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:

    1. Wound location
    2. Wound type – pressure, diabetic, venous, arterial, surgical, trauma, other.
    3. Depth of tissue involvement – partial-thickness, full-thickness, undermining, tunneling, exposed structure.
    4. Exudate amount – scant, minimal, moderate, heavy, copious
    5. Exudate consistency – color, odor
    6. Wound bed tissue type(s) or color(s)
    7. Periwound, wound edges, and surrounding skin
    8. 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:

    1. Number, size, type, and stage of wounds being treated.
    2. If debrided, the method of debridement used.
    3. State if use is for a primary or secondary dressing.
    4. All clinical information supporting the reasonableness and necessity of surgical dressing type and quantity.
    5. Wound evaluation on at least a monthly basis.
    6. 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:

    1. Number of wounds.
    2. Statement about response to previous treatment if other treatments have been prescribed.
    3. Evaluation period (10, 15, 30 days) for collagen dressing.
    4. Manufacturer's name (Human BioSciences, Inc.).
    5. Product name, product size and product number (Medifil® II particles, 5 ml, MF 1010).
    6. 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