Article - Surgical Dressings - Policy Article (A54563)

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, andAny 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) isused, 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 serviceManufacturer nameProduct name and numberSupplier Price List (PL) amountThis 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 GUIDELINESProducts 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, andEither 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.