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 July 1 and September 30, 2023. The error rate for this quarter is 37.50%. 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 when required after debridement of a wound. | 17.78% |
2. | 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). | 16.67% |
3. | Frequency of use or frequency of change is not supported by the medical records. | 13.89% |
4. | 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). | 8.89% |
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. | 8.33% |
6. | 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. | 4.44% |
7. | The medical records do not show that the Alginate or other fiber gelling dressing or filler is being used to cover or fill a moderately to highly exudative full thickness wound (Stage III or Stage IV ulcer). | 3.89% |
8. | The size of the wound in the medical records does not support the HCPCS code being billed. | 3.33% |
9. | The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. | 2.78% |
10. | The documentation does not contain a valid Standard Written Order (SWO). Refer to Standard Documentation Requirements A55426. | 2.78% |
*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:
- Surgical Dressings Documentation Checklist
- Surgical Dressings – LCD (L33831)
- Surgical Dressings – Policy Article (A54563)
- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
Updated: November 15, 2023