If Medicare determines there is medical necessity, the standard allowable for the following items are listed below. Medicare may sometimes approve larger quantities, but that decision is made on a month-to-month basis by the individuals reviewing the claims. They may approve larger quantities one month, but disapprove them a different month. For the most consistent reimbursement by Medicare, you may want to consider placing one order per month, staying within the limits listed below.

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1. Some Medicare Coverage Rules that should be noted:
1. The staging of pressure ulcers used in this policy is as follows:
1. Stage I - Observable pressure-related alteration of intact skin whose indicators, as compared to the adjacent or opposite area on the body, may include changes in one of more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel) and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.
2. Stage II - Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
3. Stage III - Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
4. Stage IV - Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be associated with
5. Stage IV - pressure ulcers. Medicare reimbursement limits Ostomy supplies to a 3 month supply at one time.
2. If treatment regimen exceeds the quantity limitations noted below, then Medicare requires a Letter of Medical Necessity signed by the physician on his or her letterhead.
3. If you fax this document, Medicare/insurance requirements are that you maintain the signed original in the patient's medical record for post-payment review audit purposes.
4. Surgical dressings are covered when either of the following criteria are met:
1. They are medically necessary for the treatment of a wound caused by, or treated by, a surgical procedure; or
2. They are medically necessary when debridement of a wound is medically necessary.
5. Surgical dressings include both primary dressings (i.e., therapeutic or protective coverings applied directly to wounds or lesions either on the skin or caused by an opening to the skin) or secondary dressings (i.e., materials that serve a therapeutic or protective function and that are needed to secure a primary dressing).
6. The surgical procedure or debridement must be performed by a physician or other healthcare professional to the extent permissible under State law. Debridement of a wound may be any type of debridement (examples given are not all-inclusive): surgical (e.g., sharp instrument or laser), mechanical (e.g., irrigation or wet-to-dry dressings), chemical (e.g., topical application of enzymes), or autolytic (e.g., application of occlusive dressings to an open wound). Dressings used for mechanical debridement, to cover chemical debriding agents, or to cover wounds to allow for autolytic debridement are covered although the agents themselves are noncovered.
7. Surgical dressings are covered for as long as they are medically necessary. Dressings over a percutaneous catheter or tube (e.g., intravascular, epidural, nephrostomy, etc.) are covered as long as the catheter or tube remains in place and after removal until the wound heals. (Refer to Coding Guidelines)
8. Examples of situations in which dressings are non-covered under the Surgical Dressings benefit are:
1. drainage from a cutaneous fistula which has not been caused by or treated by a surgical procedure; or
2. a Stage I pressure ulcer; or
3. a first degree burn; or
4. wounds caused by trauma which do not require surgical closure or debridement - e.g., skin tear or abrasion; or
5. a venipuncture or arterial puncture site (e.g., blood sample) other than the site of an indwelling catheter or needle.
9. Surgical dressing codes billed without modifiers X1-X9 (see Coding Guidelines) are non-covered under the Surgical Dressings benefit. Certain dressings may be covered under other benefits (e.g., see Ostomy Supplies policy).
10. If a physician applies surgical dressings as part of a professional service that is billed to Medicare, the surgical dressings are considered incident to the professional services of the health care practitioner and are not separately payable.
11. Dressing size must be based on and appropriate to the size of the wound. For wound covers, the pad size is usually about 2 inches greater than the dimensions of the wound. For example, a 5 cm x 5 cm (2 in. x 2 in.) wound requires a 4 in. x 4 in. pad size.
12. The quantity and type of dressings dispensed at any one time must take into account the current status of the wound(s), the likelihood of change, and the recent use of dressings.

Better living Now, Inc. assumes no responsibility in regards to Medicare coverage and has interpreted Medicare Rules for the benefit and understanding of the patient. For detailed information regarding Medicare coverage please visit their web site at: www.cms.gov. For Coverage Information for Surgical Supplies go to: http://www.tricenturion.com/content/dmerc/1202SURG126.cfm. For Coverage Information for Pressure Reducing Support Surfaces go to:

• Pressure Reducing Support Surfaces - Group 1 (Posted 1/03)
• Pressure Reducing Support Surfaces - Group 2 (Posted 1/03)
• Pressure Reducing Support Surfaces - Group 3 (Posted 1/03)