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Feature Article

Dressed for Success: What Clinicians Need to Know about Ordering Wound Dressings

  Over the years we have seen many sad illustrations of what happens when patients don’t have proper wound dressings. We have all seen patients arrive with dressings made from paper towels, cleaning rags, saran wrap or underwear. Sadly, in some cases, the problem was not that patients lacked insurance coverage for dressing supplies, but that no caregiver had told them of this benefit. Patients followed for months by clinicians who ought to have known better (eg, excellent surgeons) are stunned and then angry when they discover that they have needlessly paid large sums of money “out of pocket” for dressings. Patients can lose faith in the clinical skills of a practitioner who is uninformed about issues like dressing coverage policy! So, the first thing clinicians need to know is that most patients who have medical insurance have some sort of DME coverage for dressings.   It is true that some patients with private insurance may have a deductible so high that they will be effectively paying for dressings “out of pocket.” Among the tricks of the trade for these patients is a visit to the local “feed store” where many familiar wound care products can be purchased at a lower price (since they are intended for use in animals). Most of us also know that for highly exudative wounds, few products work better than newborn baby diapers. We may also provide patients with the “recipes” for saline, acetic acid and “dakins” (diluted bleach). The topic of “low cost” and “semi-homemade” dressings is worthy of a separate article and might be an excellent item for discussion on the TWC website. Meanwhile, the purpose of this article is to discuss the “dirty secrets” of how things work with the surgical dressing coverage policy from a clinicians’ point of view. So, let’s assume that you have seen a patient, documented their wound, agreed with them that they will do their own dressing changes and not a home nursing agency (otherwise the home nursing agency would be required to provide the supplies), and now you are going to order dressings to be “drop shipped” to their home by a DME. You think that you have everything properly sorted out and when you see the patient next week, one of two things has happened: 1) the patient says they never got any supplies (and of course you don’t know why) or 2) the supplies they received were different from what you ordered (and of course you don’t know why).   Why Use a DME for Dressing Supplies?   Why do we have to use a medical device company to get products for our patients? Why can’t we just GIVE patients dressings? Medicare has very specific rules about “inducements to treat.” Clinicians cannot provide, free of charge, products or services, which are normally paid for by Medicare. In other words, if dressings are covered, giving patients dressings could be considered an “inducement” to get the patient to continue to come see you. If that is the case, why can’t we just charge for them in the clinic? We certainly can charge for the dressings we apply at the time the patient is seen. However, if we were to hand the patient several extra dressings and then charge them to their visit, hospital based outpatient clinics (or private practitioners) would be in the business of “selling” medical supplies. For this you need a license to sell supplies. Almost no hospitals have a durable medical equipment (DME) license, so we need to work with a DME. This can create awkward issues with patients who are frustrated as to why we can’t just “hand them a few extra of those pads.” Patients ask us that so often we give everyone a “patient information” sheet just about dressings.   There are some other areas of the Medicare surgical dressing policy about which we try to alert patients. The dressing ordered has to be used to treat the wound itself, so saline, moisturizers, and skin protectants are not covered. This also means a patient cannot continue to get dressings after a wound has healed in order to keep it from coming back. Patients also need to understand that if they have home nursing, the home nursing agency is required by law to provide the dressing supplies.   Wound Care Documentation and Supplies   So let’s rewind back to that patient visit. There are 3 key areas of documentation which affect dressing supplies: 1) drainage amount, 2) depth of wound and 3) wound number and size. Let’s use as an example, a diabetic foot ulcer which you documented as having minimal exudate, and then ordered (for the sake of this example), AQUACEL® Ag. Although a hydrofiber, AQUACEL® Ag is classified as an alginate. As far as the surgical dressing policy is concerned, an “alginate” (and thus AQUACEL® Ag) is only covered for wounds with moderate and high drainage. So, your documentation will not justify the provision of AQUACEL® Ag under the Medicare surgical dressing policy.   Furthermore, you suggested that the AQUACEL® Ag be covered with a foam dressing. You know that the additional padding might be a good idea due to the location of the wound, but you documented the wound as a partial thickness ulcer. That makes the foam a “secondary dressing,” which is not covered for a partial thickness ulcer. It also made sense to you that the patient might change it daily since he has to shower every day. But, even if the ulcer WAS full thickness, the surgical dressing policy limits the patient to 15 foam pads per month (every other day changes), so he will not have enough supplies to last a month if he uses one daily. In other words, you may have made a plan that was reasonable to YOU, but the DME cannot carry out those orders based on your documentation. So, this might be the reason that no supplies were delivered.   There are many potential problems of this nature. For example you cannot order a hydrocolloid if you have documented that a wound has a high amount of exudate. Unless you have practically memorized the surgical dressing policy, you are likely to make “mistakes” like this on at least one or two patients a day. In some cases, the policy requirements can be satisfied simply by re-classifying the drainage description. In truth, studies have shown that quantifying drainage may be the least reliable assessment we make, so in many cases, this “re-classification” of drainage is often not unreasonable and may lead to a more accurate assessment of the situation. In other words, you may have instinctively selected the best product for the wound but not done a very accurate job of describing the wound itself. (What you NEVER want to do is to falsify records for ANY reason!) But how can anyone keep all these arcane dressing rules straight? If you are like me and provide a lot of DME supplies to patients, you spend a lot of time “initialing and dating” various small changes to forms involving things like drainage amount, or correcting the frequency of dressing change orders so that supplies will last the proper length of time. The DME company has a viewpoint in all this, and it may help the clinician to understand what that is.   