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:

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

NHMS Reimbursement Support Services

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

Our goal is to help ensure your patients receive the care they need—without reimbursement delays.