondary dressing or for some noncovered use (e.g., wound cleansing) must be obtained from the physician, nursing home, or home care nurse. the source of that information and date obtained must be documented in the supplier's records.
current clinical information which supports the reasonableness and necessity of the type and quantity of surgical dressings provided must be present in the patient's medical records. evaluation of a patient's wound(s) must be performed at least on a monthly basis unless there is documentation in the medical record which justifies why an evaluation could not be done within this timeframe and what other monitoring methods were used to evaluate the patient's need for dressings. evaluation is expected on a more frequent basis (e.g., weekly) in patients in a nursing facility or in patients with heavily draining or infected wounds. the evaluation may be performed by a nurse, physician or other health care professional. this evaluation must include the type of each wound (e.g., surgical wound, pressure ulcer, burn, etc), its location, its size (length x width in cm.) and depth, the amount of drainage, and any other relevant information. this information does not have to be routinely submitted with each claim. however a brief statement documenting the medical necessity of any quantity billed which exceeds the quantity needed for the usual dressing change frequency stated in the policy must be submitted with the claim.
coverage and payment rules
for any item to be covered by medicare, it must: 1) be eligible for a defined medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable medicare statutory and regulatory requirements. for the items addressed in this medical policy, "reasonable and necessary" is defined by the following coverage and payment rules.
surgical dressings are covered when either of the following criteria are met:
*they are medically necessary for the treatment of a wound caused by, or treated by, a surgical procedure; or
*they are medically necessary when debridement of a wound is medically necessary.
*surgical dressings include both primary dressings (i.e., therapeutic or protective coverings applied directly to wounds or lesions either on the skin or caused by an opening to the skin) or secondary dressings (i.e., materials that serve a therapeutic or protective function and that are needed to secure a primary dressing).
the surgical procedure or debridement must be performed by a physician or other healthcare professional to the extent permissible under state law. debridement of a wound may be any type of debridement (examples given are not all-inclusive):
surgical (e.g., sharp instrument or laser),
mechanical (e.g., irrigation or wet-to-dry dressings),
chemical (e.g., topical application of enzymes), or
autolytic (e.g., application of occlusive dressings to an open wound).
dressings used for mechanical debridement, to cover chemical debriding agents, or to cover wounds to allow for autolytic debridement are covered although the agents themselves are noncovered.
surgical dressings are covered for as long as they are medically necessary. dressings over a percutaneous catheter or tube (e.g., intravascular, epidural, nephrostomy, etc.) are covered as long as the catheter or tube remains in place and after removal until the wound heals. (refer to coding guidelines).
examples of situations in which dressings are noncovered under the surgical dressings benefit are:
a) drainage from a cutaneous fistula which has not been caused by or treated by a surgical procedure; or
b) a stage i pressure ulcer; or
c) a first degree burn; or
d) wounds caused by trauma which do not require surgical closure or debridement - e.g., skin tear or abrasion; or
e) a venipuncture or arterial puncture site (e.g., blood sample) other than the site of an indwelling catheter or needle
surgical dressings used in conjunction with investigational wound healing therapy (e.g., platelet derived wound healing formula) may be covered if all applicable coverage criteria are met based on the number and type of surgical dressings that are appropriate to treat the wound if the investigational therapy were not being used.
when a wound cover with an adhesive border is being used, no other dressing is needed on top of it and additional tape is usually not required. reasons for use of additional tape must be well documented. an adhesive border is usually more binding than that obtained with separate taping and is therefore indicated for use with wounds requiring less frequent dressing changes.
use of more than one type of wound filler or more than one type of wound cover in a single wound is rarely medically necessary and the reasons must be well documented. an exception is an alginate wound cover or a saline, water, or hydrogel impregnated gauze dressing which might need an additional wound cover.
it may not be appropriate to use some combinations of a hydrating dressing on the same wound at the same time as an absorptive dressing (e.g., hydrogel and alginate).
because composite dressings, foam and hydrocolloid wound covers, and transparent film, when used as secondary dressings, are meant to be changed at frequencies less than daily, appropriate clinical judgement should be used to avoid their use with primary dressings which require more frequent dressing changes. when claims are submitted for these dressings for changes greater than once every other day, the quantity in excess of that amount will be denied as not medically necessary. while a highly exudative wound might require such a combination initially, with continued proper management the wound usually progresses to a point where the appropriate selection of these products results in the less frequent dressing changes which they are designed to allow. an example of an inappropriate combination is the use of a specialty absorptive dressing on top of non-impregnated gauze being used as a primary dressing.
