Medicare requires the following information in order to cover these items: The beneficiary must have a valid prescription, and the number of wounds being treated must be documented. Their location, size and depth must also be in the medical record. Also, the amount of drainage/exudate, the date of debridement or the date of last dressing change, the type and size of dressing used, the quantity of dressings to be used each time the dressing is changed. They will also want to know how often this is done, and the expected duration of the need. And in order for the coverage to continue, the wound must be assessed every 30 days.

Physician Order
The supplier generally takes the responsibility of obtaining the new physician order, when necessary, and there are differing requirements depending upon where the beneficiary is to receive treatment. Your Wound Care handout has information regarding coverage guidelines for beneficiaries receiving treatment at home through home healthcare, at a nursing home (including skilled and non-skilled facilities, as well as assisted living centers), an acute care-based wound clinic, and the physician’s office. 

 

Categories and HCPCS Codes
Dressings are classified into generic descriptive categories and each category is assigned a HCPCS Code, and each code assigned an allowable fee amount. The fee remains the same regardless of the manufacturer.

Allowable Fee Schedule
The allowable fee is the value Medicare has set for each dressing category. The fee amount varies by the type of dressing and the size. Payment of the allowable fee is the shared responsibility of Medicare (80%) and the beneficiary (20%), just like the other

categories we have examined.

 

Supplier Notes
A supplier that is a Medicare Provider can submit claims and accept payment directly from Medicare.

Medicare allows the supplier to dispense and bill up to one (1) month’s worth of dressings at a time. Suppliers submit claims to one of four (4) insurance companies, called DME MACs, designated to process Medicare Part B claims. Each of the four (4) DME MACs service a specific geographic area, based on the beneficiary’s permanent address.