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2019 Quarterly Status Report – HCPCS Code A6010, A6021, A6196-A6199, A6210-A6212

A summary report for claims reviewed between July 1, 2019 and September 30, 2019 follows:

An analysis of the claim denials showed that the top 10 reasons a determination was made not to pay the claim were:

Rank Reason for Denial Percent*
1 The frequency of the dressing changes is not supported by the medical records. Refer to L33831. 22.89%
2 The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. Refer to L33831. 22.09%
3 The medical records do not establish that the dressing is being used as a primary or secondary dressing or for some non-covered use (e.g. wound cleansing). Refer to L33831. 19.28%
4 Medical records do not support that the surgical dressings are required for either the treatment of a wound caused by, or treated by, a surgical procedure; or when required after debridement of a wound. Refer to L33831. 15.26%
5 The monthly evaluation of the wound by the healthcare professional did not include the type of each wound, its location, its size and depth, the amount of drainage and any other relevant information. Refer to L33831. 13.25%
6 The size of the wound in the medical records does not support the HCPCS code being billed. Refer to L33831. 11.65%
7 More than a one month supply of dressings were provided at one time and there was not documentation to support the necessity of greater quantities in the home setting in an individual case. Refer to L33831. 10.04%
8 The medical records do not show that the Foam dressing is being used on a full thickness wound with moderate to heavy exudate (Stage III or Stage IV ulcer). Refer to L33831. 9.24
9 The documentation does not contain a valid detailed written order. Refer to Medicare Program Integrity Manual 5.2.3. 8.03%
10 The supplier indicates the item(s) were billed in error. Refer to SDL A55426. 5.62%

Total percentage will be greater than 100% because some claims were denied for multiple reasons.

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