Cath Lab Digest

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  More times than we’d like to acknowledge, we have encountered new patients in our practice who either are covering their open wounds with paper towels, mini-pads or tissue because they simply couldn’t afford even gauze and tape for coverage, or even more disconcerting, have gone from using the most basic gauze dressings to more advanced dressings and expressed concern at the costs they have incurred over time simply because they had not been informed that either their insurance or their Medicare Part B plan would have provided coverage.

  The uninsured patient is a challenge that does require some creativity, and is not the focus of this article. The patient who may have been receiving care from their primary provider who sent the patient off to the pharmacy with a prescription for an over the counter antibiotic ointment, gauze and tape can be forgiven; but a patient who has been discharged from a long term care facility, a home health agency or previously cared for in another wound clinic? Well, shame on us.

  The Surgical Dressing Policy is alive and well. And though it is Medicare Part B coverage we are referring to, many, or actually most insurance carriers have coverage for the dressings in a similar fashion. But beware: if you call an insurance company customer service line you will likely be referred to their Durable Medical Equipment (DME) provider, then when calling the DME provider, you will likely be informed that they don’t provide dressings. If we stop there, the patients will not get their dressings. Oddly enough, we have found that it is the Part B Providers themselves who have the best information as to which plans they provide coverage for, and if they aren’t the provider, they know who is. So again, it’s that time consuming social work part of the care that we provide rearing its ugly head, but the end result is the patient getting the supplies they need to carry out the plan of care that we are setting up.

  The aim of our article is not to attempt to explain every nitty gritty detail of the coverage policy. That is definitely Kathleen Schaum’s domain. (To self-examine your knowledge of the policy, see Kathleen’s article, "Can You Pass the Surgical Dressing Ordering and Documentation Test?" Advances in Skin & Wound Care: March 2011;Volume 24,Issue 3, pp 112—117). Our goal rather is to resurrect awareness of the policy and discuss using it day-to-day for the better of our patients.

  In April of 1994, the Durable Medical Equipment Regional Carriers, contractors for the Healthcare Financing Administration (HCFA, now CMS, the Center for Medicare and Medicaid Services), made a landmark policy change that enabled access for Medicare Part B recipients to obtain advanced wound care products under the Surgical Dressing Policy. This change was the culmination of a tremendous amount of collaborative effort on the part of the Health Industry Manufacturers Association (HIMA), led by Marcia Nusgart, the International Association of Enterostomal Therapy (IAET, now WOCN), led by Glenda Motta, the National Pressure Ulcer Advisory Panel (NPUAP), led by Diane Krasner and countless other interested parties. Through many workgroups and meetings, the result was a policy which was fair and actually generous and resulted in a huge benefit for wound care patients in the US covered by Medicare Part B.

  There have been changes over the years, but the policy is still intact, and since there continues to be new products coming to the market, there is a mechanism in place to apply for coding and coverage. It may sound easy, but there is definitely hard work involved. Marcia Nusgart, MPh, is still a guiding force in these efforts, as Executive Director of the Coalition of Wound Care Manufacturers, as well as the Alliance of Wound Care Stakeholders. “The policy change in 1994 was certainly landmark and enabled clinicians to obtain quality dressings for their patients. There continues to be ongoing efforts made by our group to stay abreast of potential changes related to policy updates, policy language and product category additions to allow our members to respond in a timely manner”. (Click on Feature 2 The Surgical Dressing PDF in this article for Table 1 and a Alliance of Wound Care Insert).

  Surgical dressings are covered when they are medically necessary for the treatment of a wound caused by or treated by a surgical procedure or when debridement of a wound is medically necessary. The surgical procedure or debridement must be performed by a physician or other healthcare professional to the extent permissible under State law. Debridement of a wound may be any type of debridement (examples given are not all-inclusive): surgical (eg, sharp instrument or laser), mechanical (eg, irrigation or wet-to-dry dressings), chemical (eg, topical application of enzymes), or autolytic (eg, application of occlusive dressings to an open wound). Dressings used for mechanical debridement, as secondary dressings over chemical debriding agents, or to create a wound environment to allow for autolytic debridement are covered although the agents themselves are non-covered. Dressings over a percutaneous catheter or tube (eg, intravascular, epidural, nephrostomy, etc) are covered as long as the catheter or tube remains in place and after removal until the wound is closed.