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Medicare Coverage Determinations for Wound Care

Medicare Coverage Determinations for Wound Care

Medicare Coverage Determinations for Wound Care

INTRODUCTION

To ensure proper Medicare reimbursement and smooth Medicare audits, clinicians must familiarize themselves with the Coding and Reimbursement guidelines for Wound Care and ensure compliance with the Centers for Medicare and Medicaid Services. This topic provides a map of the Medicare Part A/B Medicare Administrative Contractors Jurisdictions and respective coverage determinations. For Medicare Coverage Determinations for Hyperbaric Oxygen Therapy, see "Medicare Coverage Determinations for Hyperbaric Oxygen Therapy


NATIONAL OR LOCAL COVERAGE DETERMINATIONS

The map below shows the Medicare Part A/B Medicare Administrative Contractors (MAC) Jurisdictions. MACs determine which types of interventions are covered along with documentation needed to justify medical necessity, utilization guidelines, frequency allowed, etc. Clinicians who bill Medicare should adhere to the guidance provided by their MAC to ensure proper reimbursement and smooth audits, should they occur. 

Instructions

  1. On the map below, find your state and respective MAC (see abbreviation of the MAC in the white bubbles)
  2. In the table below the map, find your MAC in the left column. In the right column, check if the MAC follows its own Local Coverage Determination (LCD) or if it follows the National Coverage Determination (NCD) 
  3. To go to the NCD or LCD, click on its reference number (in blue brackets in the right column). On the reference page, click on the green button "View Source" to go to the specific LCD or NCD on the CMS website.
  4. See details on requirements, medical necessity and documentation on specific Medicare National and Local Coverage Determinations
  5. For latest updates of each NCD, LCD or local coverage article, scroll to the bottom section 'Revision History Information'    


