Fistulas

WoundCon Faculty's picture

By: Dianne Rudolph, DNP, GNP-BC, CWOCN

What are some ways to achieve insurance coverage for fistula pouches or to use ostomy supplies for a fistula? We often run into the issue of supplies not being covered for Medicare or Medicaid patients.

Unfortunately, coverage is inadequate. CMS (Centers for Medicare & Medicaid Services) coverage for fistulas is limited for fistulas caused by or resulting from a surgical procedure, and even then, it may be difficult to get reimbursed. Spontaneous fistulas (15% to 25%) are generally not covered. The Wound, Ostomy and Continence Society is working on trying to effect a change in coverage. Some insurance companies may be more amenable to reimbursement, and it may require a case-by-case application or appeal. For patients being discharged home, it may be possible to secure a short-term supply of 10 to 14 days. The cost for the pouches may run $255 and up for a box of 10.

WoundSource Editors's picture
Fistulas

By the WoundSource Editors

Fistulas are abnormal connections or passageways between two organs or vessels that do not usually connect. Although they typically develop as a result of an injury or surgery, they can also be caused by infection or inflammation. The World Health Organization estimates that there are between 50,000 and 100,000 new cases of obstetric fistula annually, and the number of all types of fistulas is substantially higher.

Holly Hovan's picture
fistula management

By Holly Hovan MSN, APRN, CWOCN-AP

A fistula is an abnormal opening between two areas that typically shouldn't be connected, or with an epithelialized tract. An example is an opening from the bowel to the abdominal wall, termed enteroatmospheric or enterocutaneous (the terms are sometimes used interchangeably) because this fistula is exposed to the atmosphere, or is open from the abdomen to the skin, and typically needs to be pouched or some type of containment of the effluent.

Lydia Corum's picture

By Lydia A Meyers RN, MSN, CWCN

Enterocutaneous Fistulae (ECF) are a major healthcare issue affecting patients, their lives and the healthcare system. ECF are defined as abnormal connections from one organ to another. The most serious condition is formation from an internal organ to the skin. According to an article by Willcutts, Scarano, & Eddins in 2005, 75% to 85% of all fistulas occur 7 to 10 days after surgery. ECF often develop as a result of the patient's medical condition, past radiation treatments in area, and malnutrition of the patient. The names of ECF are related to exit and entrance points. According to Baranoski & Ayello, 2012, the mortality rate for patients with ECF ranges from 12% to 25%. The mortality is the result of sepsis, malnutrition, and dehydration. The ECF patient faces several problems including: cost of supplies, control of exudate and quality of life issues for the patient.