Reimbursement
Collagen advanced wound care dressings are reimbursed by Medicare Part B, Medicaid, HMO’s, and other primary payors. Following Medicare Part B and third-party payer guidelines are critical in paid reimbursement claims. Medicare Part B will generally pay 80% of the Medicare-approved amount after paid deductible. Third-party payers can vary by State, plan type, and Provider.
Physician Guidelines
Purpose:
To deliver evidence-based advanced wound care while utilizing established and developed medical standards to optimize wound healing outcomes:
-
Weekly wound assessment should include:
- Wound location
- Wound type – pressure, diabetic, venous, arterial, surgical, trauma, other.
- Depth of tissue involvement – partial-thickness, full-thickness, undermining, tunneling, exposed structure.
- Exudate amount – scant, minimal, moderate, heavy, copious
- Exudate consistency – color, odor
- Wound bed tissue type(s) or color(s)
- Periwound, wound edges, and surrounding skin
- Pain level – location, duration, frequency
- Use appropriate primary dressing, collagen formulation (KollagenTM particles, sheet, or gel) based on wound assessment.
- Secondary dressings are used as a cover dressing: e.g., transparent, gauze, abdominal pad, foam, super-absorbent pad, hydrocolloid, Unna's boot, and multi-layer wrap.
- Dressing size is determined by wound measurements that may or may not include periwound. A larger dressing may be used if the clinical rationale supports product size.
- Physician progress note/wound note must substantiate advanced wound care products and frequency of change.
- Wound photos can be used as an adjunct to written documentation. Always follow your policy and procedures.
- Physician detailed written order must be signed and dated for each product billed, including # of dressings and directions for us. Orders may be placed every 30 days per Medicare Part B guidelines.
- The physician will monitor wound progress and treatment plan weekly and make changes to treatments as appropriate if no wound healing progress >2 weeks.
Supplier Guidelines
Purpose:
To deliver professional services in strict compliance with specific payer guidelines.
- Test documentation for Medicare and/or third-party payer eligibility for all product orders.
- Follow Medicare coding guidelines.
- Understand and exercise Medicare coverage and payment rules.
- Comply with Medicare guidelines for delivery and product support to patient.
- Provide support to patient with the paperwork required to process and submit claims.
- Submit claim to payer for reimbursement.
- Repeat guideline process for renewal orders.
Obtaining Medicare Reimbursement
Provider / Supplier:
- Review and understand DMERC Surgical Dressing Medical Policies and all updates.
-
Verify that the patient file includes the following information to document medical necessity:
- Number, size, type, and stage of wounds being treated.
- If debrided, the method of debridement used.
- State if use is for a primary or secondary dressing.
- All clinical information supporting the reasonableness and necessity of surgical dressing type and quantity.
- Wound evaluation on at least a monthly basis.
- Written confirmation of the physician's supply order.
- Keep record of source and date of medical necessity information for review or audit when necessary.
- Consider developing an internal Certificate of Medical Information.
-
Submit claim with following information:
- Number of wounds.
- Statement about response to previous treatment if other treatments have been prescribed.
- Evaluation period (10, 15, 30 days) for collagen dressing.
- Manufacturer's name (Human BioSciences, Inc.).
- Product name, product size and product number (Medifil® II particles, 5 ml, MF 1010).
- Statement that the product is used as a primary dressing, is medically necessary, and improvement is expected by using collagen dressings.
Medifil® II
Available Size: 1gm Vials and 1gm Pouches
HCPCS Code: A6010
SkinTemp® II
Available Size: 2”x2”, 3”x4”, and 8”x12” Sheets
HCPCS Code: A6021/A6022/A6023
Collatek®
Available Size: 30gm/1oz Tubes
HCPCS Code: A6011
