Surgical Dressings Pre-Pay Review Quarterly Status Report
Below is the analysis of claim denials for surgical dressings HCPCS codes A6010, A6021, A6196-A6199, A6203, A6209-A6212, A6231-A6233, A6234-A6241, A6242-A6248, and A6251-A6256 reviewed between January 1 and March 31, 2023. The error rate for this quarter is 23.93%. The top 10 reasons for claim denials are as follows:
Rank | Reason | Percent |
---|---|---|
1. | 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 required after debridement of a wound. |
23.43% |
2. | The healthcare professional’s monthly evaluation of the wound did not include the type of each wound, its location, its size and depth, the amount of drainage, and any other relevant information. | 13.14% |
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 (such as wound cleansing). | 8.00% |
4. | The surgical dressing code was billed without modifiers A1-A9 for the correct number of wounds being treated by the particular dressing. |
6.86% |
5. | The medical records do not support frequency of use or frequency of change. | 6.86% |
6. | The documentation does not contain a valid standard written order (SWO). Refer to Standard Documentation Requirements A55426. | 6.29% |
7. | The medical records do not show that the Collagen dressing is being used on full thickness wound, a wound with light to moderate exudate, or on a wound that has stalled or has not progressed towards a healing goal. | 4.57% |
8. | The medical records do not show that the Composite dressing is being used to cover moderately to highly exudative wounds. | 4.57% |
9. | The medical records do not include an evaluation of the wounds performed on a monthly basis or justification for why they could not be evaluated monthly and what other methods were used to evaluate the need for the dressings. | 4.00% |
10. | The medical records received lack sufficient information concerning the beneficiary’s condition to determine if medical necessity coverage criteria were met. | 3.43% |
*The total percentage will be greater than 100% because some claims were denied for multiple reasons.
**The error rate included is an overall average for the supplier specific reviews as a part of the Targeted Probe and Educate program. This is not meant to represent an overall error rate for the HCPCS code or policy under medical record review.
Resources:
- Local Coverage Article for Surgical Dressings – Policy Article (A54563)
- Local Coverage Determination for Surgical Dressings (L33831)
- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
- Surgical Dressings Documentation Checklist
- Medicare Claims Processing Manual
- Medicare Program Integrity Manual
Additional Education: