Wound Care Reimbursement

The Centers for Medicare & Medicaid Services (CMS) has developed a medical coverage policy for Support Surfaces, which defines the information required to determine medical necessity and product reimbursement eligibility. Medicare requires all of the information below before a coverage determination can be made.

If you have any further questions or comments about the reimbursement of KCI products, please email us at Reimbursement@KCI1.com.

Medicare Coverage Criteria Summary*

Medicare requires a complete physician’s order/prescription that must include:

The patient’s full name and address
Description of the product, with the start date and length of need (in months)
Physician’s signature and date (no date stamps allowed)

Additionally, Medicare requires the treating physician to certify that the patient meets the coverage criteria listed below:

Multiple stage II pressure ulcers located on the trunk or pelvis, and
The patient has been on a comprehensive ulcer treatment program for at least the past month, which has included the use of an appropriate Group I support surface, and
The ulcers have worsened or remained the same over the past month, or
Large or multiple stage III or IV pressure ulcer(s) are located on the trunk or pelvis, or
Recent myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis (surgery within the past 60 days), and
The patient has been on a Group II or III support surface immediately prior to a recent discharge from a hospital or nursing facility (discharge within the past 30 days)

Medicare patients should also be on a care plan established by the physician or home care nurse. A comprehensive ulcer treatment plan is explained in the Medicare Jurisdiction A Coverage Policy

Ongoing Coverage Criteria

Medicare coverage is limited to 60 days or, if healing does not continue, the medical record documents that:

Other aspects of the care plan are being modified to promote healing, or
The use of the surface is medically necessary for wound management

*This summary is not intended to be all-inclusive and should not be relied on for final coverage determinations. Specific DMERC, Medicaid or Health Plan coverage policies should be reviewed prior to making any coverage determinations. Additional criteria may be required for coverage of eligible patients depending on individual circumstances. The information contained in this website is provided for informational purposes only and represents no statement, promise or guarantee by KCI concerning the levels of reimbursement, payment, calculations, eligibility, charge or that these policies and codes will be appropriate for specific services or products provided or that reimbursement will be made. Information is current as of the date of publication and is subject to change at anytime. KCI recommends that you consult your local CMS contracted carrier, Medicaid carrier or other applicable payor organization with regard to specific reimbursement policies, coverage, documentation, payment and criteria. Individual circumstances and situations may vary.