Article - Surgical Dressings - Policy Article (A54563)

CMS National Coverage PolicyN/AArticle TextNON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULESFor 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 beneficiarys 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 WOUNDSurgical 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) orAutolytic (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 REQUIREMENTSProducts 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 solutionsSolutions used to moisten gauze (e.g., saline)Silicone gel sheets (A6025)Topical antisepticsTopical antibioticsEnzymatic debriding agentsGauze or other dressings used to cleanse or debride a wound but not left on the woundFirst-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.MISCELLANEOUSIf 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 availablehere.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 REQUIREMENTSIn 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 practitioners 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.