Surgical Dressings - Policy Article

**NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES**

For any item to be covered by Medicare, it must 1) be eligible for a defined
Medicare benefit category, 2) be reasonable and necessary for the diagnosis or
treatment of illness or injury or to improve the functioning of a malformed
body member, and 3) meet all other applicable Medicare statutory and
regulatory requirements. Information provided in this policy article relates
to determinations other than those based on Social Security Act 1862(a)(1)(A)
provisions (i.e. "reasonable and necessary").

Surgical Dressings are covered under the Surgical Dressings Benefit (Social
Security Act 1861(s)(5)). The CMS Benefit Policy Manual (IOM 100-02), CH 15,
100 provides interpretive guidance to contractors for the implementation of
this provision. The relevant part of the manual section establishes two
separate benefit criteria:

  * The necessity for and definition of a qualifying wound; and,
  * The requirements necessary for any product to be classified as a surgical dressing for purposes of coverage under this benefit.

In order for a beneficiary's item(s) to be eligible for reimbursement, all
benefit requirements discussed below and the reasonable and necessary (R&N)
requirements set out in the related Local Coverage Determination must be met.

QUALIFYING WOUND

Surgical dressings are covered when a qualifying wound is present. A
qualifying wound is defined as either of the following:

  * A wound caused by, or treated by, a surgical procedure; or,
  * After debridement of the wound, regardless of the debridement technique.

The surgical procedure or debridement must be performed by a treating
practitioner or other healthcare professional to the extent permissible under
State law. Debridement of a wound may be any type of debridement (examples
given are not all-inclusive):

  * Surgical (e.g., sharp instrument or laser)
  * Mechanical (e.g., irrigation or wet-to-dry dressings)
  * Chemical (e.g., topical application of enzymes) or
  * Autolytic (e.g., application of occlusive dressings to an open wound).

Dressings used for mechanical debridement, to cover chemical debriding agents,
or to cover wounds to allow for autolytic debridement are covered although the
debridement agents themselves are noncovered.

Examples (not all-inclusive) of clinical situations in which dressings are
noncovered under the Surgical Dressings benefit are:

  * Drainage from a cutaneous fistula which has not been caused by or treated by a surgical procedure; or,
  * A Stage 1 pressure ulcer; or,
  * A first degree burn; or,
  * Wounds caused by trauma which do not require surgical closure or debridement - e.g., skin tear or abrasion; or,
  * A venipuncture or arterial puncture site (e.g., blood sample) other than the site of an indwelling catheter or needle.

Claims for surgical dressings used for clinical conditions other than the
qualifying wounds as described above will be denied as statutorily non-
covered, no benefit.

QUALIFYING DRESSING REQUIREMENTS

Products that are eligible to be classified as a surgical dressing are defined
as:

  * Primary dressings - Therapeutic or protective coverings applied directly to wounds or lesions either on the skin or caused by an opening to the skin.
  * Secondary dressings - Materials that serve a therapeutic or protective function and that are needed to secure a primary dressing. Items such as adhesive tape, roll gauze, bandages, and disposable compression material are examples of secondary dressings.

Some items, such as transparent film, may be used as a primary or secondary
dressing.

The following are examples of wound care items which are non-covered under the
surgical dressing benefit because they do not meet the statutory definition of
a dressing (not all-inclusive):

  * Skin sealants or barriers (A6250)
  * Wound cleansers (A6260) or irrigating solutions
  * Solutions used to moisten gauze (e.g., saline)
  * Silicone gel sheets (A6025)
  * Topical antiseptics
  * Topical antibiotics
  * Enzymatic debriding agents
  * Gauze or other dressings used to cleanse or debride a wound but not left on the wound
  * First-aid type adhesive bandage (A6413)
  * Any item listed in the latest edition of the Orange Book (e.g., an antibiotic-impregnated dressing which requires a prescription)
  * Surgical stockings (A4490, A4495, A4500, A4510)
  * Non-elastic binder for an extremity (A4465)
  * Small adhesive bandages (e.g., Band-Aid or similar product) are not primarily used for the treatment of wounds addressed in the Surgical Dressings policy.

