Surgical Dressings Questions & Answers (Q&As)
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- How do I use the A1-A9 modifiers? Does each dressing on the claim need a separate A1-A9 modifier depending on how many wounds each dressing is being used for, or the total number of wounds?
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Modifiers A1-A9 have been established to indicate that a particular item is being used as a primary or secondary dressing on a surgical or debrided wound, and to indicate the number of wounds on which that dressing is being used. The modifier number must correspond to the number of wounds on which the dressing is being used, not the total number of wounds treated. For example, if the beneficiary has 4 wounds but a particular dressing is only used on 2 of them, the A2 modifier must be used with that HCPCS code.
Originally published: 01.08.20
Reviewed: 12.08.23
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- I have submitted a claim for one impregnated gauze dressing, and it keeps getting denied. But another impregnated gauze dressing has been paid with no problem. Why would one be paid and the other not?
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There could be several possible reasons for denial of one and not the other.
The Surgical Dressings policy specifies substances or agents incorporated into dressings that are deemed impregnated gauze dressings that may qualify for coverage (when other policy and statutory requirements are met). Gauze, when impregnated with other than water, normal saline, hydrogel, or zinc paste (A6222-A6224, A6266) is covered under the Surgical Dressings benefit, while gauze impregnated with water or normal saline (A6228-A6230) is denied as not reasonable and necessary, because there is no medical necessity for these compared to non-impregnated gauze moistened with bulk saline or sterile water.
Keep in mind that those dressings which contain substances not recognized as effective dressing materials (such as honey or silver) may result in denial. There are also some impregnated dressings that are not covered as surgical dressings because they are impregnated with a drug listed in the FDA's Orange Book. This type of dressing (for example, antibiotics which require a prescription) would not be covered as a surgical dressing, but as a drug.
Originally published: 01.08.20
Reviewed: 12.08.23
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- We have a patient whose wounds are being managed by their primary care physician. She is wheelchair bound, and her provider's office is not able to facilitate transfer. Therefore, she cannot have all of her wounds evaluated by her provider. Her spouse is able to measure the wounds at home, and they then discuss the wounds when she sees her provider. Does this reflect a situation in which "other monitoring methods" are being appropriately used to evaluate ongoing need for dressing supplies?
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Evaluation of the beneficiary’s wounds must be performed by a qualified health care professional (such as a nurse or treating practitioner) involved in the regular care of the beneficiary. If there is documentation in the beneficiary’s medical records which (1) justifies why such an evaluation could not be completed within the specified timeframe and (2) documents the other monitoring methods implemented to evaluate the beneficiary’s need for ongoing utilization of dressings, evaluation of the wounds performed by the beneficiary’s spouse does meet this requirement.
Originally published: 01.08.20
Reviewed: 12.08.23
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- What are the required elements of a wound evaluation?
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It depends on whether it is an initial wound evaluation or the ongoing evaluation to support continued use/need of a particular dressing and quantity dispensed.
For initial wound evaluations, the treating practitioner's medical record, nursing home, or home care nursing records must specify
- The type of qualifying wound
- Information regarding the location, number, and size of qualifying wounds being treated with a dressing
- Whether the dressing is being used as a primary or secondary dressing or for some noncovered use (such as wound cleansing)
- Amount of drainage
- The type of dressing (such as hydrocolloid wound cover, hydrogel wound filler, etc.)
- The size of the dressing (if applicable)
- The number/amount to be used at one time
- The frequency of dressing change
- Any other relevant clinical information
Clinical information, which demonstrates that the reasonable and necessary requirements in the policy regarding the type and quantity of surgical dressings provided, must be present in the beneficiary's medical records. This information must be updated by the treating practitioner (or their designee) on a monthly basis. This evaluation of the beneficiary's wound(s) is required unless there is documentation in the medical record that justifies why an evaluation could not be done within this timeframe and what other monitoring methods were used to evaluate the beneficiary's need for ongoing use of dressings.
For beneficiaries in a nursing facility or for beneficiaries with heavily draining or infected wounds, wound evaluations are expected on a weekly basis. The evaluation may be performed by a nurse, treating practitioner, or other health care professional involved in the regular care of the beneficiary. This person may have no financial relationship with the supplier. This prohibition does not extend to treating practitioners who are also the supplier.
The weekly or monthly evaluation must include
- The type of each wound (such as surgical wound, pressure ulcer, burn, etc.)
- Wound(s) location
- Wound size (length x width) and depth
- Amount of drainage
- Any other relevant wound status information
Originally published: 01.08.20
Reviewed: 12.08.23
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- What dressing would I use for pressure ulcers?
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Surgical dressings are covered when a qualifying wound is present. A qualifying wound is defined as either a wound caused by, or treated by, a surgical procedure; or after the debridement of the wound, regardless of the debridement technique. Therefore, unless a pressure ulcer has been treated by a surgical procedure or has been debrided, pressure ulcers are never covered under the surgical dressing benefit.
Originally published: 01.08.20
Reviewed: 12.08.23
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- What kind of situation would warrant the medical need for using alginate as primary and secondary?
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When the wound has heavy exudate, it can overwhelm the primary dressing, thus necessitating a secondary dressing. This is commonly called “strike-through” in clinical terms.
Originally published: 02.17.21
Reviewed: 12.08.23
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- Can a secondary wound cover be billed only in conjunction with a primary wound cover? For example, if a primary wound dressing is not billable due to containing silver or honey, is the secondary not billable as well?
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Medicare covers primary and secondary dressings that meet the surgical dressings benefit. Even if the primary dressing is non-covered, a secondary covered dressing type is billable if reasonable and necessary based on the exudate and wound characteristics.
Originally published: 02.17.21
Reviewed: 12.08.23
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- We have a practitioner prescribing a debriding agent applied to a primary dressing every day, and then a foam secondary cover that has a frequency of up to 3x/week. Should we tell the doctor that he needs to order a different secondary with a frequency of 1x/day?
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Per the Surgical Dressings Local Coverage Determination (LCD) (Miscellaneous Section): The frequency of recommended dressing changes depends on the type and use of the surgical dressing. When combinations of primary dressings, secondary dressings, and wound filler are used, the change frequencies of the individual products should be similar. For purposes of this policy, the product in contact with the wound determines the change frequency. It is not reasonable and necessary to use a combination of products with differing change intervals. For example, it is not reasonable and necessary to use a secondary dressing with a weekly change frequency over a primary dressing with a daily change interval. Such claims will be denied as not reasonable and necessary. (Emphasis Added)
Originally published: 02.17.21
Reviewed: 12.08.23
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- Some patients who use negative pressure wound therapy (NPWT) durable medical equipment (DME)/canisters/dressings may need a primary surgical dressing underneath the NPWT dressing. If the surgical dressing meets all the requirements located in the Surgical Dressings LCD and LCD-related Policy Article, and if the NPWT DME meets all the requirements of the Negative Pressure Wound Therapy Pumps LCD and LCD-related Policy Article, will the DME MAC cover and pay for both the NPWT dressings and the primary surgical dressing ordered by the practitioner?
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No, NPWT is not designed for use with a separate primary dressing. The purported efficacy of NPWT is, in part, related to the direct contact of the NPWT dressing with the wound bed. Code A6550 describes an allowance for a dressing set which is used in conjunction with a stationary or portable NPWT pump (E2402). A single code A6550 is used for each single, complete dressing change and contains all necessary components, including but not limited to any separate, non-adherent porous dressing(s), drainage tubing, and an occlusive dressing(s) which creates a seal around the wound site for maintaining sub-atmospheric pressure at the wound.
Originally published: 02.17.21
Reviewed: 12.08.23
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