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Surgical Dressings Documentation and Coding Requirements

National Government Services, the Jurisdiction B DME MAC has identified an increase in the number of requests for reopenings for surgical dressing claims. While the reopening process is available to correct minor errors and omissions it is more cost effective to submit the claim correctly the first time.

As a reminder, suppliers must ensure that the wound(s) which requires treatment using surgical dressings meets the coverage criteria requirements for the type of dressing being applied, the documentation supporting these requirements is available, and the appropriate A1–A9 modifiers are being appended. Per the LCD for surgical dressings, the wound(s) requiring a surgical dressing must be caused by a surgical procedure or after debridement. For patients who do not meet this criterion, their surgical dressing claims must be submitted with a GY modifier.

Once the basic criterion has been established, then the wound must also qualify for the particular type of wound dressing being applied. For example, if a foam dressing (A6209–A6215) is being applied the wound must be a full thickness wound with moderate to heavy exudates. Suppliers should also ensure they are following the policy parameters regarding frequency of change. As in this example of a foam dressing, the policy indicates that the usual frequency of change for a foam wound covering used as a primary dressing is up to three times per week. Therefore if the beneficiary is receiving supplies exceeding the policy limits, the medical record documentation must support the need for the excess supplies for each wound. An order alone is not sufficient documentation. Documentation regarding the need and quantities being ordered must be available upon request.

In addition to establishing the medical necessity for the dressings, suppliers must code their surgical dressing claims with a corresponding wound modifier (A1–A9). Wound modifiers are required to tell the DME MACs the total number of wounds each surgical dressing is being applied to. The following is a listing of the corresponding wound modifiers and their meaning:

  • A1 – Dressing for one wound
  • A2 – Dressing for two wounds
  • A3 – Dressing for three wounds
  • A4 – Dressing for four wounds
  • A5 – Dressing for five wounds
  • A6 – Dressing for six wounds
  • A7 – Dressing for seven wounds
  • A8 – Dressing for eight wounds
  • A9 – Dressing for nine wounds

In the example reference above, if the patient required a foam dressing (A6209–A6215) for three wounds, the supplier would append the A3 modifier to the foam dressings HCPCS code and indicate the total number of units required for all three wounds. Failure to append the appropriate modifiers to surgical dressing claims could result in nonpayment or a reduction in payment.

For additional information, suppliers should refer to the surgical dressing LCD and policy article accessible from the Medical Policy Center on the National Government Services Web site.

Surgical Dressings Documentation and Coding Requirements
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