These dressings are noncovered under the surgical dressing benefit.

Claims for products that are not able to be used as a primary or secondary
dressing on a qualifying wound of the skin or that are composed of materials
that do not serve a therapeutic or protective function will be denied as
statutorily non-covered, no benefit.

MISCELLANEOUS

If a treating practitioner applies surgical dressings as part of a
professional service that is billed to Medicare, the surgical dressings are
considered incident to the professional services of the health care
practitioner and are not separately payable. Claims for these dressings must
not be submitted. Claims for the professional service, which includes the
dressings, must be submitted to the local carrier or intermediary. If dressing
changes are sent home with the beneficiary, claims for these dressings may be
submitted. In this situation, use the place of service corresponding to the
beneficiary's residence; Place of Service Office (POS=11) must not be used.

Claims for tape (A4450 and A4452) which are billed without an AW modifier (see
Coding Guidelines section) or another modifier indicating coverage under a
different policy will be rejected as missing information.

When dressings are covered under other Medicare benefits, there is no separate
payment using surgical dressing codes. Payment for any type of dressing in
these other benefits is included (bundled) in the allowance for applicable
supply codes. Examples, not all-inclusive, are:

  * Dressings used with infusion pumps (which are covered under the DME benefit) are included in the allowance for code A4221.
  * Dressings used with parenteral nutrition (covered under the prosthetic device benefit) are included in the allowance for code B4224.
  * Dressings used with gastrostomy tubes for enteral nutrition (covered under the prosthetic device benefit) are included in the allowance for codes B4034, B4035, B4036.
  * Dressings used with tracheostomies (covered under the prosthetic device benefit) are included in the allowance for code A4625 and A4629.
  * Dressings used with dialysis access catheters (covered under the end stage renal disease benefit) are included in the composite rate (outpatient facility dialysis) or payment cap (method 1 home dialysis) paid to the dialysis provider.

Note that the allowance for items referred to using the term "kit" (e.g. in
HCPCS codes A4625, A4629, B4224, B4034, B4035, B4036) includes not only the
individual major supply items, but also any gauze, tape, other dressing
supplies, etc. necessary for their use. Refer to the applicable LCD and
related Policy Article for additional coverage, coding and documentation
requirements for these items.

Claims separately billed for dressings that are included in a bundled supply
or kit code will be denied as unbundling. (Refer to the CODING GUIDELINES
section for additional information)

Gradient compression stockings (A6530, A6533, A6534, A6535, A6536, A6537,
A6538, A6539, A6540, A6541, A6544, A6549) are non-covered under the surgical
dressing benefit because they do not meet the statutory definition of a
dressing; however, they may be considered for coverage under the lymphedema
compression treatment items benefit and billed in accordance with CMS Final
Rule CMS-1780-F.

LIGHT COMPRESSION BANDAGE (A6448, A6449, A6450), MODERATE/HIGH COMPRESSION
BANDAGE (A6451, A6452), SELF-ADHERENT BANDAGE (A6453, A6454, A6455),
CONFORMING BANDAGE (A6442, A6443, A6444, A6445, A6446, A6447), PADDING BANDAGE
(A6441)

Light compression bandages, self-adherent bandages, and conforming bandages
are covered when they are used to hold wound cover dressings in place over any
wound type i.e., as a secondary dressing over a qualified wound.

Moderate or high compression bandages, conforming bandages, self-adherent
bandages, and padding bandages are covered when they are part of a multi-layer
compression bandage system used in the treatment of a venous stasis ulcer that
meets the requirements to be a qualified wound.

All of these bandages are non-covered when used for non-qualifying conditions
such as, strains, sprains, edema, or situations other than as a dressing for a
qualified wound. Claims for items used in these scenarios will be denied as
statutorily non-covered, no benefit.

