Medicare Coverage: You Cannot Play the Game If You Do Not Know the Rules

Abstract

Wound care stakeholders should remember that Medicare reimbursement requires three parts: a relevant code, a published Medicare payment rate, and positive coverage or coverage based upon medical necessity. Qualified healthcare professionals, scientists, and manufacturers should establish a monthly routine, where they personally review revisions to pertinent National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). These documents provide specific guidelines for positive coverage by the specific Medicare Administrative Contractor that processes the Medicare claims in a specific jurisdiction. When given an opportunity to provide comments on draft coverage determinations, wound care stakeholders should take advantage of the opportunity of educating the contractor medical director. After a LCD has become active, wound care stakeholders can and should request revisions, through the LCD Reconsideration Process, when new clinical evidence becomes available.