Medicare Administrative Contractor (MAC)  
Local Coverage Determinations (LCD) and Policy Articles
CGS Administrators, LLC (CGS)
  • L34045 Non-Invasive Vascular Studies, updated on 11/02/2023 [1]
  • A56697 Billing and Coding: Non-Invasive Vascular Studies, updated on 11/22/2023 [2]
  • L34049 Outpatient Physical and Occupational Therapy Services, updated on 05/25/2023 [3]
  • A57067 Billing and Coding: Outpatient Physical and Occupational Therapy Services, updated on 11/22/2023 [4]
  • L36690   Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities, updated on 09/01/2022 [5]
  • A56696   Billing and Coding: Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities, updated on 12/28/2023 [6]
  • A55276  Response to Comments: Wound Application of Cellular and/or Tissue Based products (CTPs), Lower Extremities [7]
  • L34032  Debridement Services, updated on 10/05/2023 [8]
  • A56459    Billing and Coding for Debridement Services, updated on 11/16/2023 [9]
  • L33942  Physical Therapy - Home Health, updated on 07/06/2023 [10]
  • A57311  Billing and Coding: Physical Therapy - Home Health, updated on 10/01/2023  [11]
  • L33830    Pressure Reducing Support Surfaces - Group 1 [12]
  • A52489  Pressure Reducing Support Surfaces - Group 1 - Policy Article [13]
  • L33642  Pressure Reducing Support Surfaces - Group 2 [14]
  • A52490    Pressure Reducing Support Surfaces - Group 2 - Policy Article [15]
  • L33692    Pressure Reducing Support Surfaces - Group 3 [16]
  • A52468    Local Coverage Article: Pressure Reducing Support Surfaces - Group 3 - Policy Article [17]
  • L33829    Pneumatic Compression Devices, updated on 10/22/2023 [18]
  • A52488    Pneumatic Compression Devices - Policy Article, updated on 10/22/2023 [19]
  • A59219   Response to Comments: Pneumatic Compression Devices - DL33829 [20]
  • L33821 Negative Pressure Wound Therapy Pumps, updated on 01/01/2024 [21]
  • A52511 Negative Pressure Wound Therapy Pumps - Policy Article [22]
  • L33831   Local Coverage Determination for Surgical Dressings, updated on 01/01/2024 [23]
  • A54563 Surgical Dressings - Policy Article, updated on 01/01/2024 [24]
  • A56175 Low frequency, non-contact, non-thermal ultrasound (CPT code 97610), updated on 11/16/2023 [25]
  • A55426   Standard Documentation Requirements for All Claims Submitted to DME MACs, updated on 01/01/2024 [26]
  • L34246   Routine Foot Care and Debridement of Nails, updated on 08/03/2023 [74]
First Coast Service Options, Inc. (FCSO)
  • L37166   Wound Care  [27]
  • A55818 Billing and Coding: Wound Care [28]
  • A55757 Wound care (L37166): Medicare Part A/B local coverage determination (LCD) comment summary [29]
  • L36377   Application of Skin Substitute Grafts for Treatment of DFU and VLU of Lower Extremities [30]
  • A57680 Billing and Coding: Application of Skin Substitute Grafts for Treatment of DFU and VLU of Lower Extremities [31]
  • L33667   Duplex Scan Of Lower Extremity Arteries [32] 
  • L33693   Non-Invasive Evaluation of Extremity Veins [33]
  • L33696 Noninvasive Physiologic Studies of Upper or Lower Extremity Arteries [34]
  • A58810   Billing and Coding: Platelet Rich Plasma, updated on 07/01/2023 [76]
  • L38720   Local Coverage Determination (LCD) Treatment of Chronic Venous Insufficiency of the Lower Extremities [35] 
  • L39071   Platelet Rich Plasma [77]
National Government Services, Inc. (NGS)
  • L33563 Incision and Drainage (I & D) of Abscess of Skin, Subcutaneous and Accessory Structures [36]
  • L33614 Debridement Services [37]
  • A56617 Billing and Coding: Debridement Services, updated on 01/01/2024 [38]
  • L33627   Non-Invasive Vascular Studies [39]
  • L33631 Outpatient Physical and Occupational Therapy Service[40]
  • A56566 Billing and Coding: Outpatient Physical and Occupational Therapy Services, updated on 01/01/2024 [41]
  • A57759 Billing and Coding: Routine Foot Care and Debridement of Nail, 01/01/2024 [42]
  • L38937   Platelet Rich Plasma [78]
Noridian
  • A53046 Wound Care and Debridement - Provided by a Therapist, Physician, NPP, or as Incident-to Service, updated on 01/01/2024 [43]
  • A53296 Wound Care & Debridement – Provided by a Therapist, Physician, NPP or as Incident-to Services, updated on 01/01/2024 [44]
  • A52959 Billing and Coding: Lymphedema Decongestive Treatment [45]
  • A55710 Lymphedema Decongestive Treatment [46]
  • A52918 Coverage of Foot Care Services [47]
  • L33821 Negative Pressure Wound Therapy Pumps, updated on 01/01/2024 [ [21]
