Reimbursement Information – New Horizon Medical Solutions

Navigating Medicare Reimbursement

with Confidence

At New Horizon Medical Solutions, we understand that access to high-quality biologic wound care depends on more than just clinical efficacy — it requires a clear and compliant reimbursement process. We work closely with providers to ensure the appropriate billing, documentation, and regulatory alignment for our advanced wound care products, including skin substitutes, biologic dressings and debridement procedures.

Understanding Medicare reimbursement

Medicare covers biologic wound care products such as skin substitutes and biologic dressings when they are deemed medically necessary. Coverage is governed by:

Local coverage determinations (LCDs) created by regional Medicare administrative contractors (MACs).
CPT codes used to bill for services such as graft application and debridement.
Setting of care, which impacts allowable reimbursement rates (physician office, ASC, or hospital).
Average sales price (ASP) for certain skin substitutes, influencing Medicare Part B payments.

Key reimbursement factors

Key Reimbursement Factors

Medical Necessity

Coverage requires that biologic products are used in clinically appropriate,documented situations, such as non-healing diabetic or venous leg ulcers.

Local Coverage Determinations (LCDs)

Each MAC publishes specific LCDs that outline coverage criteria, including wound type, treatment history, size, duration, and prior conservative therapies.

CPT Codes

Correct CPT code selection is critical for reimbursement. Examples include:

Setting of Care

Reimbursement varies based on service location:

Physician office
Often includes product cost and application in one global payment.
Ambulatory surgery center (ASC)
Separate billing for facility and professional components.
Hospital outpatient
Reimbursement may follow OPPS bundling or pass-through payment logic.

Average Sales Price (ASP)

For Medicare Part B billing in physician settings, many skin substitutes are reimbursed based on the ASP + 6% model, as reported quarterly to CMS.

Documentation Requirements

To secure reimbursement, documentation must support:

Medical necessity.
Previous treatments and failure of standard care.
Wound size, location and progression.
Product type, lot number, and exact application details.

Reimbursement by Product Type

Skin Substitutes

Covered for chronic wounds (e.g., DFUs, VLUs) when conservative treatment has failed. Documentation must align with LCDs and CPT coding guidelines.

Biologic Dressings

In select cases, covered as Durable Medical Equipment (DME) under Medicare Part B. Compliance with dressing frequency limits and clinical indicators is essential.

Coding & compliance considerations

NCCI edits Be aware of the National Correct Coding Initiative edits, which restrict certain CPT/HCPCS code pairings.
Prior authorization May be required by some MACs or commercial payers for specific biologics.
Coding errors Incorrect modifier use, missing diagnosis codes, or misaligned documentation can result in claim denials or audits.
MAC region variation LCDs vary by MAC jurisdiction — know your region's guidelines.

NHMS reimbursement support services

We support your team throughout the billing and claims process with:

Product-specific billing guidance and templates
Coding education by care setting (office, ASC, hospital)
Sample documentation and prior authorization checklists
Real-time field support and escalation for denied claims
Access to regional LCD and MAC resources