dressing size must be based on and appropriate to the size of the wound. for wound covers, the pad size is usually about 2 inches greater than the dimensions of the wound. for example, a 5 cm x 5 cm (2 in. x 2 in.) wound requires a 4 in. x 4 in. pad size.
the following are examples of wound care items which are noncovered under the surgical dressing benefit: skin sealants or barriers (a6250), wound cleansers (a6260) or irrigating solutions, solutions used to moisten gauze (e.g. saline), silicone gel sheets, topical antiseptics, topical antibiotics, enzymatic debriding agents, gauze or other dressings used to cleanse or debride a wound but not left on the wound. also any item listed in the latest edition of the orange book (e.g., an antibiotic-impregnated dressing which requires a prescription) is considered a drug and is noncovered under the surgical dressing benefit.
the quantity and type of dressings dispensed at any one time must take into account the current status of the wound(s), the likelihood of change, and the recent use of dressings.
dressing needs may change frequently (e.g., weekly) in the early phases of wound treatment and/or with heavily draining wounds. suppliers are also expected to have a mechanism for determining the quantity of dressings that the patient is actually using and to adjust their provision of dressings accordingly. no more than a one month's supply of dressings may be provided at one time, unless there is documentation to support the necessity of greater quantities in the home setting in an individual case. an even smaller quantity may be appropriate in the situations described above.
wound fillers are dressing materials which are placed into open wounds to eliminate dead space, absorb exudate, or maintain a moist wound surface.
wound covers are flat dressing pads. a wound cover with adhesive border is one which has an integrated cover and distinct adhesive border designed to adhere tightly to the skin.
in this policy, the term alginate includes other fiber gelling dressings.
composite dressings are products combining physically distinct components into a single dressing that provides multiple functions. these functions must include, but are not limited to: (a) a bacterial barrier, (b) an absorptive layer other than an alginate, foam, hydrocolloid, or hydrogel, and © either a semi-adherent or nonadherent property over the wound site.
contact layers are thin non-adherent sheets placed directly on an open wound bed to protect the wound tissue from direct contact with other agents or dressings applied to the wound. they are porous to allow wound fluid to pass through for absorption by an overlying dressing.
impregnated gauze dressings are woven or non-woven materials into which substances such as iodinated agents, petrolatum, zinc compounds, crystalline sodium chloride, chlorhexadine gluconate (chg), bismuth tribromophenate (btp), water, aqueous saline, hydrogel, or other agents have been incorporated into the dressing material by the manufacturer.
specialty absorptive dressings are unitized multi-layer dressings which provide (a) either a semi-adherent quality or nonadherent layer, and (b) highly absorptive layers of fibers such as absorbent cellulose, cotton, or rayon. these may or may not have an adhesive border.
a wound pouch is a waterproof collection device with a drainable port that adheres to the skin around a wound.
the staging of pressure ulcers used in this policy is as follows:
stage i observable pressure-related alteration of intact skin whose indicators, as compared to the adjacent or opposite area on the body, may include changes in one of more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel) and/or sensation (pain, itching). the ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.
stage ii partial thickness skin loss involving epidermis, dermis, or both. the ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
stage iii full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. the ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
stage iv full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). undermining and sinus tracts also may be associated with stage iv pressure ulcers.
the following are some specific coverage guidelines for individual products when the products themselves are necessary in the individual patient. the medical necessity for more frequent change of dressing must be documented in the patient's medical record and submitted with the claim to the dmerc (see documentation section).
alginate dressing (a6196-a6199)
alginate dressing covers are covered for moderately to highly exudative full thickness wounds (e.g., stage iii or iv ulcers); and alginate fillers for moderately to highly exudative full thickness wound cavities (e.g., stage iii or iv ulcers). they are not medically necessary on dry wounds or wounds covered with eschar. usual dressing change is up to once per day. one wound cover sheet of the approximate size of the wound or up to 2 units of wound filler (1 unit = 6 inches of alginate rope) is usually used at each dressing change. it is usually inappropriate to use alginates in combination with hydrogels.
composite dressing (a6200-a6205)
usual composite dressing change is up to 3 times per week, one wound cover per dressing change.
contact layer (a6206-a6208)
contact layer dressings are used to line the entire wound; they are not intended to be changed with each dressing change. usual dressing change is up to once per week.
