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What Is Wound Therapy?
Medicare refers to the medical care needed to treat chronic wounds as "wound therapy." A chronic wound is a sore, blister, or skin injury that has not healed after 30 days of treatment by a doctor. Chronic wounds are serious and need medical attention. They can take months or years to heal; and some never do heal. They can be very painful and cause a lot of discomfort for the person who has one.
These wounds affect the lives of millions of people in the United States and are very expensive to treat. Well over half of the people with chronic wounds are over 60. Many are also living with mobility problems and/or long-term illnesses, (i.e., heart disease, stroke, kidney disease, diabetes, circulation disorders, paralysis, and more), which complicate treatment and increases the time it takes to heal the wound.
Why Won't These Sores Heal?
Chronic wounds don't heal because something is interfering with the normal healing process. Many reasons may contribute to poor healing. The most common include:
- Infection
- Something inside the wound (piece of wood, glass, etc.)
- Poor health
- The wound is repeatedly reinjured (common in people who are unable to get out of bed safely)
- Smoking
- Some medications
- Out-of-control diabetes
- A poorly functioning immune system
- Age (the healing processes slows down as age increases)
- Skin cancer
What Do I Do If I Have a Sore That Is Not Healing?
The first step in dealing with a non-healing sore is a visit to your doctor. Your doctor will examine the sore and prescribe an appropriate course of treatment, which may include treatment by a wound care specialist. These are doctors and nurses who specialize in the care of chronic wounds. Wound care can be provided in your home, at the doctor's office or in the hospital.
Does Medicare Cover the Cost of Wound Care?
Yes, Medicare will cover the cost of wound care, if the care is deemed medically reasonable and necessary by your doctor. Coverage includes the following services, equipment and supplies:
- A negative wound therapy pump
- Up to 15 dressing kits per wound per month, unless there is documentation that the wound size requires more than one kit for each dressing change
- Up to 10 drainage kits per month, unless there is documentation of the need for more due to a large volume of drainage
Wound care provided in the home must be provided by a provider or home health agency approved by the Medicare program.
How Do I Qualify for Wound Care Therapy?
Your doctor must write an order for the care, and document that your need for the service and supplies is medically reasonable and necessary.
Documentation of reasonable and necessary wound care includes:
- Weekly documented evidence in the patient's record that the wound is getting better in response to the care given. Evidence will include documentation of measurable changes in at least some of the following areas:
- Drainage
- Inflammation
- Swelling
- Pain
- Wound size
- Tissue health
- A wound showing no improvement after 30 days requires reassessment by the doctor.
- The service provided must be safe and effective and given in an appropriate setting by qualified personnel.
If you get care through a Medicare Advantage or MediGap/Medicare Supplemental plan, call the plan and ask about their coverage for wound care. They must cover at least what Medicare does, although they often cover more.
What Are My Out-Of-Pocket Costs?
Your out-of pocket cost will depend on which type of Medicare coverage you receive. For example:
- Original Medicare covers 80% of their approved amount. You are responsible for the remaining amount.
- If you have a MediGap/Medicare Supplemental Plan, call and ask what is covered by the plan. Many times with MediGap plans you will pay little or nothing.
- If you have a Medicare Advantage Plan, call your plan and ask what is covered and what is your share of the cost. Remember the plan must cover at least what Medicare does; many cover more.
Important things to know:
- You must have paid your annual deductible for Part B services and supplies before Medicare begins to pay its share.
- Actual amounts you pay may be higher if the doctor, health care provider or supplier does not accept assignment. You may have to pay the entire bill before you get your supplies and services.
How Do I Find a Wound Care Specialist?
Always start by asking your doctor, friends, and family for recommendations. If you get your coverage from a Medicare Advantage plan, you may have to use one of the wound care providers that they have on contract.
If you are covered by Original Medicare, do your homework before choosing a provider. Ask the provider/supplier:
- If they are participating providers/suppliers
- If they accept assignment
- To write down what they will charge and how much of it you will have to pay
If your provider/supplier does not accept assignment:
- You may have to pay more than the Medicare approved amount
- You may have to pay the entire cost of your supplies when you get them
- You may have to bill Medicare yourself and wait several weeks before you will be reimbursed
Other important things to know:
- If the supplier is not enrolled in Medicare, Medicare will not pay the claim.
- You must have paid your annual deductible for services and supplies before Medicare will begin to pay its share.
- An order (prescription) must be on file with the supplier and must be signed and dated by your doctor.
You may pay little or nothing if you are covered by a MediGap/Medicare Supplemental plan. Call the plan and ask about your share of cost.
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