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 July 1 – September 30, 2024. The error rate for this quarter is 44.14 %. 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. | 28.57% |
2. | 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. | 10.99% |
3. | Frequency of use or frequency of change is not supported by the medical records. | 10.99% |
4. | The medical records do not show that the dressing is being used as a primary or secondary dressing or for some non-covered use (for example wound cleansing). | 9.34% |
5. | Medical records do not support that the surgical dressings are needed for either the treatment of a wound caused by, or treated by, a surgical procedure; or when required after debridement of a wound. | 6.59% |
6. | The size of the wound in the medical records does not support the HCPCS code being billed. | 6.59% |
7. | The documentation does not have a valid order. | 5.49% |
8. | 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. | 4.40% |
9. | 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). | 3.30% |
10. | Payment for supplies billed above normal policy usage is being denied due to lack of documentation to support that they are reasonable and necessary. | 2.75% |
*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.
Resources:
- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
- Supplier Manual Chapter 3 – Supplier Documentation
- Surgical Dressings Documentation Checklist
- Surgical Dressings – LCD (L33831)
- Surgical Dressings – Policy Article (A54563)
Updated: November 5, 2024