foam dressing (a6209-a6215)
foam dressings are covered when used on full thickness wounds (e.g., stage iii or iv ulcers) with moderate to heavy exudate. usual dressing change for a foam wound cover used as a primary dressing is up to 3 times per week. when a foam wound cover is used as a secondary dressing for wounds with very heavy exudate, dressing change may be up to 3 times per week. usual dressing change for foam wound fillers is up to once per day.
gauze, non-impregnated (a6216-a6221, a6402-a6404)
usual non-impregnated gauze dressing change is up to 3 times per day for a dressing without a border and once per day for a dressing with a border. it is usually not necessary to stack more than 2 gauze pads on top of each other in any one area.
gauze, impregnated, with other than water, normal saline, or hydrogel (a6222-a6224, a6266)
usual dressing change for gauze dressings impregnated with other than water, normal saline, or hydrogel is up to once per day.
gauze, impregnated, water or normal saline (a6228-a6230)
there is no medical necessity for these dressings compared to non-impregnated gauze which is moistened with bulk saline or sterile water. when these dressings are billed, payment will be based on the least costly medically appropriate alternative, sterile non-impregnated gauze. bulk saline or sterile water is noncovered under the surgical dressing benefit.
hydrocolloid dressing (a6234-a6241)
hydrocolloid dressings are covered for use on wounds with light to moderate exudate. usual dressing change for hydrocolloid wound covers or hydrocolloid wound fillers is up to 3 times per week.
hydrogel dressing (a6231-a6233, a6242-a6248)
hydrogel dressings are covered when used on full thickness wounds with minimal or no exudate (e.g., stage iii or iv ulcers). hydrogel dressings are not usually medically necessary for stage ii ulcers. documentation must substantiate the medical necessity for use of hydrogel dressings for stage ii ulcers (e.g., location of ulcer is sacro-coccygeal area). usual dressing change for hydrogel wound covers without adhesive border or hydrogel wound fillers is up to once per day. usual dressing change for hydrogel wound covers with adhesive border is up to 3 times per week.
the quantity of hydrogel filler used for each wound must not exceed the amount needed to line the surface of the wound. additional amounts used to fill a cavity are not medically necessary. documentation must substantiate the medical necessity for code a6248 billed in excess of 3 units (fluid ounces) per wound in 30 days.
use of more than one type of hydrogel dressing (filler, cover, or impregnated gauze) on the same wound at the same time is not medically necessary.
specialty absorptive dressing (a6251-a6256)
specialty absorptive dressings are covered when used for moderately or highly exudative wounds (e.g., stage iii or iv ulcers). usual specialty absorptive dressing change is up to once per day for a dressing without an adhesive border and up to every other day for a dressing with a border.
transparent film (a6257-a6259)
transparent film dressings are covered when used on open partial thickness wounds with minimal exudate or closed wounds. usual dressing change is up to 3 times per week.
wound pouch (a6154)
usual dressing change is up to 3 times per week.
tape (k0572, k0573)
tape is covered when needed to hold on a wound cover, elastic roll gauze or non-elastic roll gauze. additional tape is usually not required when a wound cover with an adhesive border is used. the medical necessity for tape in these situations must be documented. tape change is determined by the frequency of change of the wound cover. quantities of tape submitted must reasonably reflect the size of the wound cover being secured. usual use for wound covers measuring 16 square inches or less is up to 2 units per dressing change; for wound covers measuring 16 to 48 square inches, up to 3 units per dressing change; for wound covers measuring greater than 48 square inches, up to 4 units per dressing change.
elastic bandage (a4460), elastic gauze (a6263, a6405), non-elastic gauze (a6264, a6406)
elastic bandages and elastic and nonelastic gauze are covered when they are used to hold wound cover dressings in place. these items are also covered when they are part of a multi-layer compression bandage system used in the treatment of a venous stasis ulcer. elastic bandages and elastic and nonelastic gauze are noncovered when used for strains, sprains, edema, or situations other than as a dressing for a wound.
most elastic bandages are reusable. usual frequency of replacement would be no more than one per week unless they are part of a multi-layer compression bandage system.
elastic and non-elastic gauze dressing change is determined by the frequency of change of the selected underlying dressing.
compression burn garments
compression burn garments are covered under the surgical dressings benefit when they are used to reduce hypertrophic scarring and joint contractures following a burn injury.
hope this helps. have teaching packet for patients pm if interested. let me know any questions you have.
remember: a bandaid is a dry sterile dressing usually 1" x2" covering a wound that "needs the skill of a professional" for evaluation of signs and symptoms of infection (esp. in high risk individuals), observation and assessment of wound healing, and need for evalution of compliance with the recomended treatment plan.
