CMS Pub. 100-02, ch. 7, § 40.1.2.8

Care of wounds, (including, but not limited to, ulcers, burns, pressure sores, open surgical

sites, fistulas, tube sites, and tumor erosion sites) when the skills of a licensed nurse are

needed to provide safely and effectively the services necessary to treat the illness or

injury, is considered to be a skilled nursing service. For skilled nursing care to be

reasonable and necessary to treat a wound, the size, depth, nature of drainage (color,

odor, consistency, and quantity), and condition and appearance of the skin surrounding

the wound must be documented in the clinical findings so that an assessment of the need

for skilled nursing care can be made. This includes whether wound care is performed via

dressing changes, NPWT using conventional DME systems or NPWT using a disposable

device. Coverage or denial of skilled nursing visits for wound care may not be based

solely on the stage classification of the wound, but rather must be based on all of the

documented clinical findings. Moreover, the plan of care must contain the specific

instructions for the treatment of the wound. Where the physician or allowed practitioner

has ordered appropriate active treatment (e.g., sterile or complex dressings, NPWT,

administration of prescription medications, etc.) of wounds with the following

characteristics, the skills of a licensed nurse are usually reasonable and necessary:

• Open wounds which are draining purulent or colored exudate or have a foul odor

present or for which the patient is receiving antibiotic therapy;

• Wounds with a drain or T-tube that require shortening or movement of such

drains;

• Wounds which require irrigation or instillation of a sterile cleansing or medicated

solution into several layers of tissue and skin and/or packing with sterile gauze;

• Recently debrided ulcers;

• Pressure sores (decubitus ulcers) with the following characteristics:

o There is partial tissue loss with signs of infection such as foul odor or

purulent drainage; or

o There is full thickness tissue loss that involves exposure of fat or invasion

of other tissue such as muscle or bone.

NOTE: Wounds or ulcers that show redness, edema, and induration, at

times with epidermal blistering or desquamation do not ordinarily require

skilled nursing care.

• Wounds with exposed internal vessels or a mass that may have a proclivity for

hemorrhage when a dressing is changed (e.g., post radical neck surgery, cancer of

the vulva);

• Open wounds or widespread skin complications following radiation therapy, or

which result from immune deficiencies or vascular insufficiencies;

• Post-operative wounds where there are complications such as infection or allergic

reaction or where there is an underlying disease that has a reasonable potential to

adversely affect healing (e.g., diabetes);

• Third degree burns, and second degree burns where the size of the burn or

presence of complications causes skilled nursing care to be needed;

• Skin conditions that require application of nitrogen mustard or other

chemotherapeutic medication that present a significant risk to the patient;

• Other open or complex wounds that require treatment that can only be provided

safely and effectively by a licensed nurse.

EXAMPLE 1:

A patient has a second-degree burn with full thickness skin damage on the back. The

wound is cleansed, followed by an application of Sulfamylon. While the wound requires

skilled monitoring for signs and symptoms of infection or complications, the dressing

change requires skilled nursing services. The home health record at each visit must

document the need for the skilled nursing services.

EXAMPLE 2:

A patient experiences a decubitus ulcer where the full thickness tissue loss extends

through the dermis to involve subcutaneous tissue. The wound involves necrotic tissue

with a physician's order to apply a covering of a debriding ointment following vigorous

irrigation. The wound is then packed loosely with wet to dry dressings or continuous

moist dressing and covered with dry sterile gauze. Skilled nursing care is necessary for

proper treatment. The home health record at each visit must document the need for the

skilled nursing services.

NOTE: This section relates to the direct, hands on skilled nursing care provided to

patients with wounds, including any necessary dressing changes on those wounds. While

a wound might not require this skilled nursing care, the wound may still require skilled

monitoring for signs and symptoms of infection or complication (see §40.1.2.1) or for

skilled teaching of wound care to the patient or the patient's family (see §40.1.2.3). For

an example of when wound care is provided separately from the furnishing of NPWT

using a disposable device, see §50.4.4.