GRADIENT COMPRESSION STOCKINGS/WRAPS (A6531, A6532, A6545)

A gradient compression stocking described by codes A6531 or A6532 or a non-
elastic gradient compression wrap described by code A6545 is only covered when
it is used in the treatment of an open venous stasis ulcer that meets the
qualifying wound requirements described above.

Codes A6531, A6532, and A6545 are non-covered for the following conditions:

  * Venous insufficiency without stasis ulcers;
  * Prevention of stasis ulcers;
  * Prevention of the reoccurrence of stasis ulcers that have healed;
  * Treatment of lymphedema in the absence of ulcers.

In these situations, since there is no ulcer, the stockings/wraps do not meet
the definition of a surgical dressing, as there is no qualifying wound. Claims
for these uses will be denied as non-covered, no benefit.

COMPRESSION BURN GARMENTS (A6501, A6502, A6503, A6504, A6505, A6506, A6507,
A6508, A6509, A6510, A6511, A6512, A6513)

Compression burn garments are covered under the Surgical Dressings benefit
when they are used to reduce hypertrophic scarring and joint contractures
following a burn injury.

**REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed.
Reg Vol 217)**

Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a
Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the
DME MACs provide a list of the specified codes, which is periodically updated.
The required Face-to-Face Encounter and Written Order Prior to Delivery List
is available [here](https://www.cms.gov/Research-Statistics-Data-and-
Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-
Review/FacetoFaceEncounterRequirementforCertainDurableMedicalEquipment).

Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol
217) that do not meet the face-to-face encounter and WOPD requirements
specified in the LCD-related Standard Documentation Requirements Article
(A55426) will be denied as not reasonable and necessary.

If a supplier delivers an item prior to receipt of a WOPD, it will be denied
as not reasonable and necessary. If the WOPD is not obtained prior to
delivery, payment will not be made for that item even if a WOPD is
subsequently obtained by the supplier. If a similar item is subsequently
provided by an unrelated supplier who has obtained a WOPD prior to delivery,
it will be eligible for coverage.

**POLICY SPECIFIC DOCUMENTATION REQUIREMENTS**

In addition to policy specific documentation requirements, there are general
documentation requirements that are applicable to all DMEPOS policies. These
general requirements are located in the DOCUMENTATION REQUIREMENTS section of
the LCD.

Refer to the LCD-related Standard Documentation Requirements article, located
at the bottom of this Policy Article under the Related Local Coverage
Documents section for additional information regarding GENERAL DOCUMENTATION
REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed
below.

A new order is needed if a new dressing is added or if the quantity of an
existing dressing to be used is increased. A new order is required every 3
months for each dressing being used.

When the prescribing practitioner is also the supplier, and is permitted to
furnish specific items of DMEPOS, a separate order is not required; however,
the medical record must still contain all of the required order elements.

For initial wound evaluations, the treating practitioner's medical record,
nursing home, or home care nursing records must specify:

  * The type of qualifying wound (see above); and,
  * Information regarding the location, number, and size of qualifying wounds being treated with a dressing; and,
  * Whether the dressing is being used as a primary or secondary dressing or for some noncovered use (e.g., wound cleansing); and,
  * Amount of drainage; and,
  * The type of dressing (e.g., hydrocolloid wound cover, hydrogel wound filler, etc.); and,
  * The size of the dressing (if applicable); and,
  * The number/amount to be used at one time; and,
  * The frequency of dressing change; and,
  * Any other relevant clinical information.

Clinical information, which demonstrates that the reasonable and necessary
requirements in the policy regarding the type and quantity of surgical
dressings provided, must be present in the beneficiary's medical records. This
information must be updated by the treating practitioner (or their designee)
on a monthly basis. This evaluation of the beneficiary's wound(s) is required
unless there is documentation in the medical record which justifies why an
evaluation could not be done within this timeframe and what other monitoring
methods were used to evaluate the beneficiary's need for ongoing use of
dressings.

