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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that for the purposes of this LCD, wound care is defined as care of wounds that are refractory to 
healing or have complicated healing cycles either because of the nature of the wound itself or because of 
complicating metabolic and/or physiological factors. This definition excludes the following: 
 Management of acute wounds, or 
 The care of wounds that normally heal by primary intention such as clean, incised traumatic wounds, or 
 Surgical wounds that are closed primarily and other postoperative wound care not separately covered 
during the surgical global period. 
Various methods to promote wound healing have been devised over time. A method which is unproven by 
valid scientific literature would be considered not reasonable and necessary. Wound care involves the 
evaluation and treatment of a wound, including identifying potential causes of delayed wound healing and the 
modification of treatment when indicated. Wound evaluations may require a comprehensive medical 
evaluation, vascular evaluation, orthopedic evaluation, functional evaluation, metabolic/nutritional evaluation, 
and a plan of care. Reduction of pressure and/or control of infection have been shown to facilitate healing and 
may reduce the need for repeated debridement services. 
Medicare coverage for wound care on a continuing basis, for a given wound, in a given patient, is contingent 
upon evidence documented in the patient's medical record that the wound is improving in response to the 
wound care being provided. Evidence of improvement may include measurable changes in the following: 
 Drainage 
 Inflammation 
 Swelling 
 Pain and/or tenderness 
 Wound dimensions (surface measurements, depth) 
 Granulation tissue 
 Necrotic tissue/slough 
 Tunneling or undermining Wound care must be performed in accordance with accepted standards for medical and surgical treatment of 
wounds. The goal of most chronic wound care should be eventual wound closure with or without grafts, skin 
replacements, or other surgery (such as amputation, wound excision, etc.). Adjunctive measures include but are 
not limited to appropriate control of complicating factors such as pressure (e.g., off-loading, padding, and 
appropriate footwear), infection, vascular insufficiency, metabolic derangement and/or nutritional deficiency. 
While complete healing of the wound may be the primary objective; a secondary desired objective is that, with 
appropriate management, a wound may reach a state at which its care may be performed primarily by the 
patient and/or the patients caregiver with periodic physician assessment and supervision. 
In appropriate cases, due to severe underlying debility or other factors such as operability, the goal of wound 
care provided in outpatient settings may be only to prevent progression of the wound and prevention of 
prolonged hospitalization.  
Active wound care procedures involve selective and non-selective debridement techniques and are performed 
to remove devitalized tissue and promote healing. The provider is required to have direct (one-on-one) patient 
contact when performing active wound care management.  
The appropriate interval and frequency of debridement depends on the individual clinical characteristics of the 
patient and the extent of the wound.  
It is highly recommended that the treatment plan for a patient who requires frequent repeated debridement be 
reevaluated to ensure that issues including, but not limited to, pressure reduction, nutritional status, vascular 
insufficiency and infection control have been adequately addressed. Overall, evaluation of the wound should be 
performed at a regular frequency to determine whether the individualized treatment goals are being met for the 
patient. 
 
Definition of terms for this policy: 
 
Dressing Changes for Wound Debridement 
 Wet dressings: Water and medication may be applied to the skin with dressings (e.g., finely woven 
cotton or gauze) soaked in solution. Wet compresses, especially with frequent changes, may provide 
gentle debridement. 
 Dry dressings: Used to provide gentle debridement, protect the skin, hold medications against the skin, 
keep clothing and sheets from rubbing, or keep dirt and air away. Such dressings may also prevent 
patients from scratching or rubbing the wound. 
 Advanced dressings: Used with increasing frequency to provide gentle debridement in the treatment of 
acute wounds, chronic venous, diabetic and pressure ulcers. 
 Dressing changes (removal and subsequent reapplication) alone generally do not require the skills of 
physicians. They may be performed by physical therapists, occupational therapists, licensed 
professional nurses, or wound care nurses. 
 
Covered Indications 
1. Medicare would expect that wound care may be necessary for the following types of wounds: 
 Surgical wounds that must be left open to heal by secondary intention. 
 Infected open wounds induced by trauma or surgery. 
 Wounds with biofilm. 
