Reimbursement 101: Medicare Reimbursement for Wound Dressings by Clinical Setting

DMCA.com Protection Status
Blog Category: 

by Glenda Motta RN, MPH

The most commonly used wound dressings are classified as medical devices. Examples of these include (but are not limited to): absorptive dressings, alginates, collagens, composites, contact layers, foams, gauzes, hydrocolloids, hydrogels, impregnated dressings, transparent films, wound fillers, and silver dressings.

Most often, dressings are included in the lump-sum payment provided in the specific clinical setting. Medicare Part B coverage policy covers these wound dressings only in certain situations and, in that case, payment is based on the HCPCS code. The following table summarizes this information by clinical setting:

Clinical Setting Payment Summary
Acute Hospital Care Dressings are included within the DRG (Diagnosis Related Group) payment.
Rehabilitation Facility Dressings are included within the CMG (Case-Mix Group) payment.
Long-Term Care Hospital Dressings are included within the MS-LTC-DRG (Medicare Severity Long-term Care Diagnosis-Related Groups.
Skilled Nursing Facility Part A: dressings are included within the RUG (Resource Utilization Group) payment. Non-Part A: dressings may be supplied by a DME and billed separately to Medicare Part B
Home Health Agency Certain dressings may be paid as non-routine medical supplies, separate from the HHRG (Home Health Resource Group) payment.
Hospital Outpatient Dressings used on day of service are included within the APC (Ambulatory Payment Classification) payment.
Dressings used at home between visits may be supplied by a DME and billed separately to Medicare Part B if coverage criteria are met.
Physician/Podiatrist Office Dressings used during office visit cannot be billed separately and are the responsibility of the provider.
Dressings used at home between visits may be supplied by a DME and billed separately to Medicare Part B if coverage criteria are met.
Beneficiary at Home Dressings used at home may be supplied by a DME and billed separately to Part B if coverage criteria are met.
DME Supplier Medicare pays 80% of the allowed amount and the Beneficiary is responsible for the remaining 20%. Allowable amounts are published for each HCPCS.

Reimbursement information changes frequently so any provider should check with the appropriate payer to verify codes and policy. The information in this article may now be outdated.

About The Author
Glenda Motta RN, MPH is a reimbursement consultant and wound care expert, publishing over 125 articles and books, serving as the President of the WOCN (1987-1989), and founding GM Associates, Inc., a healthcare marketing and reimbursement firm.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

Comments

is wound vac billable?

Add new comment

Important Notice: The contents of the website such as text, graphics, images, and other materials contained on the website ("Content") are for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. The content is not intended to substitute manufacturer instructions. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition or product usage. Refer to the Legal Notice for express terms of use.