For beneficiaries in a nursing facility or for beneficiaries with heavily
draining or infected wounds, wound evaluations are expected on a weekly basis.
The evaluation may be performed by a nurse, treating practitioner or other
health care professional involved in the regular care of the beneficiary. This
person may have no financial relationship with the supplier. This prohibition
does not extend to treating practitioners who are also the supplier.

The weekly or monthly evaluation must include:

  * The type of each wound (e.g., surgical wound, pressure ulcer, burn, etc.),
  * Wound(s) location,
  * Wound size (length x width) and depth,
  * Amount of drainage, and
  * Any other relevant wound status information.

The source of that information and date obtained must be documented in the
supplier's records. This information must be available upon request.

When surgical dressings are billed, the appropriate modifier (A1 - A9, AW, EY,
or GY) must be added to the code when applicable. If modifier A9 (DRESSING FOR
NINE OR MORE WOUNDS) is  used, information must be submitted with the claim
indicating the number of wounds. If GY is used, a brief description of the
reason for non-coverage (e.g., "A6216GY - used for wound cleansing") must be
entered in the narrative field of the electronic claim.

When codes A4649, A6261 or A6262 are billed, the claim must include:

  * Description of the item or service
  * Manufacturer name
  * Product name and number
  * Supplier Price List (PL) amount

This information must be entered in the narrative field of the electronic
claim. Miscellaneous HCPCS codes billed without this information will be
return/rejected for missing information.

Claims lines for A4649, A6010, A6011, A6021, A6022, A6023, A6024, A6154,
A6196, A6197, A6198, A6199, A6203, A6204, A6205, A6206, A6207, A6208, A6209,
A6210, A6211, A6212, A6213, A6214, A6215, A6217, A6218, A6219, A6220, A6221,
A6222, A6223, A6224, A6228, A6229, A6230, A6231, A6232, A6233, A6234, A6235,
A6236, A6237, A6238, A6239, A6240, A6241, A6242, A6243, A6244, A6245, A6246,
A6247, A6248, A6251, A6252, A6253, A6254, A6255, A6256, A6257, A6258, A6259,
A6261, A6262, A6266, A6402, A6403, A6404, A6441, A6442, A6443, A6444, A6445,
A6446, A6447, A6448, A6449, A6450, A6451, A6452, A6453, A6454, A6455, A6456,
A6457 billed without A1-A9 modifiers will be rejected as missing information.

Claims lines for A4450 and A4452 billed without AW and A1-A9 modifiers will be
rejected as missing information.

Claim lines for A6531, A6532 and A6545 without an AW modifier (A1-A9 modifiers
are not required for these codes) will be rejected for missing information.

**CODING GUIDELINES**

Products containing multiple materials (excluding basic construction elements
such as backing material, adhesive used in borders, binders, preservatives,
etc.(not all-inclusive)) are classified as either composite dressings or as
multi-component dressings. Impregnated gauze dressing are not included in this
classification.

Composite dressings (A6203, A6204, A6205) are products combining physically
distinct components into a single dressing that provides multiple functions.
These functions must include all of the following:

  * A physical (not chemical) bacterial barrier that is present over the entire dressing pad and extends out into the adhesive border,
  * An absorptive layer other than an alginate or other fiber gelling dressing, foam, hydrocolloid, or hydrogel, and
  * Either a semi-adherent or a non-adherent property over the wound site.

Surgical dressings with a backing that provides a physical bacterial barrier
but does not have an adhesive border do not meet the definition of a composite
dressing because there is no assurance that it will prevent bacterial access
to a wound. These types of dressings are to be coded as specialty absorptive
dressings (A6251, A6252, A6253).