 Wounds associated with complicating autoimmune, metabolic, and vascular or pressure factors. 
 Open or closed wounds complicated by necrotic tissue and/or eschar. 
2. Active Wound Care Management 
Debridement may be indicated whenever necrotic tissue as well as cellular or proteinaceous debris is 
present on an open wound in order to keep the wound in an active state of healing. Debridement may 
also be indicated in cases of abnormal wound healing or repair. The routine application of a topical or local anesthetic does not elevate active wound care management to surgical debridement. Debridement 
may be categorized as selective or non-selective. 
 Wound Care Selective Debridement includes: 
o Removal of specific, targeted areas of devitalized or necrotic tissue from a wound along 
the margin of viable tissue by sharp dissection utilizing scissors, scalpel, curettes, and/or 
tweezers/forceps. This procedure typically requires no anesthesia and generally has no or 
minimal associated bleeding. 
 Wound Care Non-Selective Debridement may include: 
o Mechanical Debridement: This type of debridement is the removal of necrotic tissue by 
cleansing, or application of a wetto-dry or dry-to-dry dressing technique. Wet-to-dry 
dressings should be used judiciously as maceration of surrounding tissue may hinder 
healing. Generally, dressing changes are not considered a skilled service. 
o Enzymatic Debridement: Debridement with topical enzymes is used when the necrotic 
substances to be removed from a wound are protein, fiber and collagen. The 
manufacturers product insert contains indications, contraindications, precautions, 
dosage and administration guidelines; it is the clinicians responsibility to comply with 
those guidelines. 
o Autolytic Debridement: This type of debridement is indicated where manageable 
amounts of necrotic tissue are present, and there is no infection. Autolytic debridement 
occurs when the enzymes that are naturally found in wound fluids are sequestered under 
synthetic dressings. 
o Maggot / larvae therapy: Debridement with medical-grade maggots in wounds. 
3. Wound Care Surgical Debridements 
 Conditions that may require surgical debridement of large amounts of skin may include but are 
not limited to rapidly spreading necrotizing process (sometimes seen with aggressive 
streptococcal infections), severe eczema, extensive skin trauma (including large abraded areas 
with ground-in dirt), or autoimmune skin diseases. 
 Surgical debridement occurs only if material has been excised and is typically reported for the 
treatment of a wound to clear and maintain the site free of devitalized tissue including but not 
limited to necrosis, eschar, slough, infected tissue, biofilm, abnormal granulation tissue, etc., 
and should be accomplished to the margins of viable tissue. 
 These procedures can be very effective but represent extensive debridement.  They may be 
complex in nature and may on occasion require the use of anesthesia. 
4. Use of Evaluation and Management (E/M) Codes in Conjunction with Surgical Debridements 
 Patients who have chronic wounds may frequently have underlying medical problems that 
require concomitant management in order to bring about wound closure. In addition, patients 
may require education, other services, and coordination of care both in the preoperative and 
postoperative phases of the debridement procedure. An E/M service provided and documented 
on the same day as a debridement service may be covered by Medicare only when the 
documentation clearly establishes the service as a "separately identifiable service" that was 
reasonable and necessary, as well as distinct, from the debridement service(s) provided. 
5. Negative Pressure Wound Therapy (NPWT) 
 Negative pressure wound therapy (NPWT), utilizing either durable or disposable medical 
equipment, is a method of wound care to manage wound exudates and promote wound closure. 
The vacuum assisted drainage collection (i.e., NPWT) may be applied in an effort to cleanse the 
wound by removing fluids and stimulate the wound bed in order to reduce localized edema and 
improve local oxygen supply. 
 NPWT involves the application of controlled or intermittent negative pressure to a properly 
dressed wound cavity. Suction (negative pressure) is applied under airtight wound dressings to 
promote the healing of open wounds resistant to prior treatments. 
