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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, 2024. The error rate for this quarter is 49.19%. The top 10 reasons for claim denials are as follows:

Rank Reason Percent
1. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. 12.90%
2. 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). When used as a secondary dressing, medical records should support very heavy exudate. 11.78%
3. 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. 11.59%
4. Frequency of use or frequency of change is not supported by the medical records. 9.72%
5. The documentation does not have a valid Standard Written Order (SWO). 9.16%
6. 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). 8.41%
7. 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. 7.85%
8. The size of the wound in the medical records does not support the HCPCS code billed. 7.48%
9. 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. 3.74%
10. The medical records do not show that the hydrogel dressing is being used on full thickness wounds (e.g., stage III or IV ulcers) with minimal or no exudate. 2.24%

*The total percentage will be greater than 100% because some claims 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 be an overall error rate for the HCPCS code or policy under medical record review.


Updated: May 21, 2024


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