A prescription or physician’s order is required for wound care dressings that are reimbursed by Medicare Part B, Medicaid, HMOs, and other primary payors. Following Medicare Part B and third-party payor guidelines is critical in paid reimbursement claims. Medicare Part B will generally pay 80% of the Medicare-approved amount after the paid deductible. Third-party payers can vary by State, plan type, and Provider. Documentation by the provider must support medical necessity for all primary and secondary dressings for claims submitted to Medicare and other payor sources. Key elements of reimbursement policy are coverage, coding, and payment. These three elements are essential for adequate reimbursement of wound care dressings.
Find your Medicare Administrative Contractor (MAC) – MACs serva (serve) a geographical area and dictate regional reimbursement schedules for facilities and provider entities. MedicareAdministrativeContractors
Find your Local Coverage Determinations (LCD) – LCDs are created based on MACs to determine coverage for a given service line by Current Procedural Terminology (CPT).
Jurisdiction A: Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachursetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont.
Jurisdiction B: Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio and Wisconsin.
Jurisdiction C: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virginia, West Virginia, and US Virgin Islands.
Jurisdiction D: Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, Northern Mariana Islands, Oregon, South Dakota, Utah, Washington and Wyoming.