 NPWT for non-healing wounds is medically necessary when at least one of the following 
conditions is met: o There are complications of a surgically created wound (e.g., dehiscence, post sternotomy 
disunion with exposed sternal bone, post sternotomy mediastinitis, or postoperative 
disunion of the abdominal wall). 
o There is a traumatic wound (e.g., preoperative flap or graft, exposed bones, tendons, or 
vessels) and a need for accelerated formation of granulation tissue not achievable by 
other topical wound treatments (e.g., the individual has comorbidities that will not allow 
for healing times usually achievable with other available topical wound treatments). 
o There is a chronic, non-healing ulcer with lack of improvement despite standard wound 
therapy, including the application of dressings, debridement of necrotic tissue (if 
present), maintenance of an adequate nutritional status, and weekly evaluations with 
documentation of wound measurements (i.e., length, width, and depth) in ONE of the 
following clinical situations: 
 Acute wounds 
 Subacute and dehisced wounds 
 Traumatic wounds 
 Ulcers (such as diabetic or pressure) 
 Chronic Stage III or Stage IV pressure ulcer 
 Chronic diabetic neuropathic ulcer 
 Chronic venous ulcer 
 Flaps and grafts 
6. Low-Frequency, Non-Contact, Non-Thermal Ultrasound (MIST Therapy) 
 Low frequency, non-contact, non-thermal ultrasound describes a system that uses continuous 
low-frequency ultrasonic energy to produce and propel a mist of liquid and deliver continuous 
low-frequency ultrasound to the wound bed. This modality is often referred to as MIST 
Therapy. 
 Low-Frequency, Non-Contact, Non-Thermal Ultrasound (MIST Therapy) is considered 
reasonable and necessary wound therapy and therefore eligible for coverage by Medicare when 
provided for any of the following clinical conditions: 
o Wounds and ulcers which are too painful for sharp or excisional debridement and have 
failed conventional debridement with documentation supporting the same. 
o Wounds and ulcers meeting Medicare coverage for debridement but with documented 
contraindications to sharp or excisional debridement. 
o Wounds and ulcers meeting Medicare coverage for debridement but with documented 
evidence of no signs of improvement after 30 days of standard wound care. 
 Low-frequency, non-contact, non-thermal ultrasound (MIST Therapy) may be provided two to 
three times per week to be considered reasonable and necessary. The length of individual 
treatments will vary per wound size. 
 Observable, documented improvements in the wound(s) should be evident after six treatments. 
Improvements include documented reduction in pain, necrotic tissue, or wound size, or 
improved granulation tissue. 
7. Application of Paste Boot (Unna Boot) or Application of Multi-Layer Compression System may be 
useful adjuncts to wound care management. 
Limitations 
1. Wound care should employ comprehensive wound management including appropriate control of 
complicating factors such as unrelieved pressure, infection, vascular and/or uncontrolled metabolic 
derangement, and/or nutritional deficiency in addition to appropriate debridement. Medicare coverage 
for professional wound care procedures requires that all applicable adjunctive measures are also 
employed as part of comprehensive wound management. Wound care in the absence of such measures, 
when they are indicated, is not considered to be medically reasonable and necessary. 2. Debridement will be considered not reasonable and necessary for a wound that is clean and free of 
necrotic tissue/slough. 
3. Debridements are considered selective or non-selective unless the medical record supports that a 
surgical excisional debridement was performed. 
4. Debridements are best provided under an individualized plan of care. 
5. Wound care may be of a palliative nature. Optimally, the overall goal of care is healing, and it would be 
neither reasonable nor medically necessary to continue a given type of wound care if evidence of 
wound improvement leading to healing of the wound as outlined in this LCD cannot be shown. 
However, if it is determined that the goal of care is not wound healing, which would lead ultimately to 
wound closure, the patient should be managed following appropriate palliative care standards. Wounds 
of some Medicare beneficiaries residing in Skilled Nursing Facilities (SNFs) and Nursing Facilities 
(NFs) may not close, heal, or be amenable to self-care in spite of optimal therapy. In those patients 
where wound closure, healing, or self-care is not a likely outcome, the goals of wound care may include 
prevention of hospitalization and improvement in quality of life. As such, due to severe underlying 
debility or other factors, the goal of wound care provided in these settings may be only to prevent 
progression of the wound by stabilizing the wound by: 
 Minimizing the risk of infection and further progression of the wound; 
 Managing the multiple issues that cause patient and family suffering; and 
 Optimizing the patients function and quality of life. 
