As wound specialists, we pride ourselves on an accurate diagnosis and delivery of evidence-based wound care. Many of us are avid researchers, spending hours combing through the literature as well as attending conferences and continuing education events to ensure that the clinical choices we make are sound. However, the best care plan and wound care products are useless to many of our patients if we are unable to help them obtain insurance authorization and reimbursement. In this report, I am going to discuss important concepts for optimizing insurance reimbursement for wound care products and home care services.
Many patients with complex or chronic wounds are older than 65 years of age and are insured through Medicare or privatized Medicare Advantage Plans. Both Medicaid and private insurance for individuals younger than 65 adhere to reimbursement guidelines that are based on Medicare guidelines. Because learning specific guidelines for every insurance plan in the United States is not feasible, I recommend that all clinicians become familiar with Medicare reimbursement guidelines and use them as a general reference tool when treating wounds.
Before diving in, I would like to make one point regarding the ethics of using insurance guidelines as a reference when formulating a wound treatment plan. You may be saying, “But these insurance companies have financial motivations behind their guidelines. My knowledge and experience contradict these recommendations. I am the provider and write orders based on what I think is best for the patient.” While the truth behind these sentiments is certainly valid, that is a discussion for another time. The fact of the matter is that documentation, coding, and product usage guidelines will dictate what will and will not be covered, and providers must recognize this reality. When choosing not to follow guidelines, a provider is ethically obligated to initiate a frank discussion with the patient about potential out-of-pocket costs due to a lack of adherence, offer an alternative reimbursable option, and allow the patient to make an informed choice regarding their care.
Medicare lists their allowable number of dressings for a wound in a 30-day period. Table 1 summarizes clinical criteria and monthly Medicare allowances for an assortment of wound dressings.1 This is not an exhaustive list, but most durable medical equipment (DME) catalogs contain a similar allowance chart for the products they carry. A provider should call the DME company or local product representative and ask for this information. In addition to U.S. Centers for Medicare & Medicaid Services (CMS) websites, product manufacturers can be an excellent resource for reliable information about insurance allowances. In the author’s experience, most companies can provide a list of qualifying criteria, codes, and allowances for each product they carry. They are typically eager to help you obtain optimal reimbursement. Make sure the product you wish to use has a Healthcare Common Procedure Coding System (HCPC) code assigned to it and use this code in your order. HCPC codes are how Medicare categorizes dressings for billing purposes. If it does not have an HCPC code, Medicare has not approved it for reimbursement. Contact the manufacturer if you cannot find the HCPC code.
You will also need to provide accurate documentation and diagnosis codes to support the wound care order. The scope of documentation and assigned International Statistical Classification of Diseases and Related Health Problems (ICD-10)2 diagnosis codes will make or break an authorization approval for wound products and home health services. It is worth your time to familiarize yourself with what codes are needed to obtain approval for specific products along with documentation requirements. One way to do this is to work in reverse; look up a product and contact the manufacturer to ask what diagnosis codes are needed for insurance authorization. Then document accordingly. Sometimes this information can be found on the manufacturer website.
Your note is just as important as your diagnosis. Documentation of wound measurements as well as wound bed descriptions including presence and percentage of necrotic tissue, amount of drainage, or lack of drainage are all mandatory. This information is used to establish medical necessity for specific wound products. For example, a hydrofiber or alginate dressing may not be authorized unless there is documentation of moderate to heavy drainage, and certain collagen products will not be authorized unless the wound bed is documented as being mostly free of necrotic tissue.