Multi-component dressings that are not classified as composite dressings are
categorized according to the clinically predominant component. The clinically
predominant component is defined based on the proportion of material(s) in the
dressing. For example, a dressing that is 60 percent hydrocolloid and 40
percent alginates would be categorized as a hydrocolloid dressing. HCPCS
Coding is determined based on the following:

  * Products where a single material comprises greater than 50% (by weight) of a product's composition are coded based upon the applicable specific HCPCS code for that material. If a specific HCPCS code does not exist for the predominant component, HCPCS code A4649 is used.
  * Products where no single material comprises greater than 50% (by weight) of the composition are coded as A4649.

Composite and multi-component products may not be unbundled and billed as the
separate components of the dressing.

Alginate or Other Fiber Gelling Dressings (A6196, A6197 and A6198) are
absorbent dressings that manage moderately to highly exudative full thickness
wounds (e.g., stage 3 or 4 ulcers), are composed of a multi-layer or multi-
component structure with either alginate or gelling fiber as the predominant
component. Codes A6196, A6197 and A6198 may be used as either a primary and/or
secondary dressing, as determined by the treating practitioner (see Policy
Specific Documentation Requirements above). When used as a secondary dressing,
the dressing size selected must be appropriate to the size of the wound,
taking into account the wound margin(s). For example, a 2 in. x 2 in. wound
may require a 4 in. x 4 in. pad size. See below for alginate wound fillers
(A6199) used as primary dressings.

Contact layers (A6206, A6207, A6208) are thin non-adherent sheets placed
directly on an open wound bed to protect the wound tissue from direct contact
with other agents or dressings applied to the wound. They are not absorptive.
They are porous to allow wound fluid to pass through for absorption by a
separate overlying dressing. They remain on the wound for an extended time
while the absorptive dressings are changed.

A foam dressing (A6209, A6210, A6211, A6212, A6213, A6214, A6215) is a
sterile, non-linting, absorptive dressing which is made of open cell, medical
grade expanded polymer.

Impregnated gauze dressings (A6222, A6223, A6224, A6228, A6229, A6230, A6231,
A6232, A6233, A6266, A6456) are woven or non-woven materials into which
substances such as iodinated agents, petrolatum, zinc paste, crystalline
sodium chloride, chlorhexidine gluconate (CHG), bismuth tribromo (BTP), water,
aqueous saline, hydrogel, or other agents have been incorporated into the
dressing material by the manufacturer. These codes are not to be used for
gauze dressings containing substances that are not recognized as effective
dressing materials such as silver, honey, copper, cadexomer iodine, charcoal
or other similar materials (not all-inclusive).

Specialty absorptive dressings (A6251, A6252, A6253, A6254, A6255, A6256) are
unitized multi-layer dressings that provide (a) either a semi-adherent quality
or non-adherent layer, and (b) highly absorptive layers of fibers such as
absorbent cellulose, cotton, or rayon. These may or may not have an adhesive
border.

A wound pouch (A6154) is a waterproof collection device with a drainable port
that adheres to the skin around a wound.

Effective for claims with dates of service on or after June 1, 2013, the only
products which may be billed to Medicare using code A6021, A6022, A6023 and
A6024 are those for which a written coding verification review (CVR) has been
made by the Pricing, Data Analysis, and Coding (PDAC) contractor and
subsequently published on the Product Classification List (PCL). Information
concerning the documentation that must be submitted to the PDAC for a Coding
Verification Request can be found on the PDAC web site or by contacting the
PDAC. A PCL with products that have received a coding verification can be
found on the PDAC web site. If a product is billed to Medicare using a HCPCS
code that requires written CVR, but the product is not on the PCL for that
particular HCPCS code, then the claim line will be denied as incorrect coding.

Code A6025 should only be used for gel sheets used for the treatment of
keloids or other scars. Hydrogel sheets used in the treatment of wounds are
billed with codes A6242, A6243, A6244, A6245, A6246, A6247.

When dressings are covered under other benefits, they may not be billed
separately using surgical dressing codes. See Non-Medical Necessity Coverage
and Payment Rules section for additional information.

