Are surgical / wound dressings covered?

Yes, both primary and secondary dressings are covered when either of the following criteria is met: If they are medically necessary for the treatment of a wound, caused by, or treated by a surgical procedure; or if they are medically required when debridement of a wound is medically necessary. The surgical procedure or debridement must be performed by a physician or other health care professional to the extent permissible under State law. Surgical dressings must be ordered by a physician or a Nurse Practitioner, Clinical Nurse Specialist, Certified Nurse-Midwife or Physician's Assistant who was acting within the scope of his or her legal authority as defined by State law or regulation. Debridement of a wound may be any type of debridement, such as mechanical, surgical, autolytic, or chemical dressings used for mechanical debridement are covered.

Is there a time limit for surgical dressings?

No, dressings may be used as long as medically necessary.

When are wound care items not covered?

The following items are not covered:

• Dressings for drainage from a cutaneous fistula which has not been caused by or treated by a surgical procedure.
• Dressings for Stage 1 pressure ulcers.
• Dressings for 1st degree burns.
• Dressings for wounds caused by trauma which do not require surgical closure or debridement. (skin tears, venipuncture, arterial puncture site)
• Skin sealants or barriers, wound cleansers or irrigating solutions, solutions used to moisten gauze (e.g. saline), topical antiseptics and topical antibiotics.
• Enzymatic debriding agents
• Gauze or other dressings used to debride a wound, but not left on the wound.
• Dressing kits. All dressings must be individualized for each patient.

What type of documentation is required?

A signed order by the physician or other health care provider legally allowed to sign this order. The order must specify:

• Type (category) of dressing
• Size of dressing
• Number / amount of dressings to be used at one time (if more than one)
• Frequency of dressing changes
• Expected duration of need

When is a new order required?

• A new dressing is added
• The quantity of an existing dressing INCREASES, not decreases.
• At least once every 3 months for each dressing being used, even if the quantity has remained the same.

DMERC Utilization Guide

The following is the official DMERC utilization guideline for wound care supplies:

Alginate wound cover : Dressing change once daily
Alginate wound filler : Dressing change once daily, up to 2 six inch strips allowed per dressing change
Composite dressing : 3 times per week, one dressing per dressing change
Contact layer : once per week
Foam dressing : up to 3 times per week
Foam wound filler : once daily
Gauze : 3 times per day, no more than 2 pads on a wound (non-impregnated)
Gauze : once daily (impregnated - other than water or saline)
Gauze : Non-covered, reduced to regular non-impregnated gauze level (impregnated with water or saline)
Hydrocolloid cover and filler : 3 times per week
Hydrogel wound cover : once daily (or 3 times per week if using adhesive border)
Hydrogel wound filler : once daily, no more than 3 ounces per wound in a 30 day period
Specialty absorptive dressing : once per day (or every other day if using adhesive border)
Transparent film : up to 3 times per week
Wound filler not classified : once per day
Wound pouch : up to 3 times per week
Tape : determined by frequency of dressing change
Elastic bandage : one per week
Gauze, elastic : determined by the frequency of dressing change of the primary dressing
Gauze, non-elastic : determined by the frequency of dressing change of the primary dressing

* Due to the constant changes in Medicare Policy, you should always contact your DMERC for current coverage policy.

Disclaimer

The Medicare guidelines in this document are for informational purposes only. CMSI is not responsible to any party that uses this information in any way.