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 encounte