  • A52511 Negative Pressure Wound Therapy Pumps - Policy Article, updated on 08/15/2021 [22]
  • L33830   Pressure Reducing Support Surfaces - Group 1 [12]
  • A52489 Pressure Reducing Support Surfaces - Group 1 - Policy Article [13]
  • L33642 Pressure Reducing Support Surfaces - Group 2 [14]
  • A52490   Pressure Reducing Support Surfaces - Group 2 - Policy Article [15]
  • L33692   Pressure Reducing Support Surfaces - Group 3 [16]
  • A52468   Pressure Reducing Support Surfaces - Group 3 - Policy Article [17]
  • L33829   Pneumatic Compression Devices, updated on 10/22/2023 [18]
  • A52488   Pneumatic Compression Devices - Policy Article, updated on 10/22/2023 [19]
  • L33831   Local Coverage Determination for Surgical Dressings, updated on 01/01/2024 [23]
  • A59219   Response to Comments: Pneumatic Compression Devices - DL33829  [20]
  • A54710   Response to Comments: Treatment of Varicose Veins of Lower Extremities [48]   
  • A54713   Response to Comments: Treatment of Varicose Veins of Lower Extremities [49]
  • A54714   Response to Comments: Treatment of Varicose Veins of Lower Extremities [50] 
  • A54715   Response to Comments: Treatment of Varicose Veins of Lower Extremities [51]
  • A54563 Surgical Dressings - Policy Article, updated on 01/01/2024  [24]
  • A58565   Billing and Coding: Wound and Ulcer Care, updated on 01/01/2024  [79]
  • A58567   Billing and Coding: Wound and Ulcer Care, updated on 01/01/2024  [80]
  • A58903   Response to Comments: Wound and Ulcer Care [81]
  • A58904   Response to Comments: Wound and Ulcer Care [82]
  • L38902   Wound and Ulcer Care [83]
  • L38904   Wound and Ulcer Care [84]
  • A57957   Billing and Coding: Routine Foot Care, updated on 01/01/2024 [88]
  • L35163   Plastic Surgery [89]
Novitas Solutions, Inc.
  • L35125   Wound Care [52]
  • A53001 Billing and Coding: Wound Care [53]
  • L35041 Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds  [54]
  • A54117   Billing and Coding: Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds [55]
  • A59517   Response to Comments: Skin Substitute Grafts/Cellular and/or Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers, effective on 08/03/2023.[56]
  • A58808   Billing and Coding: Platelet Rich Plasma [90]
  • L39068   Platelet Rich Plasma [92]
  • L34924   Local Coverage Determination (LCD) Treatment of Chronic Venous Insufficiency of the Lower Extremities [57] 
  • L34938   Removal of Benign Skin Lesions [93]
  • L34887   Surgical Treatment of Nails [94]
Palmetto
  • L34428 Outpatient Physical Therapy [58]
  • L34427 Outpatient Occupational Therapy [59]
  • A53057 Billing and Coding: Home Health Occupational Therapy, updated on 01/01/2024 [60] 
  • A56731  Billing and Coding: Nerve Blocks and Electrostimulation for Peripheral Neuropathy, updated on 01/01/2024 [61] 
  • A53065  Billing and Coding: Outpatient Physical Therapy, updated on 01/01/2024 [62]
  • A53781  Billing and Coding: Spiracur SNaP® Wound Care System, updated on 01/01/2024 [63]
  • A54555 Billing and Coding: Low frequency, non-contact, non-thermal ultrasound (CPT code 97610), updated on 01/01/2024 [64] 
  • A53064   Billing and Coding: Outpatient Occupational Therapy, updated on 01/01/2024 [65]
  • A53773 Low frequency, non-contact, non-thermal ultrasound (CPT code 97610), updated on 01/01/2024 [66]
  • A53058   Billing and Coding: Home Health Physical Therapy, updated on 01/01/2024 [95]
  • L34560   Home Health Occupational Therapy [96]
  • A56392   Response to Comments: Topical Oxygen Therapy [98]
  • L37873   Topical Oxygen Therapy, updated on 05/04/2023 [99]
  • L39121   Local Coverage Determination (LCD): Treatment of Varicose Veins of the Lower Extremities [67]
  • A59001  Response to Comments: Treatment of Varicose Veins of the Lower Extremities [68] 
  • A59281  Response to Comments: Near-Infrared Spectroscopy in Wound and Flap Management [69]
Wisconsin Physicians Service Insurance Corporation (WPS)
  • L37228 Wound Care [70]
  • DL37228 Wound Care [71]
  • A55910   Response to Comments: Wound Care (DL37228) [71]
  • A55909 Billing and Coding: Wound Care [72]
  • L35761   Non-Invasive Peripheral Arterial Vascular Studies, updated on 10/26/2023 [73]   
  • A57593   Billing and Coding: Non-Invasive Peripheral Arterial Vascular Studies, updated on 10/1/2023  [74]
  • A57846   Response to Comments: DL37228 Wound Care [100]
  • A56232   Billing and Coding: Foot Care, updated on 10/01/2023 [75]



