Top 5 Questions Regarding Outpatient Reimbursement for Wound Care

Do outpatient reimbursement for Wound Care challenges frustrate you a lot? Medicare reimbursement regulations that are currently impacting wound care practices. Wound care professionals still have to follow the coding, payment, and coverage regulations for submitting claims to traditional Medicare.

Issues in Outpatient Reimbursement for Wound Care:

Q. 1: Why it is crucial to know whether the outpatient wound clinic is a hospital-based outpatient wound care department or just a wound clinic?

When patients are examined in a hospital-based outpatient wound care clinic they receive 2 bills i.e. one from HOPD and another from QHP.

Hence; the patients are seen by a QHP in his or her office, the patients and Medicare only receive one bill. Patients should be informed about whether they should expect one or two bills.

Q. 2: There’s always coding confusion and diagnoses typically need to be updated – how to do that?

Codes for products, procedures/services, and diagnoses are typically updated on an annual basis, although some codes for drugs/biologics and coding edits (see below) may be modified on a quarterly basis. Two major coding regulations are impacting the wound care industry and deserve special attention from wound care professionals:

  • Define patients’ clinical status and treat their complex medical conditions
  • Coordinate care among providers, and support new payment methods that drive quality of care

Q. 3: If an LCD is not written about a particular service, procedure, or product, Medicare does not cover it?

No, it doesn’t. If a MAC has not released an LCD, it means the Medicare administrative contractor has not found a reason to control the utilization of the particular service, procedure, or product.

In this case, coverage will be based on medical necessity as proven by the patient’s diagnosis and the documentation in the medical record.

Q. 4: How often should wound care professionals look for updates to LCDs?

Medicare administrative contractors may update LCDs as often as they deem necessary. However; some LCDs were updated 5 or 6 times a year.

Therefore, wound care professionals should assign someone to review LCDs on a monthly basis. When LCDs are revised, all wound care professionals should read them carefully.

Q. 5: Why do all wound care professionals require reading the NCDs and LCDs that pertain to the wound care work they perform?

Wound care professionals must know these coverage rules. If a Medicare patient’s medical condition aligns with the coverage rules, the service/product/procedure has a good chance of Medicare payment.

If not, the wound care professional should explain the coverage situation to the Medicare beneficiary and give the beneficiary the opportunity to receive and personally pay for the necessary care.

That is achieved by the wound care professional providing the Medicare beneficiary with an Advance Beneficiary Notice of Non-coverage and by the beneficiary signing the notice and agreeing to pay for the care.

If you wish to learn more about these and other reimbursement topics, you and your revenue cycle team may connect with Medical Billers and Coders Experts – the only professional medical billing and coding service provider that you can trust.

To know more about our wound care medical billing and coding services, contact us at