Medicare coverage and reimbursement for wound dressings varies by healthcare setting. Please see the definitions below to identify your setting:

• Home Health Care
• Nursing Home
• Hospital Based Wound Care Clinic
• Physician Office
• Residing at Home

HOME HEALTH CARE

Definition
As a beneficiary, it is your responsibility to notify your retailer that you are receiving home health care at the time of purchase of medical supplies. You are under your home health benefit if you receive any of the following in your home: part-time skilled nursing care, physical therapy, occupational therapy, speech therapy, home health aide services, or medical social services.

Dressing Coverage
The Medicare regulations state that it is the responsibility of the home health agency to provide ostomy supplies from the first visit through the last visit. Medicare will deny claims to retailers for all ostomy supplies provided directly to beneficiaries and billed to Medicare during their home health episode of care. Determining eligibility prior to the transaction will help reduce the risk of denials.

NURSING HOME

Medicare Skilled:

Definition
If you receive skilled nursing care after a related 3-day inpatient hospital stay, you are covered under Medicare Part A. Your Medicare Part A benefit is in effect up to 100 days, as long as you meet the skilled care guidelines.

Dressing Coverage
All dressings are provided by the nursing home.

Medicare Non-Skilled or Assisted Living:

Definition
If you reside in a nursing home and do not meet the Medicare Part A skilled care guidelines, or reside in an Assisted Living Facility.

Dressing Coverage
Your Medicare Part B benefit covers your dressing supplies, under the same guidelines as Residing at Home.

HOSPITAL BASED WOUND CARE CLINIC

Definition
If you receive care for an acute or chronic wound in a hospital clinic.

Dressing Coverage:
Medicare regulations state that wound care clinics are responsible for providing dressing used during the visit. Physician Office Definition: If you receive care for an acute or chronic wound in a physician office or a non-hospital clinic. Dressing Coverage: Medicare regulations state that the physician or non-hospital clinics are responsible for providing dressings used during the visit. No additional payment can be collected for dressings.

PHYSICIAN OFFICE

Definition:
If you receive care for an acute or chronic wound in a physician office or a non-hospital clinic.

Dressing Coverage:
Medicare regulations state that the physician or non-hospital clinics are responsible for providing dressings used during the visit. No additional payment can be collected for dressings.

RESIDING AT HOME

Definition
You may qualify for Medicare Part B coverage if you:

• Reside at home and are not receiving Home Health Care
• Reside in a nursing home and do not meet the skilled nursing guidelines for Medicare Part A
• Reside in an Assisted Living Facility

Physician Order
The supplier generally takes the responsibility of obtaining the new physician order. An order is required when any of the following occurs:

• Initial dressing order
• Every three (3) months order
• Increased amount of dressings are needed

Utilization Guidelines

Medicare has established utilization guidelines for each dressing category. This is the amount Medicare will routinely approve on a weekly/monthly basis. If a quantity higher than the guidelines is required, a statement of medical necessity is required from the physician.

Categories and HCPCS Codes
Dressings are classified into generic descriptive categories and each category is assigned a HCPCS Code, and each code assigned an allowable fee amount. The fee remains the same regardless of the manufacturer.

Click here for HCPCS Codes for ConvaTec products.

Allowable Fee Schedule
The allowable fee is the value Medicare has set for each dressing category. The fee amount varies by the type of dressing and the size. Payment of the allowable fee is the shared responsibility of Medicare and the beneficiary:

• Medicare responsibility – 80% of allowable fee
• Beneficiary responsibility – 20% of allowable fee

Choose a Supplier
As a Medicare beneficiary, it is important to select a supplier that is an authorized Medicare Provider for prompt reimbursement of your wound dressing purchase. A supplier that is a Medicare Provider can submit claims and accept payment directly from Medicare.

Medicare allows the supplier to dispense and bill up to one (1) month worth of dressings at a time.

Suppliers submit claims to one of four (4) insurance companies, called DME MACs, designated to process Medicare Part B claims. Each of the four (4) DME MACs service a specific geographic area, based on your permanent address.

Medicare Assignment:

• Supplier must be a Medicare Provider
• Supplier accepts the Medicare Allowable as Payment in Full
• Supplier submits claim to Medicare and is directly reimbursed 80% of the allowable fee
• Supplier collects the remaining 20% of the allowable fee from beneficiary
• No additional money can be collected from the beneficiary for this transaction

Medicare Non-Assignment:

• Supplier must be a Medicare Provider
• Beneficiary purchases products at the supplier’s retail price as a “cash” transaction
• Supplier is obligated to submit a claim to Medicare on behalf of the beneficiary
• Claim must be filed within one year of the date of service
• Medicare issues a check for 80% of the allowable fee directly to the beneficiary
• The beneficiary total expense is the difference between the “cash” transaction price and 80% of the allowable fee amount
• The beneficiary has a higher out-of-pocket expense with the non-assignment method

The Medicare benefit is applicable for both assigned and non-assigned claims.

If you have questions about selecting a supplier in your area, contact the ConvaTec Customer Interaction Center at 1-800-422-8811.