Article - Surgical Dressings - Policy Article (A54563)

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 A6024are 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 HCPCS code is being used as a primary or secondary dressing on a qualifying surgical or debrided wound. Modifiers A1-A9 are used to indicate the number of qualifying wounds on which a specific dressing HCPCS code is being used.The modifier number must correspond to the number of qualifying wounds on which the dressing HCPCS code is being used, not the total number of wounds treated.Modifiers A1-A9 are not used with codes A6531 and A6532.Example Scenarios:September 1 Dressing Shipment: Beneficiary has two wounds that require two different categories of dressings, A61XX (max allowance of 30 per month) and A62XX (max allowance of 12 per month)Supplier should bill:A61XX A1 UOS = 30A62XX A1 UOS = 12September 15 Dressing Shipment: Beneficiary has a new wound that requires one of the same categories of dressings as another wound (A61XX  max allowance of 30 per month)Supplier should supply and bill 15 units (to last for the next 2 weeks) and should append the A2 modifier because this dressing category is now used on 2 wounds. NOTE: The modifier number corresponds to the number of wounds on which the dressing is being used, not the total number of wounds treated.A61XX A2 UOS = 15October 1 Dressing Shipment: Beneficiary still has three wounds: two require A61XX (max allowance of 60 per month) and one requires A62XX (max allowance of 12 per month)Supplier should bill:A61XX A2 UOS = 60A62XX A1 UOS = 12