clinical documentation to reflect homebound status be clearly documented monthly in notes and with 60day summary. we include a checklist statement combined with clinical assessment in oasis recert package. minimum of weekly wound assessment using flow sheet. if no change/improvement in 3 weeks of treatments, consult to pcp/cetn re trying other treatment. daily wound care greater than 6 months, cut back to every other day to prove worsening status of wound without daily visits (1 week trial). daily wound care greater than 3 weeks must have end date statement from doctor or medicare won't pay.
pearls from hoolahan's home healthcare nurse website: http://www.geocities.com/vnarn_nj/
the wound ostomy continence nurse association has posted guidelines on their site for how to answer wound care questions on the oasis. these guidelines and definitions have been tested for interater reliability by a panel of wound care nurse experts. you can download the 6 page pdf, easy-to-read file, guidance on oasis skin and wound great info! (updated 11/5/08)
world wide wounds. everything you would want to know about wound care.
wound care net. another great wound care site. 3/20/05: deleted not active
edited to include more websites from hoolahan
journal: added 3/20/2005
advances in skin & wound care - home
healthpoint (mfg of panofil): thewoundinstitute added 7/29/05
closing the gap between evidence and action: how outcome measurement informs the implementation of evidence-based wound care practice in home care added 11/6/08
vnaa wound healing principles (many links) added 11/6/08
who evidence based practice committee: who wound care guidelines
hoolahan, ASN, RN
Holy Smokes Karen!! That was incredibly helpful!!! THanks for taking the time to post it here!! I think all I need to do is post a link to this thread!!
Now, what about Medicaid? I have a hard time understanding that $50 a month thing, and then families need diapers, enteral supplies, etc... Could I possible impose on you to add that??? I'm a devil for asking, but you are a Saint for posting!!! :kiss
NRSKarenRN, BSN, RN
Medicaid reimbursement for surgical wound supplies is the same as under same Centers for Medicare and Medicaid (CMS) program.
Info re Medicaid:
Each states Medicaid program is a combination of federal AND the states share (Share dickered with yearly).
Don't know exactly what the $50.00 you are referring to--possibly long term/disabled expense account to cover out-of- pocket, medically related expenses?
Expenses covered under PA MA:
Ensure type supplements are avail with RX from PCP and appropriate Dx: Dementia, failure to thrive, AIDS, muscle waisting, GI problem, COPD, MS etc.
We have a "diaper club" benefit with PCP RX for infants and adults (premise to prevent skin breakdown which is more costly to tx):
Children over age 3 would be eligable for diapers due to enuresis.
(Loved it the day a mom called in and asked for Huggies Lil'swimmers underpants and argued they were covered. NOPE)
Anyone with birth defect: Spinal Bifida, Cerebral Palsy, Tuberous Sclerosis etc and incontinence are eligable.
Adults any age with medical problem causing permanent urinary incontinence. Also covered for adults: underpads, dermal skin cleaners and skin barrier creams.
High density medical foam mattresses (like Hill Rom and Pegasus
provide) for clients with Arthritis, difficulty changing position--Medicare (MC) covered too.
Pressure reducion devices in one prone to skin breakdown:
Eggrate at least 2" thick (come in 2", 3" and 4"), low air-loss mattress, gel cushions for Wheelchairs. (MC covers all.)
Geri chairs with letter of medical necessity.
These most important items. I have a PA MA covered supply list and can infom you if covered in PA. Some states have more restrictive coverage ( eg no diapers, ensure) but most cover above pressure ulcer prevention devices.
Hi Karen, I just realized, it's not Medicaid that has the $50 dollar rule, it was CCPED, whihc is a medicaid program here in NJ anyway, stands for ??Program for the elderly and disabled. (I forget the CC part)
Thank you! This is very helpful, I'm printing out a copy to put in my ever-expanding accordian file for reference!
this is a great, all in one place, piece of information.
i'm goint to print out to keep on my clip board.....
thanks so much. so glad i logged on today. :)
Effective blood circulation to and from the wound is requisite for appropriate healing to take place. Ineffective circulation is often responsible for the wound (decubitus ulcer).
Therefore medical conditions associated with the poor circulation such as congestive heart failure,anemia, and dehydration must, of necessity, be appropriately diagnosed and treated for appropriate wound healing.
hi new here.. great info, thanks.. question?? any info or links to clean technique or aseptic technique wound care dressing change, step by step with how often glove change??
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