Glenda J. Motta, RN, MPH, ET
Under Medicare Part B, wound care products are subject to the surgical dressing policy. The benefit includes both primary dressings (applied directly to the wound) and secondary dressings (used to secure a dressing or provide protection). A wound must meet the medical necessity criteria (i.e., be surgically created or debrided by any means) to qualify the beneficiary for surgical dressings. The surgical procedure or debridement must be performed by a physician or other healthcare professional, as allowed by state law.
Surgical dressings are not covered for the following conditions:
Types of wounds that may qualify for surgical dressings under Medicare Part B include:
Suppliers who bill Medicare must be able to determine the quantity of dressings actually being used by the patient in any clinical setting and only supply that amount. No more than one month's supply may be provided at one time unless there is documentation to support medical necessity. The quantity and type of dressings dispensed at any one time must take into account the current status of the wounds, the likelihood of a change in the treatment plan, and the recent use of dressings.
An order signed and dated by the patient's attending physician must be kept on file by the supplier. It must specify the type of dressing; size of the dressing; the number/amount to be used at one time; the frequency of dressing change; and 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.
An evaluation of wounds must be performed at least monthly and patients in a nursing facility or those with infected or heavily draining wounds should be evaluated more frequently (e.g., weekly). The evaluation must include type of each wound (e.g., surgical, pressure ulcer, burn); location; size (length x width x depth in cm.); amount of drainage; any other relevant data. Ideally, the supplier will have this documentation, provided by a healthcare professional, on file for review by the DMERC (the Medicare carrier) if necessary.
It is important to note that many wound care supplies are not covered under Part B. These include:
Elastic stockings, support hose, foot coverings, leotards, knee supports, surgical leggings, gauntlets and pressure garments for the arms and hands are items that are not ordinarily covered as surgical dressings. I the rare situation when one of these items might be used as a secondary dressing, individual consideration will be given to each claim submitted with documentation demonstrating the medical necessity, therapeutic function, and role in securing the primary dressing.
The coverage criteria and normal use parameters are itemized in the policy by generic dressing category. For example, use parameter for alginate dressings is one per day and the dressing is covered for use on moderately to highly exudative full thickness wounds. Call 1-305-919-9192 for a chart indicating dressing category and allowable usage.