DME Secrets   Remember that the DME company is a business. It has to package and ship supplies, pay for staff members to process all the necessary paperwork, and bill insurance. There has to be some profit margin to make these functions possible. Each of the dressing categories within the surgical dressing policy has a “reimbursement rate.” Therefore, the “profit margin” for the DME is the difference between the cost of the ACTUAL product (plus the DME’s overhead), and the reimbursement rate for that particular product. When a particular product is expensive within its “category” the profit margin for the DME diminishes, making it impossible for it to realistically supply that product.   Now let’s return to our patient with the diabetic foot ulcer. Let’s assume that this patient DID have a highly exudative, full thickness ulcer. You recommend AQUACEL® Ag covered by a foam dressing (you prefer one with an adhesive border to avoid tape) to be changed every other day. You know that you have gotten the documentation, dressing category, dressing change frequency, primary and secondary dressings all properly aligned and you are rightly proud of yourself. You order these products from the DME, and next week the patient returns to clinic with completely different products. WHAT HAPPENED?   Now it is time for you to learn what I call “DME facts of life.”   AQUACEL® Ag is a unique product, having the ability to balance moisture and control bacteria. In many ways it is uniquely different from the other products in its category, but as far as the Medicare surgical dressing policy is concerned, it is simply “another alginate.” Yet, because of its unique hydrofiber composition, nano-silver technology and the cost of production, the manufacturer has priced the pads at an amount higher than “other” alginates. That means that it costs more than Medicare reimburses for products in its category. The manufacturer will justify this on the basis of the fact that the dressing can stay in place for as long as a week, substantially reducing the overall cost of care. And indeed, if the patient is hospitalized, or is paying “out of pocket” this is a huge argument for the use of this product. However, the DME company cannot supply the product for less than the amount of money it costs them to purchase it. Therefore, because of this cost vs. reimbursement issue, the DME will likely wish to substitute some silver alginate for AQUACEL® Ag in the order you have sent them. When the shipment arrives to the patient with the substitution, you will wonder why it happened, in part because you may not realize that this “hydrofiber” ended up in the “alginate” category per Medicare policy, and in part because you were not aware of the cost differential.   Whenever there are substantial price differences within categories, DME companies may look to other dressings within the same class in order to maintain a reasonable profit margin. But some DMEs may be willing to commit to offering products like AQUACEL® without substitution, which means you may want to comparison shop regarding the DME Companies you use for your patients and here is the catch that you might not know. AQUACEL® Ag rope is packaged in 18 inch segments and reimbursed on a per 6 inch segment basis. Therefore, it IS possible to maintain a profit margin on this product if the ROPE is used, by cutting off the appropriate amount and placing it over the wound bed. So, it is possible for the DME to provide this product if you are willing to order the ROPE rather than the pads, even for superficial wounds, assuming that the rest of the documentation supported its use.   You also wanted to cover that dressing with a self-adhesive foam border. This seemed like a great idea because that keeps the patient from having to use tape. Foams come in 3 categories according to Medicare: 48 inches square. If they are non-bordered, all three-size categories are paid for. If they have a border, the 16-48 square inch category (the most common) is NOT covered by Medicare. Why? I have no idea! Even though you did not know these rules, the DME does, so it will substitute for a foam dressing without adhesive border if the 16- 48 square inch pad is ordered. They will also include tape in the order to provide a way to secure the dressing. However, that comfortable fabric tape you and your patients have come to love on account of its decreased likelihood of tearing the skin is probably not what will be sent to the patient. The DME will make a choice regarding tape based on profitability issues. In clinic we may feel it is clinically indicated to apply a dressing, which is larger than the actual wound because the periwound skin needs protection. However, don’t try this with your DME orders! Because the Medicare surgical dressing policy stipulates that the size of the dressing be matched to the size of the wound, the DME Company will substitute a smaller dressing and provide the “Medicare allowable amounts” for the month. So, forget about the idea of providing the patient with a larger than needed dressing and telling them to “cut it into pieces to make it last over several dressing changes.”   What do you mean some products are not reimbursed AT ALL?   Many facilities have dressings available in the clinic, which are not reimbursed at all by Medicare. How could that be? These products are typically introduced into the facility/hospital system when the manufacturer sells the product to the physician and/or the Purchasing department. The rationale for these products may be excellent in that they may reduce total cost of care and be highly efficient for other reasons. Two of my favorite products are Iososorb Gel and Multidex powder. I like Iodosorb gel in the tube because it is very useful for wounds in need of an antimicrobial dressing but which require some packing. The Multidex powder is very helpful for malodorous wounds. Both of these products have the benefit of multiple uses per tube and can be combined with relatively inexpensive dressings to make “the perfect size dressing for any wound.” Unfortunately, neither of these fantastic products is reimbursable on the outpatient side under the surgical dressing policy.  