Throughout 2019, this author has encountered a variety of situations involving wound management providers’ lack of knowledge about coverage guidelines for surgical dressings used by Medicare Part B-covered patients. For example:
- A durable medical equipment (DME) supplier was upset when they received notice that they would be audited via the Targeted Probe and Education (TPE) program. When their current billing practices for the surgical dressings were reviewed, the audit found that the DME supplier was supplying all surgical dressings ordered by physicians even if the orders and medical record documentation were not compliant with the Surgical Dressing Local Coverage Determination (LCD)1 and Coding Article.2,3 When the DME supplier was questioned about this practice, they said they did not want to lose the physicians’ referrals, so they did not question the physicians and always supplied what was ordered.
- Another DME supplier contacted this author about a similar TPE audit. This author learned that the owner knew about the Surgical Dressing LCD and Coding Article but had not adequately trained staff about the coverage guidelines. Therefore, the DME supplier was filling all the physicians’ orders even if they did not align with the LCD and Article.
- A surgical dressing manufacturer complained because the DME Medicare Administrative Contractors (MACs) were conducting TPE audits of the DME suppliers who distributed their products. The reasons for the audits were the lack of medical record documentation of the medical necessity for the products ordered, as well as the lack of documentation that surgical dressings were even ordered. For some reason, the manufacturer thought the DME MACs had released new coverage rules without going through a public comment period. The manufacturer was surprised to learn that the Surgical Dressing LCD has been in place for decades.
- At a recent wound management seminar, multiple surgical dressing sales representatives had no idea which of their surgical dressings, when used as primary and secondary dressings on the same wound, would or would not be covered by Medicare. When questioned why they were marketing their products in a manner that did not align with the Surgical Dressing LCD and Coding Article, many of them had no idea that either existed.
These and many other real-life scenarios indicate that, even though the LCD and Article have existed for more than 20 years, we must continue to educate wound management professionals, manufacturers and sales representatives, DME suppliers, and coders/billers about the utilization guidelines, documentation requirements, and ordering requirements for surgical dressings. This author recommends that each of these wound management stakeholders download, print, read, and highlight the LCD and Coding Article. Manufacturers should create/refine marketing materials to align with the coverage guidelines. Wound management professionals should use the information in these coverage documents to refine their ordering and documentation practices.
If a DME supplier does not receive the required documentation and orders, the DME supplier has one of four choices: (1) contact the ordering physician to obtain the documentation and orders, (2) contact the ordering physician to obtain new orders that align with the coverage documents, (3) tell the patient that Medicare does not cover the dressing(s) and deny service to the patient, or (4) give the patient an Advance Beneficiary Notice of Noncoverage, provide the dressings, and bill the patient for the full cost of the products.
Key Points to Remember
- To qualify for a surgical dressing covered by Medicare Part B, a wound must be caused by or treated with a surgical procedure, or must have been debrided.
- The medical record should include the patient’s medical condition that substantiates the medical necessity for the type of surgical dressing ordered, and the following information must be shared with the DME supplier or a Medicare auditor upon request:
- ○ wound evaluation (type, location, size, depth, amount of drainage, and any other relevant information);
- ○ the number of surgical/debrided wounds being treated with a dressing;
- ○ the reason for dressing use (surgical wound, debrided wound); and
- ○ if the dressing is being used as a primary or secondary dressing or for some noncovered use (such as wound cleansing).
- The physician must write patient-specific orders that include the beneficiary’s name, date of the order, surgical dressing description, size of the dressing (if appropriate), number/amount of dressing to be used, frequency of dressing change and/or expected duration of use, and prescribing physician signature and signature date.
The LCD and Article specify guidelines to assist the wound management professional in selecting primary and secondary dressings that are covered by Medicare Part B. Most of the guidelines pertain to wound depth, exudate and frequency of dressing change. The coverage guidelines also discuss the appropriate use of primary and secondary dressings on the same wound at the same time. For example, the LCD states that a hydrating dressing (eg, hydrogel) and an absorptive dressing (eg, alginate) should not be used on the same wound at the same time. In another example, the LCD states that it is not reasonable and necessary to use a secondary dressing with a weekly change frequency over a primary dressing with a daily change interval.
Because wound management professionals and manufacturers appear to be confused by the LCD’s direction about primary and secondary surgical dressing selection, one of the DME MACs has created an excellent surgical dressings webpage.4 It includes a link to the LCD and Article and an excellent surgical dressings reference chart that provides a quick look at what surgical dressings are covered for various wound depths and exudates, along with Medicare's recommended frequency of change coverage information. In the LCD, Coding Article, and Reference Chart, you will learn such important facts as:
- Alginates are not covered for wounds with minimal exudate, but are covered for wounds with moderate and heavy exudate, and are usually changed daily.
- Contact layers may be used on wounds with any amount of exudate and are usually changed once per week.
- Foams are not covered for wounds with minimal exudate, but are covered for wounds with moderate and heavy exudate, and are usually changed up to three times per week.
- Hydrocolloids are covered for wounds with minimal and moderate exudate but not for wounds with heavy exudate and are usually changed up to three times per week.
The Noridian webpage also includes three easy-to-use surgical dressing look-up tools.5 The first tool helps the wound management professional determine the type of dressings covered based on the amount of exudate and wound depth information. For example, if a minimal amount of exudate and a partial-thickness wound are entered, the look-up tool provides the following information:
- Exudate: Minimal
- Wound Depth: Partial or closed
- Dressing Type: Transparent film
- Usual Dressing Change: Up to three times week
The second tool allows the wound management professional to search by Healthcare Common Procedure Coding System (HCPCS) code and find the dressing type, wound depth, exudate, and usual dressing change information. For example, if HCPCS code A6248 is selected, the look-up tool provides the following information:
- Dressing Type: Hydrogel - wound filler
- Wound Depth: Full thickness
- Exudate: Minimal
- Usual Dressing Change: 3 units per wound per 30 days
The third tool allows the wound management professional to determine wound depth, exudate, and usual dressing change interval by selecting a dressing type. For example, if “collagen dressing” is selected, the look-up tool provides the following information:
- Dressing Type: Collagen
- Wound Depth: Full thickness
- Exudate: Minimal to moderate
- Usual Dressing Change: Up to 7 days
Both DME MACs6 continue to provide educational materials and webinars pertaining to Medicare Part B coverage of surgical dressings. They even share the results of their surgical dressing TPE audits. In addition to the top denial reasons, the DME MACs provide the exact coverage language that was not followed and myriad educational resources. Surgical dressing manufacturers should take advantage of these tools for their executives and sales and marketing teams. Wound management professionals should learn the details of the LCD and Article and should also take advantage of the resources available.
Armed with this information, surgical dressing manufacturers can design their sales and marketing efforts around the DME MACs’ coverage guidelines. Wound management professionals can develop their plans of care, document their wound assessments, and write detailed orders that comply with the coverage guidelines. Most important, patients will receive the Medicare Part B-covered dressings they need because the DME suppliers will be able to provide the medically necessary surgical dressings and pass all surgical dressing TPE audits with flying colors.