Wound fillers are primary dressings placed into open wounds to eliminate dead
space, absorb exudate, or maintain a moist wound surface.

Wound fillers come in hydrated forms (e.g., pastes, gels), dry forms (e.g.,
powder, granules, beads), or other forms such as rope, spiral, pillows, etc.
For certain materials, unique codes have been established - i.e., collagen
wound filler (A6010, A6011, A6024), alginate or other fiber gelling wound
filler (A6199), foam wound filler (A6215), hydrocolloid wound filler (A6240,
A6241), hydrogel wound filler (A6248), and non-impregnated packing strips
(A6407). Wound fillers made of recognized dressing materials, not falling into
any of these categories are coded as A6261 or A6262. Wound fillers comprised
of substances that are not recognized as effective dressing materials are
coded as A9270.

The units of service for wound fillers are 1 gram, 1 fluid ounce, 6-inch
length, or one yard depending on the product. If the individual product is
packaged as a fraction of a unit (e.g., 1/2 fluid ounce), determine the units
billed by multiplying the number dispensed times the individual product size
and rounding to the nearest whole number. For example, if eleven (11) 1/2 oz.
tubes of a wound filler are dispensed, bill 6 units (11 x 1/2 = 5.5; round to
6).

For some wound fillers, the units on the package do not correspond to the
units of the code. For example, some pastes or gels are labeled as grams
(instead of fluid ounces), some wound fillers are labeled as cc. or ml.
(instead of fluid ounces or grams), and some are described by linear
dimensions (instead of grams). In these situations, the supplier must contact
the manufacturer to determine the appropriate conversion factor or unit of
service, which corresponds to that used by the code narrative.

Wound covers are flat dressing pads that may serve as either primary or
secondary dressings. A wound cover with adhesive border has an integrated
cover and distinct adhesive border designed to adhere tightly to the skin. In
order to be billed using a "with adhesive border" code, the adhesive border
must be present along all sides of the dressing and must be proportionate to
the size of the dressing pad. All dressing types that utilize an adhesive
border should be sized to appropriately account for the wound margin(s) to
avoid tissue damage.

Some wound covers are available both without and with an adhesive border. For
wound covers with an adhesive border, the code to be used is determined by the
pad size, not by the outside adhesive border dimensions. For example, a
hydrocolloid dressing with outside dimensions of 6 in. x 6 in. has a 4 in. x 4
in. pad surrounded by a 1 in. border on each side and is correctly coded as
A6237, "... pad size 16 sq. inch or less..."

A first-aid type adhesive bandage (e.g., Band-Aid or similar product) is a
wound cover with a pad size of less than 4 square inches. It must be billed
with code A6413.

For products with features that go beyond the usual scope of surgical
dressings (e.g., a large wound cover with a slit in the middle and a plastic
pouch which covers the dressing and is intended to protect an indwelling
venous catheter), the coding determination will be based on the dominant
component that falls under the Surgical Dressings benefit category and that is
appropriate for the management of the wound itself.

Gauze or gauze-like products are typically manufactured as a single piece of
material folded into a several ply gauze pad. Coding must be based on the
functional size of the pad as it is commonly used in clinical practice.

For all dressings, if a single dressing is divided into multiple
portion/pieces, the code and quantity billed must represent the originally
manufactured size and quantity.

Impregnated dressings that are listed in the FDA Orange Book must be billed
using code A9270 and must not be billed using codes A6222, A6223, A6224,
A6231, A6232, A6233, or A6266.

Elastic bandages are those that contain fibers of rubber (latex, neoprene),
spandex, or elastane. Roll bandages that do not contain these fibers are
considered non-elastic bandages even though many of them (e.g., gauze
bandages) are stretchable. Codes A6442, A6443, A6444, A6445, A6446, A6447
describe roll gauze-type bandages made either of cotton or of synthetic
materials such as nylon, viscose, polyester, rayon, or polyamide. These
bandages are stretchable, but do not contain elastic fibers. These codes
include short-stretch bandages.

