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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".
  4. See details on requirements, medical necessity and documentation on specific Medicare National and Local Coverage Determinations

Medicare Administrative Contractor (MAC)  
Local Coverage Determination (LCD)
CGS Administrators, LLC (CGS)

CGS NCDs

  • L34049 Outpatient Physical and Occupational Therapy Services [1]
  • L36690 Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities [2]
  • L34032 Debridement Services [3]
  • L33942 Physical Therapy - Home Health [4]
  • L33642 Pressure Reducing Support Surfaces - Group 2 [5]
  • L33829 Pneumatic Compression Devices [6]
  • L33821 Negative Pressure Wound Therapy Pumps [7]
CGS Articles
  • A57067 Billing and Coding: Outpatient Physical and Occupational Therapy Services [8]
  • A57311 Billing and Coding: Physical Therapy - Home Health [9]
  • A52400 Outpatient Physical and Occupational Therapy Services Supplemental Instructions Article[10]
  • A56175 Low frequency, non-contact, non-thermal ultrasound (CPT code 97610) [11]
  • A54563 Surgical Dressings - Policy Article [12]
  • A52489 Pressure Reducing Support Surfaces - Group 1 - Policy Article [13]
  • A52511 Negative Pressure Wound Therapy Pumps - Policy Article [14]
First Coast Service Options, Inc. (FCSO)

FCSO LCDs

  • L33413 Therapy and Rehabilitation Services [15]
  • L37166 Wound Care [16]
  • L36377 Application of Skin Substitute Grafts for Treatment of DFU and VLU of Lower Extremities [17]

FCSO Articles

  • A55375 Application of skin substitute grafts for treatment of DFU and VLU of lower extremities overpayments resulting from claims processing issue[18]
  • A55757 Wound care (L37166): Medicare Part A/B local coverage determination (LCD) comment summary [16]
  • A55837 Wound care revision to the Part A and Part B LCD [19]
  • A55767 Wound care – New Part A and Part B LCD [20]
  • A56350 Revisions to multiple Part A and Part B LCDs [21]
  • A55818 Wound Care Coding Guidelines [22]
National Government Services, Inc. (NGS)

NGS LCDs

  • L33614 Debridement Services [23]
  • L33631 Outpatient Physical and Occupational Therapy Services [24]

NGS Articles

  • A56617 Billing and Coding: Debridement Services [25]
Noridian

Noridian LCDs 

  • L33642 Pressure Reducing Support Surfaces - Group 2 [5]
  • L33829 Pneumatic Compression Devices [6]
  • L33821 Negative Pressure Wound Therapy Pumps [7]

Noridian Articles

  • A53046 Wound Care and Debridement - Provided by a Therapist, Physician, NPP, or as Incident-to Services  [26]
  • A53296 Wound Care & Debridement – Provided by a Therapist, Physician, NPP or as Incident-to Services [27]
  • A52489 Pressure Reducing Support Surfaces - Group 1 - Policy Article [13]
  • A52511 Negative Pressure Wound Therapy Pumps - Policy Article [14]
  • A54563 Surgical Dressings - Policy Article [12]
Novitas Solutions, Inc.

Novitas LCDs

  • L35041 Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds [28]
  • L35036 Therapy and Rehabilitation Services (PT, OT) [29]
  • L35125 Wound Care [30]

Novitas Articles

  • A55578 Response to Comments: DL35125, Wound Care [30]
  • A53001 Billing and Coding: Wound Care [31].
Palmetto

Palmetto LCDs

  • L34428 Outpatient Physical Therapy [32]
  • L34427 Outpatient Occupational Therapy [33]

Palmetto Articles

  • A53781 Billing and Coding: Spiracur SNaP® Wound Care System [34]
  • A54555 Billing and Coding: Low frequency, non-contact, non-thermal ultrasound (CPT code 97610) [35] A53064 Billing and Coding: Outpatient Occupational Therapy [36]
  • A53057 Billing and Coding: Home Health Occupational Therapy [37] A56731 Billing and Coding: Nerve Blocks and Electrostimulation for Peripheral Neuropathy [38] A53065 Billing and Coding: Outpatient Physical Therapy [39]
  • A53773 Low frequency, non-contact, non-thermal ultrasound (CPT code 97610) [40]
Wisconsin Physicians Service Insurance Corporation (WPS)

WPS LCDs

  • L37228 Wound Care [41]
  • DL37228 Wound Care [42]

WPS Articles

  • A55910 Response to Comments: Wound Care (DL37228) [42]
  • A55909 Billing and Coding: Wound Care [43]


