Wound care is provided in various healthcare settings like inpatient hospital, outpatient clinics, long-term care facilities, home health settings, hospice and skilled nursing facilities. The specific healthcare setting where wound care is provided depends on the patient’s individual needs and the severity of their wound. For example, patients who require ongoing wound care but do not need to be hospitalized can receive treatment in outpatient clinics. Patients who are able to receive wound care at home may receive treatment from home health agencies. Whatever might be healthcare facility, it’s important to get accurately reimbursed for wound care services. In this article, we shared wound care reimbursements in certain healthcare facilities.
Wound Care Reimbursements in Various Healthcare Settings
Inpatient Hospital
Wound care in an inpatient hospital setting is reimbursed through the Diagnosis-Related Group (DRG) payment system. DRGs are a payment classification system used by Medicare and other insurance providers to categorize patients into groups based on their diagnosis, severity of illness, and the resources required for their care. Hospitals are paid a fixed amount for each DRG, regardless of the actual cost of the care provided. For example, if a patient with a complex wound is admitted to the hospital and requires surgery and post-operative wound care, the hospital will receive a DRG payment that covers the cost of the entire episode of care, including the wound care.
Outpatient Clinic
In an outpatient clinic setting, wound care is reimbursed through the Medicare Physician Fee Schedule (MPFS) or the Outpatient Prospective Payment System (OPPS). The MPFS is a payment system that reimburses healthcare providers for services rendered to Medicare patients in an outpatient setting. The OPPS is a payment system used by hospitals and other healthcare providers to reimburse for services provided in an outpatient setting. Under both payment systems, wound care is reimbursed based on the type of service provided, the complexity of the wound, and the geographic location of the clinic.
Home Health
Medicare and Medicaid are two of the largest insurance providers for home health services, and they have specific guidelines for wound care reimbursement. Medicare, for example, reimburses home health agencies for services provided to patients with chronic wounds, such as pressure ulcers, diabetic ulcers, and arterial and venous ulcers. The reimbursement amount depends on the severity of the wound and the type of treatment provided. Wound care provided in a patient’s home is reimbursed through the Home Health Prospective Payment System (HHPPS). The HHPPS is a payment system used by Medicare to reimburse home health agencies for services provided to Medicare patients in their homes. Wound care services are reimbursed based on the patient’s diagnosis and the complexity of the wound.
Skilled Nursing Facilities (SNFs)
Medicare is the primary payer for wound care services provided in skilled nursing facilities (SNFs). Medicare reimbursement for wound care in SNFs is governed by the Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS). The SNF PPS is a bundled payment system that reimburses SNFs based on a fixed rate per patient day, which covers all costs associated with the patient’s stay, including wound care. To be eligible for Medicare reimbursement, wound care provided in SNFs must be considered reasonable and necessary for the treatment of the patient’s condition. The wound must also meet specific criteria, such as being a non-healing wound, and must be documented appropriately in the patient’s medical record. In addition to Medicare reimbursement, SNFs may also receive reimbursement from other payers, such as Medicaid, private insurance, or self-pay patients. However, the reimbursement rates and requirements may vary depending on the payer.
It’s important to note that wound care reimbursements and policies vary based on location and insurance coverage, so it’s always a good idea to check with your specific insurance provider or Medicare to determine the coverage and reimbursement for wound care services. Medisys Data Solutions is a leading medical billing company providing complete billing and coding services for various medical billing specialties. Whatever might be the facility, we can assist you in receiving accurate for delivered wound care services. To know more about our wound care billing and coding services, contact us at info@medisysdata.com / 888-720-8884