Other examples of products not covered under the surgical dressing policy are “Wound Veil” and Acticoat. Wound Veil is classified as a “contact layer” which is only reimbursed for sheets, which are 16 to 48 inches square. Acticoat falls into multiple classifications with limited coverage dependent on the type. This brings up an important issue for hospital based outpatient wound centers. When the product sales representatives are detailing these products, make sure they tell you into which dressing category the product has been placed, and the Medicare reimbursement rate for each product size. If you are going to bring into your clinic a product (or size), which is NOT reimbursed, you need to be clear about the rationale for its use, and understand that this product will not be available on through a DME.   We are grateful that Medicare covers surgical dressings for our patients, and we do understand that there have to be rules covering the use of products to prevent abuse. Some of these rules have also been put in place in hopes of preventing misuse by uninformed clinicians. However, at times the details of coverage policy can seem nonsensical (why are some product sizes covered but not others?). And now that you understand the wide variations in “profit margin” depending upon the dressing category in which a product is placed, you realize that what product a patient actually receives is subject to even more complex decision making on the part of the DME.   What is the best way to handle this? One way to keep from having to remember all these rules is to limit yourself to just a few products whose coverage policy you know really well, but somehow that does not seem the very best solution. Another is to just “leave it up to the DME” and hope for the best. However, it is very frustrating not to know whether the order for the supplies has been processed and whether, when or what products will arrive.   It seems that almost every day, patients return to clinic for follow up and say, “I never got my supplies.” There are so many potential “points of failure.” The clinicians had to document the wound properly, the nurse had to fax orders, a DME employee had to create an order form, the order form had to be faxed to your clinic, the nurse may have had to fill out more details (dressing amount, ICD-9 diagnosis), the doctor has to sign it and append some of his/her Medicare provider information, and then supplies had to be shipped to the patient. HOPEFULLY someone checked that the home address was correct. However, all the information that the DME needs is already contained in the clinical chart, from the home address and third party billing information to the clinical details. Since many clinics use electronic health records (EHRs) to manage this data, it is possible to harness this information to automate the order processing. Rather than simply creating “automated faxes,” the DME can actually use the EHR to create and process the dressing orders themselves. Furthermore, the DME can notify the EHR when the products are shipped. So, it is possible for the clinical staff to directly order DME supplies “through” the EHR, without having to fill out additional paperwork, and to subsequently know exactly WHAT supplies got ordered, and when those supplies ought to have been received by the patient. Standard hospital EHRs will not be able to perform functions like this, but wound care specific EHRs can do this.   Furthermore, as these programs evolve, the arcane rules governing what supplies can be provided for a specific type of documentation can be automated as well, so that no one has to “remember” these complex rules. Whether you will have access to more advanced and efficient methods of DME ordering will be determined by which EHR you use, and whether the DME company you are working with is prepared to accept electronic orders.   Dr. Fife received her BS and MD degrees from Texas A&M University College of Medicine (AOA). After a residency in Family Medicine at the University of Texas, Southwestern in Dallas she completed a two-year Fellowship in Undersea and Hyperbaric Medicine at Duke University and then joined the faculty of the University of Texas Health Science Center, Houston where she is a Professor of Medicine in the Division of Cardiology. She is subspecialty Board Certified in Undersea and Hyperbaric Medicine through the American Board of Preventive Medicine and has been a Certified Wound Specialist since 1998, previously serving on the Boards of the American Academy of Wound Management and the Association for the Advancement of Wound Care. She initiated the Memorial Hermann Center for Wound Healing in 1990, affiliated with the University of Texas, Houston, and the Memorial Hermann Center for Lymphedema Therapy in 1998. She is a past President of the Undersea and Hyperbaric Medical Society. Dr. Fife is co-editor of the books Wound Care Practice, and, Women and Pressure: Diving and Flying, both published by Best Publishing. Dr. Fife is also the Chief Medical Officer of “Intellicure,” a Texas based software company which, since 2000 has provided a specialty specific electronic medical record system to wound and hyperbaric centers across the U.S. She is the Director of Clinical Research for the U.S. Wound Registry; responsible for performing the largest outcome studies in the wound care industry.   Vonda Wall, MBA, Director of Business Services, Intellicure, Inc. Vonda Wall received her undergraduate degree from the University of Houston in Accounting with a MBA from the University of Houston, Clear Lake. This education is coupled with 21 years of administrative experience in the operations of wound care and hyperbaric centers. She worked extensively with Dr. Fife has they developed the centers at Memorial Hermann – Texas Medical Center and satellites throughout the Memorial Hermann Healthcare System. With a focus on the profitability of the facility and the physicians, Vonda monitored reimbursement and when necessary appealed claims to Medicare and the other insurance providers resulting in the reversal of the denials and payments to the facility and physicians. Vonda joined the Intellicure team to bring real life experience to the clients, as well as, to develop other related services lines like the addition of DME providers to the Intellicure software offerings and a Physician Billing division.
Feature Article
Caroline Fife, MD, FAAFP, CWS; Vonda Wall, MBA
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