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 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 show 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 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, use the A2 modifier with that HCPCS code.
Originally published: 01.08.2020
Revised: 12.30.2024
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- I 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 1 be paid and the other not?
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There are several reasons one would deny but not the other.
The surgical dressings policy specifies substances or agents incorporated into dressings that are considered impregnated gauze dressings that may qualify for coverage (when other policy and statutory requirements are met). Gauze, when impregnated with anything 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 dressings which hold substances not recognized as effective dressing materials (such as honey or silver) may result in denial. There are also some impregnated dressings that Medicare does not cover 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: 01.08.2020
Revised: 12.30.2024
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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. Due to this she cannot have all her wounds evaluated by her provider. Her spouse can 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 justifies why such an evaluation could not be completed within the specified timeframe and which 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: 01.08.2020
Revised: 12.30.2024
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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 an ongoing evaluation to support continued use/need of a particular dressing and quantity dispensed.
An initial evaluation must include:
- The type of dressing (hydrocolloid wound cover, hydrogel wound filler)
- The number or amount to be used at one time (if more than one)
- The frequency of dressing change
An evaluation for continued use and need should include:
- The type of each wound (surgical wound, pressure ulcer, burn)
- Wound location
- Wound size (length x width) and depth
- Amount of drainage
- Any other relevant wound status information
Originally published: 01.08.2020
Revised: 12.30.2024
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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: 01.08.2020
Revised: 12.30.2024
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- What kind of situation would call for the medical need for using alginate as primary and secondary?
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It is acceptable to use 2 alginate dressings together (primary and secondary) for a wound with moderate to heavy exudate.
Originally published: 02.17.2021
Revised: 12.30.2024
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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: 02.17.2021
Revised: 12.30.2024
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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 3 times per week. Should we tell the doctor that he needs to order a different secondary with a frequency of 1 time per day?
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The Surgical Dressings Local Coverage Determination (LCD) states: “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.”
Originally published: 02.17.2021
Revised: 12.30.2024
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- Some patients who use negative pressure wound therapy (NPWT) durable medical equipment canisters or dressings may need a primary surgical dressing underneath the NPWT dressing. If the surgical dressing meets all the surgical dressing policy requirements, and if the NPWT meets all the NPWT policy requirements, will Medicare cover 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 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 dressings, drainage tubing, and an occlusive dressing which creates a seal around the wound site for maintaining sub-atmospheric pressure at the wound.
Originally published: 02.17.2021
Revised: 12.30.2024
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