6. Complicating circumstances that support additional wound care services as reasonable and necessary 
must be supported by adequate medical record documentation. 
7. Autolytic debridement is contraindicated for infected wounds. 
8. Debridement of extensive eczematous or infected skin is not appropriate for debridement of a localized 
amount of tissue normally associated with a circumscribed lesion. Examples of this are ulcers, 
furuncles, and localized skin infections. 
9. Surgical debridement will be considered not reasonable and necessary when documentation indicates 
the wound is without devitalized, fibrotic, nonviable tissue, infection, necrosis, foreign matter, or if the 
wound has pink to red granulated tissue. When utilized, it is expected that the frequency of debridement 
will decrease over time. 
10. Wound debridement utilizing a method which is unproven by valid scientific literature would be 
considered investigational and not reasonable and necessary. 
11. If a treatment is investigational, under waiver of liability provisions of Medicare law, an Advance 
Beneficiary Notice must be obtained for the beneficiary. 
12. When performed in conjunction with another wound care service, the dressing change is considered an 
integral component of that service and is not a separately covered service. 
13. A wound that shows no improvement after 30 days may require a new approach, which may include a 
physician reassessment of underlying infection, off-loading, biofilm, metabolic, nutritional, or vascular 
problems which may inhibit wound healing. 
14. Procedures performed for cosmetic reasons or to prepare tissues for cosmetic procedures are statutorily 
excluded from coverage by Medicare. 
15. Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia are included in the 
reimbursement for wound care services and are not separately covered. 
16. The following procedures are considered part of an E/M service and are not separately covered when an 
E/M service is performed: 
 Removal of necrotic tissue by cleansing and dressing, including wet or dry-to-dry dressing 
changes, 
 Cleansing and dressing small or superficial lesions, and 
 Removal of coagulated serum from normal skin surrounding an ulcer. 
17. NPWT is contraindicated for any of the following wound types/conditions: 
 Necrotic tissue with eschar present, 
 Untreated osteomyelitis, 
 Non-enteric and unexplored fistulas,  Malignancy in the wound, 
 Exposed vasculature, 
 Exposed nerves, 
 Exposed anastomotic site, or 
 Exposed organs. 
18. Continuing MIST treatments for wounds demonstrating no improvement after six treatments is 
considered not reasonable and necessary. 
 Observable, documented improvements in the wound(s) should be evident after 2 weeks or 4-6 
MIST treatments. Improvements may include documented reduction in pain, necrotic tissue, or 
wound size; or improved granulation tissue. 
19. The following services are considered to be not reasonable and necessary wound debridement services: 
 Removal of necrotic tissue by cleansing or dry-to-dry or wet-to-dry dressing. 
 Washing bacterial or fungal debris from lesions. 
 Removal of secretions and coagulation serum from normal skin surrounding an ulcer. 
 Dressing of small or superficial lesions. 
 Paring or cutting of corns or non-plantar calluses. 
 Incision and drainage of abscess including paronychia, trimming or debridement of mycotic 
nails, avulsion of nail plates, acne surgery, or destruction of warts. 
 Removal of non-tissue integrated fibrin exudates, crusts, or other materials from a wound 
without removal of tissue does not meet the definition of any debridement code and may not be 
reported as such. 
20. Wet-to-dry dressings, jet hydrotherapy, or wound irrigations should be used cautiously as maceration of 
surrounding tissue may hinder healing. 
21. Jet therapy and wound irrigation for wound debridement must be performed by skilled personnel in 
order to be considered reasonable and necessary. 
22. Medicare expects that with appropriate care: 
 Wound volume or surface dimension should decrease, or 
 Wounds optimally will demonstrate granulation tissue. 
23. Debridements of the wound(s) if indicated must be performed judiciously and at appropriate intervals. It 
is expected that, with appropriate care, and no extenuating medical or surgical complications or 
setbacks, wound volume or surface dimension should decrease overtime. It is also expected the wound 
care treatment plan is modified in the event that appropriate healing is not achieved. 
You can find this rule at the Medicare Local Coverage Determination (LCD) L35125: Wound Care. 
The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.