Local Coverage Determinations (LCDs) Development and Reconsideration Processes

All stakeholders are encouraged to participate in the LCD Process as well as the LCD Reconsideration Process. Recent regulations have made both processes transparent and open to everyone, including Medicare beneficiaries. For more information, consult the MLN Matters document on the topic MM10901.[76]  
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NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.

REFERENCES

  1. CGS. Local Coverage Determination (LCD): Non-Invasive Vascular Studies (L34045) . 2019;.
  2. CGS. Billing and Coding: Non-Invasive Vascular Studies A56697 . 2019;.
  3. CGS Administrators. Local Coverage Determination (LCD): Outpatient Physical and Occupational Therapy Services (L34049) . 2015;.
  4. CGS Administrators, LLC et al. Local Coverage Article: Billing and Coding: Outpatient Physical and Occupational Therapy Services (A57067) . 2019;.
  5. CGS Administrators, LLC et al. LCD: Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities (L36690) . 2022;.
  6. CGS Administrators, LLC et al. Billing and Coding: Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities (A56696) . 2022;.
  7. CGS Administrators, LLC et al. Response to Comments: Wound Application of Cellular and/or Tissue Based products (CTPs), Lower Extremities (A55276) . 2016;.
  8. CGS Administrators, LLC et al. Local Coverage Determination (LCD): DEBRIDEMENT Services (L34032) . 2022;.
  9. CGS Administrators, LLC et al. Local Coverage Article: Billing and Coding for DEBRIDEMENT Services (A56459) . 2022;.
  10. CGS Administrators, LLC et al. Physical Therapy - Home Health (L33942) . 2015;.
  11. CGS Administrators, LLC et al. Billing and Coding: Physical Therapy - Home Health (A57311) . 2019;.
  12. CGS Administrators, LLC, Noridian Healthcare Solutions, LLC et al. Local Coverage Determination: Pressure Reducing Support Surfaces - Group 1(L33830) . 2015;.
  13. Noridian Healthcare Solutions, LLC, CGS Administrators LLC et al. Local Coverage Article: Pressure Reducing Support Surfaces - Group 1 - Policy Article (A52489) . 2017;.
  14. CGS Administrators, LLC, Noridian Healthcare Solutions, LLC et al. Local Coverage Determination: Pressure Reducing Support Surfaces - Group 2 (L33642) . 2015;.
  15. CGS Administrators, LLC, Noridian Healthcare Solutions, LLC et al. Local Coverage Article: Pressure Reducing Support Surfaces - Group 2 - Policy Article (A52490) . 2015;.
  16. CGS Administrators, LLC, Noridian Healthcare Solutions, LLC et al. Local Coverage Determination: Pressure Reducing Support Surfaces - Group 3 (L33692) . 2015;.
  17. CGS Administrators, LLC, Noridian Healthcare Solutions, LLC et al. Local Coverage Article: Pressure Reducing Support Surfaces - Group 3 - Policy Article (A52468) . 2015;.
  18. CGS Administrators, LLC et al. Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829) . 2015;.
  19. CGS Administrators, LLC and Noridian Healthcare Solutions, LLC et al. Pneumatic Compression Devices - Policy Article (A52488) . 2015;.
  20. CGS Administrators and Noridian. Response to Comments: Pneumatic Compression Devices - DL33829 (A59219) . 2023;.
  21. CGS Administrators, LLC and Noridian Healthcare Solutions, LLC et al. Local Coverage Determination for Negative Pressure Wound Therapy Pumps (L33821) . 2015;.
  22. CGS Administrators, LLC et al. Local Coverage Article: Negative Pressure Wound Therapy Pumps - Policy Article (A52511) . 2015;.
  23. Center for Medicare and Medicaid Services (CMS), et al. Local Coverage Determination for Surgical Dressings (L33831) . 2015;.
  24. Centers for Medicare and Medicaid Services, et al. Local Coverage Article for Surgical Dressings - Policy Article (A54563) . 2015;.
  25. CGS Administrators, LLC et al. Low frequency, non-contact, non-thermal ultrasound (CPT code 97610) (A56175) . 2018;.
  26. Centers for Medicare and Medicaid Services. Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) . 2017;.
  27. First Coast Service Options. Local Coverage Determination (LCD): Wound Care (L37166) . 2017;.
  28. First Coast Service Options, Inc. et al. Billing and Coding: Wound Care (A55818) . 2017;.
  29. First Coast Service Options, Inc. et al. Local Coverage Article: WOUND CARE (L37166): Medicare Part A/B local coverage determination (LCD) comment summary (A55757) . 2017;.
  30. First Coast Service Options, Inc. et al. LCD: Application of Skin Substitute Grafts for Treatment of DFU and VLU of Lower Extremities (L36377) . 2015;.
  31. First Coast Service Options, Inc. et al. Billing and Coding: Application of Skin Substitute Grafts for Treatment of DFU and VLU of Lower Extremities (A57680) . 2018;.
  32. First Coast Service Options, Inc. et al. Duplex Scan Of Lower Extremity Arteries (L33667) . 2015;.
  33. First Coast Service Options, Inc. et al. Non-Invasive Evaluation of Extremity Veins (L33693) . 2015;.
  34. First Coast Service Options, Inc. et al. Local Coverage Determination (LCD): Noninvasive Physiologic Studies of Upper or Lower Extremity Arteries (L33696) . 2015;.
