Rule 5160-10-34 | DMEPOS: wound dressings and related supplies.
(A) Coverage.
(1) No particular form or format is specified for the certification of medical necessity.
(2) Payment may be made for wound dressings and related supplies as long as medical necessity exists.
(3) Payment may be made for dressings placed over a percutaneous catheter or tube as long as the catheter or tube remains in place and after removal until the insertion point heals.
(4) Clinical indications, contraindications, and application guidelines for certain types of wound dressing are summarized in the appendix to this rule.
(B) Documentation.
(1) A prescription for a wound dressing or related supply is necessarily based on an evaluation of the wound performed by a qualified healthcare provider. Frequent evaluation is expected if a wound is heavily draining or infected. Each evaluation report, which will be made available to the department on request, includes the wound type; wound location; wound length, width, and depth; the amount of drainage; and any other relevant clinical information.
(2) The provider keeps the prescription for dressings or related supplies on file. The prescription includes the following clinical information, which can be no older than one year:
(a) The type and number of wounds;
(b) The type, size, and quantity of each dressing;
(c) The purpose of each dressing (e.g., primary or secondary covering for a surgical or debrided wound, wound cleansing);
(d) The quantity to be applied at one time (if more than one unit);
(e) The frequency of dressing change; and
(f) The expected duration of need.
(3) A prescription is valid for not longer than three months. A new prescription is needed for the addition of a dressing or for an increase in the quantity of a dressing already prescribed. (No new prescription is needed for a decrease in quantity.)
(C) Constraints and limitations.
(1) Providers should not dispense dressings that will be used together but have conflicting characteristics (e.g., a hydrating dressing with an absorptive dressing, a primary dressing that must be changed daily with a secondary dressing that needs to be changed less frequently).
(2) The use of more than one type of wound filler or more than one type of wound cover on a single wound is rarely medically necessary. (An additional, dry wound cover is not incompatible, however, with an alginate or other fiber-gelling dressing or saline-, water-, or hydrogel-impregnated gauze.)
(3) Providers should gauge the quantity of dressings actually being used by an individual and adjust the dispensing of dressings accordingly. Not more than one month's supply of dressings may be dispensed at one time.
(4) No payment is made for gauze impregnated with water or normal saline, because there is no medical necessity for it. Standard gauze may instead be moistened with bulk saline or sterile water.
Last updated January 2, 2024 at 9:00 AM
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