Wound Care Under the Medicare Home Health Benefit

Wound care treatment typically involves three skilled nursing interventions, which may be performed at the same time or separately from each other.

The three services are:

Performing the actual wound care, which must be of a complexity to require the skills of a licensed nurse. In Section 40.1.2.8 of the Medicare Benefit Policy Manual, Chapter 7, CMS states wounds with the following characteristics usually reasonable and necessary.

Open wounds draining purulent or colored exudate, or have a foul odor present, or for which patient is receiving antibiotic therapy;
Wounds with a drain or T-tube that require shortening or movement;
Wounds requiring irrigation or installation of sterile cleansing or medicated solution into several layers of tissue and/or packing with sterile gauze;
Recently debrided ulcers;
Pressure sores (decubitus ulcers) that present one of the following characteristics:
- Partial tissue loss with signs of infection such as foul odor or purulent drainage; or
- Full thickness tissue loss that involves exposure of fat or invasion of other tissues such as muscle or bone.
  Note: Wounds or ulcers that show redness, edema, and induration, at times with epidermal blistering or desquamation do not ordinarily require skilled nursing care.
Wounds with exposed internal vessels or a mass that may have a tendency for hemorrhage when a dressing is changed (e.g., post radical neck surgery, cancer of the vulva);
Open wounds or widespread skin complications following radiation therapy, or which result from immune deficiencies or vascular insufficiencies;
Post-operative wounds where there are complications such as infection or allergic reaction or an underlying disease that has a reasonable potential to adversely affect healing (e.g., diabetes);
Third degree, and second degree burns where the size of the burn or presence of complications causes skilled nursing care to be needed;
Skin conditions that require application of nitrogen mustard or other chemotherapeutic medication that present a significant risk to the patient;
Other open or complex wounds that require treatment that can only be provided safely and effectively by a licensed nurse.

Assessing the wound when medically necessary. Factors that help to support medical necessity for skilled assessment include:

Wounds that are significant enough to have an active risk of complications.
Chronic wounds that continue to be actively treated by the patient’s primary care provider or a wound care clinic with recent changes to the wound care treatment plan that require assessment of the effectiveness of the new wound care protocols.
Wounds that have recent documented changes in the size, drainage and high risk for complications
Other active functional limitations/co-morbidities that may increase the risk of wound complications

Teaching the patient and/or caregiver how to perform the wound care and what changes to the wound would prompt a call to the physician.

Skilled wound care must meet the requirements for intermittent skilled nursing care. CMS defines intermittent skilled nursing care within Section 40.1.3 of the Medicare Benefit Policy Manual, Chapter 7, as “skilled nursing care that is either provided or needed on fewer than 7 days each week, or less than 8 hours each day for periods of 21 days or less (with extensions in exceptional circumstances when the need for additional care is finite and predictable).” Chronic wound care needed at a daily frequency may not have a finite and predictable endpoint, making it ineligible for continued Medicare coverage. The provider must assess if there is a realistic finite and predictable endpoint to the need for daily skilled nursing visits for wound care. Repeated extensions of the finite and predictable endpoint on subsequent claims is not acceptable.

The home health provider must also evaluate whether the wound care/service provided is skilled care. To be payable under Medicare, there must be a skilled service provided. As stated in 42 CFR 409.32(a), “To be considered a skilled service, the service must be so inherently complex that it can be safely and effectively performed only by, or under the supervision of, professional or technical personnel." If a service can be safely and effectively performed by an unskilled person, without the direct supervision of a nurse, the service cannot be regarded as a skilled nursing service even though a nurse actually performs the service. Finally, as it states within the CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 40.1.1, "The unavailability of a competent person to provide a nonskilled service, regardless of the importance of the service to the patient, does not make it a skilled service when a nurse provides the service.” Examples of a nonskilled service would include a simple cleansing of a superficial wound and applying a new dressing, or application of a compression device to the lower extremities.

The frequency of SN visits to perform skilled wound care and/or assess the wound(s) must be consistent to the size and severity of the wound. The documentation should include a description of the wound characteristics with each visit (i.e., amount of drainage, color, odor, presence of necrotic tissue or eschar) with wound measurements documented at least weekly. If there have been no changes to the wound size and characteristics and no changes to the treatment plan for a period of time, skilled care becomes questionable.

Wound Care Under the Medicare Home Health Benefit

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