Codes A6448, A6449, A6450 describe ACE-type elastic bandages. Codes A6451 and
A6452 describe elastic bandages that produce moderate or high compression that
is sustained typically for one week. They are commonly included in multi-layer
compression bandage systems. Suppliers billing these new codes must be able to
provide, upon request, documentation from the manufacturer verifying that the
performance characteristics specified in the code narratives have been met.

When multi-layer compression bandage systems are used for the treatment of a
venous stasis ulcer, each component is billed using a specific code for the
component - e.g., moderate or high compression bandages (A6451, A6452),
conforming bandages (A6443, A6444), self-adherent bandages (A6454), padding
bandages (A6441), zinc paste impregnated bandage (A6456).

For the compression stocking codes A6531 and A6532, one unit of service is
generally for one stocking. However, if a manufacturer has a product
consisting of two components that are designed to be worn simultaneously on
the same leg, the two components must be billed as one claim line with one
unit of service - e.g., a product that consists of an unzippered liner and a
zippered stocking.

The only products that may be billed using code A6545 (non-elastic compression
wrap) are those for which a written CVR has been made by the PDAC contractor
and subsequently published on the PCL. Information concerning the
documentation that must be submitted to the PDAC for a Coding Verification
Request can be found on the PDAC web site or by contacting the PDAC. A PCL
with products that have received a coding verification can be found on the
PDAC web site. If a product is billed to Medicare using a HCPCS code that
requires written CVR, but the product is not on the PCL for that particular
HCPCS code, then the claim line will be denied as incorrect coding.

Modifiers A1 - A9 have been established to indicate that a particular item is
being used as a primary or secondary dressing on a surgical or debrided wound
and to indicate the number of wounds on which that dressing is being used. The
modifier number must correspond to the number of wounds on which the dressing
is being used, not the total number of wounds treated. For example, if the
beneficiary has four (4) wounds but a particular dressing is only used on two
(2) of them, the A2 modifier must be used with that HCPCS code. Modifiers
A1-A9 are not used with codes A6531 and A6532.

If the dressing is not being used as a primary or secondary dressing on a
surgical or debrided wound, do not use modifiers A1-A9. When dressings are
provided in noncovered situations (e.g., use of gauze in the cleansing of a
wound or intact skin), a GY modifier must be added to the code and a brief
description of the reason for non-coverage included - e.g., "A6216GY - used
for wound cleansing."

When tape codes A4450 and A4452 are used with surgical dressings, they must be
billed with the AW modifier (in addition to the appropriate A1-A9 modifier).
When gradient compression stocking codes A6531 and A6532 or the gradient
compression wrap code A6545 are used for an open venous stasis ulcer, the code
must be billed with the AW modifier (but not an A1-A9 modifier). For this
policy, codes A4450, A4452, A6531, A6532, and A6545 are the only codes for
which the AW modifier may be used.

The RT and/or LT modifiers must be used with codes A6531, A6532, and A6545 for
gradient compression stockings and wraps. Effective for claims with dates of
service (DOS) on or after 3/1/2019, when the same code for bilateral items
(left and right) is billed on the same date of service, bill each item on two
separate claim lines using the RT and LT modifiers and 1 unit of service (UOS)
on each claim line. Do not use the RTLT modifier on the same claim line and
billed with 2 UOS. Claims billed without modifiers RT and/or LT, or with RTLT
on the same claim line and 2 UOS, will be rejected as incorrect coding.

When dressing codes are billed for items covered under another benefit (e.g.,
gauze for a continent ostomy which is covered under the prosthetic device
benefit) claims must be billed according to the documentation requirements
specified in the applicable policy (see Ostomy Supplies policy for details).

Suppliers should contact the PDAC contractor for guidance on the correct
coding of these items.