Wound care billing in Medicare has a concentration problem. One nurse practitioner in West Palm Beach billed $18,491,753 in a single year using just 4 wound care codes. The 20th-ranked provider on the same list collected $6,076,700. That gap, nearly 3-to-1 between first and twentieth place, tells you something about how this specialty works.

$699 Million and Rising, With Fewer Providers Doing More

Total Medicare payments for wound care and debridement codes grew from $456 million in 2013 to $699 million in 2023, a 53% increase over the decade. Submitted charges grew even faster, from $1.45 billion to $2.32 billion over the same period. The gap between what providers bill and what Medicare pays has widened, which matters for understanding where the financial incentives sit.

The provider count tells a different story. Unique providers billing wound care codes peaked at 41,400 in 2017 and fell to 36,231 by 2023. Fewer practitioners are generating more revenue, which means average billing per provider has risen substantially. For patients, that concentration raises access questions in regions where wound care specialists are scarce. For program integrity analysts, it raises different ones.

The pandemic year of 2020 created a visible break in the trend: total services dropped from 9,793,894 in 2019 to 7,450,026 in 2020. Services partially recovered to 8,230,820 by 2023, but never returned to pre-pandemic levels. Payments, however, fully recovered and then exceeded prior peaks, reaching $699 million in 2023 against $538 million in 2019. More dollars for fewer services means the revenue-per-service figure has climbed.

Florida's Outsized Footprint and the Charge-to-Payment Signal

Six of the top 25 providers by total Medicare payment are located in Florida cities: West Palm Beach, The Villages, Fort Walton Beach, Port Saint Lucie, Lecanto, and Lakeland. That geographic clustering is not random. Florida's large Medicare-eligible population creates volume, but concentration at the top of a national billing ranking suggests something beyond demographics.

The coding patterns add another layer. Skin substitute application code 15271 carries a charge-to-payment ratio of 8.37, more than double the 3.88 average across all non-drug procedure codes. Code 97598, removal of tissue from wounds per session, runs at 6.61. When providers submit charges at 8 times what Medicare pays, it can reflect aggressive chargemaster pricing, but it can also signal that the submitted charge is functioning as an anchor rather than a genuine cost estimate. Either way, these ratios stand out against the broader procedure landscape.

The top provider's profile sharpens this picture. Carlos Reyes Chouza, a nurse practitioner in West Palm Beach, generated $18,491,753 in Medicare payments across 15,643 services using only 4 wound codes in a single active year. The second-ranked provider, a dermatologist in The Villages, billed $13,162,866 across 11 years and 18 codes. The contrast is stark: one provider, one year, four codes, $18.5 million.

What the Billing Architecture Allows

Wound care codes, particularly debridement and skin substitute applications, are procedure-based and volume-sensitive. Each patient encounter can generate multiple billable units depending on wound size and treatment type. That structure creates legitimate pathways to high billing for busy wound care practices. It also creates pathways that are harder to explain clinically.

The 36,231 providers billing across 88 codes in 2023 represent a broad ecosystem, from hospital-based wound centers to solo practitioners. Most of that $699 million reflects routine, necessary care for diabetic ulcers, surgical wounds, and pressure injuries in an aging Medicare population. The aggregate number is not itself evidence of a problem.

But the distribution within that aggregate is where the data gets uncomfortable. A single practitioner generating payments nearly 50% higher than the next highest provider, using a narrow set of codes in one year, sits well outside any normal distribution. Medicare's fee-for-service structure for wound care doesn't require that outcome. It just doesn't prevent it.