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.[44] 
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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 Administrators. Local Coverage Determination (LCD): Outpatient Physical and Occupational Therapy Services (L34049) . 2015;.
  2. Administrators, CGS et al. Local Coverage Determination (LCD) - Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities (L36690) . 2016;.
  3. CGS Administrators, LLC et al. Local Coverage Determination (LCD): DEBRIDEMENT Services (L34032) . 2015;.
  4. CGS Administrators, LLC et al. Local Coverage Determination (LCD): Physical Therapy - Home Health (L33942) . 2015;.
  5. CGS Administrators, LLC, Noridian Healthcare Solutions, LLC et al. Local Coverage Determination: Pressure Reducing Support Surfaces - Group 2 (L33642) . 2015;.
  6. CGS Administrators, LLC et al. Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829) . 2015;.
  7. Centers for Medicare and Medicaid Services . Local Coverage Determination for Negative Pressure Wound Therapy Pumps (L33821) . 2017;.
  8. CGS Administrators, LLC et al. Local Coverage Article: Billing and Coding: Outpatient Physical and Occupational Therapy Services (A57067) . 2019;.
  9. CGS Administrators, LLC et al. Local Coverage Article: Billing and Coding: Physical Therapy - Home Health (A57311) . 2019;.
  10. CGS Administrators, LLC et al. Local Coverage Article: Outpatient Physical and Occupational Therapy Services Supplemental Instructions Article (A52400) . 2015;.
  11. CGS Administrators, LLC et al. Local Coverage Article: Low frequency, non-contact, non-thermal ultrasound (CPT code 97610) (A56175) . 2018;.
  12. Centers for Medicare and Medicaid Services, et al. Local Coverage Article for Surgical Dressings - Policy Article (A54563) . 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 et al. Local Coverage Article: Negative Pressure Wound Therapy Pumps - Policy Article (A52511) . 2015;.
  15. First Coast Service Options. Local Coverage Determination (LCD): Therapy and Rehabilitation Services (L33413) . 2015;.
  16. 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;.
  17. First Coast Service Options, Inc. et al. Local Coverage Determination (LCD): Application of SKIN SUBSTITUTE Grafts for Treatment of DFU and VLU of Lower Extremities (L36377) . 2015;.
  18. First Coast Service Options, Inc. et al. Local Coverage Article: Application of skin substitute grafts for treatment of DFU and VLU of lower extremities overpayments resulting from claims processing issue (A55375) . 2016;.
  19. First Coast Service Options, Inc. et al. Local Coverage Article: Wound Care revision to the Part A and Part B LCD (A55837) . 2017;.
  20. First Coast Service Options, Inc. et al. Local Coverage Article: Wound Care – New Part A and Part B LCD (A55767) . 2017;.
  21. First Coast Service Inc. Local Coverage Article: Revisions to multiple Part A and Part B LCDs (A56350) . 2019;.
  22. First Coast Service Options, Inc. et al. Local Coverage Article: WOUND Care Coding Guidelines (A55818) . 2017;.
  23. National Government Services, Inc. et al. Local Coverage Determination (LCD): Debridement Services (L33614) . 2015;.
  24. National Government Services. Local Coverage Determination (LCD): Outpatient Physical and Occupational Therapy Services (L33631) . 2015;.
  25. National Government Services, Inc. et al. Local Coverage Article: Billing and Coding: Debridement Services (A56617) . 2019;.
  26. Noridian Healthcare Solutions LLC. Local Coverage Article: Wound Care and Debridement - Provided by a Therapist, Physician, NPP, or as Incident-to Services (A53046) . 2015;.
  27. Noridian. Local Coverage Article: WOUND Care & Debridement – Provided by a Therapist, Physician, NPP or as Incident-to Services (A53296) . 2015;.
  28. Novitas Solutions, Inc. et al. Local Coverage Determination (LCD) Application of Bioengineered SKIN SUBSTITUTEs to Lower Extremity Chronic Non-Healing Wounds (L35041) . 2015;.
  29. Novitas Solutions. Local Coverage Determination (LCD): Therapy and Rehabilitation Services (PT, OT) (L35036) . 2015;.
  30. Novitas Solutions, Inc. et al. Local Coverage Article: Response to Comments: DL35125, WOUND CARE (A55578) . 2017;.
  31. Novitas Solutions Inc. Local Coverage Article: Billing and Coding: Wound Care (A53001) . 2015;.
  32. Palmetto GBA. Local Coverage Determination (LCD): Outpatient Physical Therapy (L34428) . 2015;.
  33. Palmetto GBA. Local Coverage Determination (LCD): Outpatient Occupational Therapy (L34427) . 2015;.
  34. Palmetto GBA. Local Coverage Article: Billing and Coding: Spiracur SNaP® WOUND CARE System (A53781) . 2015;.
  35. Palmetto GBA. Local Coverage Article: Low frequency, non-contact, non-thermal ultrasound (CPT code 97610) (A54555) . 2015;.
  36. Palmetto GBA. Local Coverage Article: Billing and Coding: Outpatient Occupational Therapy (A53064) . 2015;.
  37. Palmetto GBA. Local Coverage Article: Billing and Coding: Home Health Occupational Therapy (A53057) . 2015;.
  38. Palmetto GBA. Local Coverage Article: Billing and Coding: Nerve Blocks and Electrostimulation for Peripheral Neuropathy (A56731) . 2019;.
  39. Palmetto GBA. Local Coverage Article: Billing and Coding: Outpatient Physical Therapy (A53065) . 2015;.
  40. Palmetto GBA. Local Coverage Article: Low frequency, non-contact, non-thermal ultrasound (CPT code 97610) (A53773) . 2015;.
  41. Wisconsin Physicians Service Insurance Corporation. Local Coverage Determination (LCD): WOUND CARE (L37228) . 2018;.
  42. Wisconsin Physicians Service Insurance Corporation. Local Coverage Article: Response to Comments: WOUND CARE (DL37228) (A55910) . 2018;.
  43. Wisconsin Physicians Service Insurance Corporation. Local Coverage Article: Wound Care Coding Companion for Wound Care L37228 (A55909) . 2018;.
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