General reimbursement guidelines

With regard to the Medicare coverage of wound care dressings and supplies, the same general rules apply here as do in other medical supplies categories.

Wound care dressings must be ordered by a physician or other healthcare professional and are generally provided one month at a time. Dressings are covered as long as medically necessary.

If Medicare determines there is medical necessity, the standard allowable will be supplied. Medicare may sometimes approve larger quantities, but that decision is made on a month-to-month basis by the individual directly reviewing that particular claim.

This may cause coverage to be inconsistent with regard to quantities they approve. Regarding wound care, for the most consistent reimbursement by Medicare, placing one order per month and staying within stated limits usually produces the best results.

Medicare’s guidelines regarding the staging of pressure ulcers are as follows:

Stage I – Characterized by alteration of intact skin due to pressure. The skin will appear warmer or cooler than surrounding skin, and either firmer or less so, and may have pain, where adjacent skin does not. The ulcer appears as a defined area of persistent redness.

Stage II – Characterized by 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. The ulcer presents clinically as a deep crater (with or without undermining of adjacent tissue).

Stage IV - Full thickness skin loss with extensive destruction and tissue necrosis (ne-kro-sis).[53]