  35. First Coast Service Options, Inc. et al. Local Coverage Determination (LCD) Treatment of Chronic Venous Insufficiency of the Lower Extremities L38720 . 2020;.
  36. National Government Services, Inc. et al. Local Coverage Determination (LCD): Incision and Drainage (I & D) of Abscess of Skin, Subcutaneous and Accessory Structures (L33563) . 2015;.
  37. National Government Services, Inc. et al. Local Coverage Determination (LCD): Debridement Services (L33614) . 2015;.
  38. National Government Services, Inc. et al. Local Coverage Article: Billing and Coding: Debridement Services (A56617) . 2019;.
  39. National Government Services, Inc. et al. Non-Invasive Vascular Studies (L33627) . 2015;.
  40. National Government Services. Local Coverage Determination (LCD): Outpatient Physical and Occupational Therapy Services (L33631) . 2015;.
  41. National Government Services, Inc. et al. Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566) . 2019;.
  42. National Government Services, Inc. et al. Billing and Coding: Routine Foot Care and Debridement of Nails (A57759) . 2019;.
  43. Noridian Healthcare Solutions LLC. Local Coverage Article: Wound Care and Debridement - Provided by a Therapist, Physician, NPP, or as Incident-to Services (A53046) . 2015;.
  44. Noridian. Local Coverage Article: WOUND Care & Debridement – Provided by a Therapist, Physician, NPP or as Incident-to Services (A53296) . 2015;.
  45. Noridian Healthcare Solutions, LLC et al. Local Coverage Article: Billing and Coding: Lymphedema Decongestive Treatment (A52959) . 2015;.
  46. Noridian Healthcare Solutions LLC. Local Coverage Article: Lymphedema Decongestive Treatment (A55710) . 2017;.
  47. Noridian. Local Coverage Article: Coverage of Foot CARE Services (A52918) . 2015;.
  48. Noridian. Response to Comments: Treatment of Varicose Veins of Lower Extremities A54710 . 2016;.
  49. Noridian. Response to Comments: Treatment of Varicose Veins of Lower Extremities A54713 . 2016;.
  50. Noridian. Response to Comments: Treatment of Varicose Veins of Lower Extremities A54714 . 2016;.
  51. Noridian. Response to Comments: Treatment of Varicose Veins of Lower Extremities A54715 . 2016;.
  52. Novitas Solutions. Local Coverage Determination (LCD): Wound Care (L35125) . 2015;.
  53. Novitas Solutions Inc. Local Coverage Article: Billing and Coding: Wound Care (A53001) . 2015;.
  54. Novitas Solutions, Inc. et al. LCD: Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds (L35041) . 2015;.
  55. Novitas Solutions, Inc. et al. Billing and Coding: Billing and Coding: Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds (A54117) . 2015;.
  56. Novitas Solutions, Inc. et al. Response to Comments: Skin Substitute Grafts/Cellular and/or Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers (A59517) . 2023;.
  57. Novitas. Local Coverage Determination (LCD) Treatment of Chronic Venous Insufficiency of the Lower Extremities L34924 . 2015;.
  58. Palmetto GBA. Outpatient Physical Therapy (L34428) . 2015;.
  59. Palmetto GBA. Outpatient Occupational Therapy (L34427) . 2015;.
  60. Palmetto GBA. Billing and Coding: Home Health Occupational Therapy (A53057) . 2015;.
  61. Palmetto GBA. Billing and Coding: Nerve Blocks and Electrostimulation for Peripheral Neuropathy (A56731) . 2019;.
  62. Palmetto GBA. Billing and Coding: Outpatient Physical Therapy (A53065) . 2015;.
  63. Palmetto GBA. Local Coverage Article: Billing and Coding: Spiracur SNaP® WOUND CARE System (A53781) . 2015;.
  64. Palmetto GBA. Local Coverage Article: Low frequency, non-contact, non-thermal ultrasound (CPT code 97610) (A54555) . 2015;.
  65. Palmetto GBA. Billing and Coding: Outpatient Occupational Therapy (A53064) . 2015;.
  66. Palmetto GBA. Local Coverage Article: Low frequency, non-contact, non-thermal ultrasound (CPT code 97610) (A53773) . 2015;.
  67. Palmetto. Local Coverage Determination (LCD): Treatment of Varicose Veins of the Lower Extremities (L39121) . 2022;.
  68. Palmetto. Response to Comments: Treatment of Varicose Veins of the Lower Extremities A59001 . 2022;.
  69. Palmetto GBA. Response to Comments: Near-Infrared Spectroscopy in Wound and Flap Management (A59281) . 2022;.
  70. Wisconsin Physicians Service Insurance Corporation. Local Coverage Determination (LCD): WOUND CARE (L37228) . 2018;.
  71. Wisconsin Physicians Service Insurance Corporation. Local Coverage Article: Response to Comments: WOUND CARE (DL37228) (A55910) . 2018;.
  72. Wisconsin Physicians Service Insurance Corporation. Local Coverage Article: Billing and Coding: Wound Care (A55909) . 2018;.
  73. Wisconsin Physicians Service Insurance Corporation . Non-Invasive Peripheral Arterial Vascular Studies (L35761) . 2019;.
  74. Wisconsin Physicians Service Insurance Corporation. Local Coverage Article: Billing and Coding: Non-Invasive Peripheral Arterial Vascular Studies (A57593) . 2019;.
  75. Wisconsin Physicians Service Insurance Corporation (WPS). Billing and Coding: Foot Care (A56232) . 2019;.
  76. CMS Medicare Learning Network. Local Coverage Determinations (LCDs) - MM10901 MLN Matters. 2019;.
Topic 1428 Version 3.1
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