CGS*, one of the Medicare Administrative Carriers (MACs) has released a quarterly status report on it’s “pre pay” review for surgical dressings.

This “pre-pay” review is a major reason it has become so difficult to get wound dressings for patients.

The most common reason for denial (23% of claims) is that the documentation does not say that the wound has undergone debridement. Remember that the debridement can be autolytic, enzymatic or mechanical – it does not have to be sharp debridement! One of my former patients blogged about this problem when she went to a different wound center that did not understand this rule.

By now I think most clinicians understand that the depth and drainage amount are key elements that have to be documented, and yet the second most common reason for dressings being denied is failure to document the basics about the wound including size, depth and amount of drainage. The “checklist for surgical dressings” is FIVE PAGES LONG!

I did notice something I hadn’t seen before. Collagen-based dressings are not covered for wound with heavy exudate or when active vasculitis is present (see below).

Basic Coverage Criteria above plus the following specific criteria below must be met for Collagen dressings (A6010, A6011, A6021-A6024):

  • Collagen-based dressing or wound filler is covered for full thickness wounds (e.g., stage 3 or 4 ulcers) wounds with light to moderate exudate, or wounds that have stalled or have not progressed toward a healing goal.
  • Collagen dressings can stay in place up to 7 days.
  • Collagen based dressings are not covered for wounds with heavy exudate, third-degree burns, or when an active vasculitis is present.

Here’s a section from the Surgical Dressings Pre-Pay Review Quarterly Status Report

Below is the analysis of claim denials for surgical dressings HCPCS codes A6010, A6021, A6196-A6199, A6203, A6209-A6212, A6231-A6233, A6234-A6241, A6242-A6248, and A6251-A6256 reviewed between January 1 and March 31, 2023. The error rate for this quarter is 23.93%. The top 10 reasons for claim denials are as follows:

Rank Reason Percent
1. Medical records do not support that the surgical dressings are required for either the treatment of a wound caused by or treated by a surgical procedure, or required after debridement of a wound. 23.43%
2. The healthcare professional’s monthly evaluation of the wound did not include the type of each wound, its location, its size and depth, the amount of drainage, and any other relevant information. 13.14%
3. The medical records do not establish that the dressing is being used as a primary or secondary dressing or for some non-covered use (such as wound cleansing). 8.00%
4. The surgical dressing code was billed without modifiers A1-A9 for the correct number of wounds being treated by the particular dressing. 6.86%
5. The medical records do not support frequency of use or frequency of change. 6.86%
6. The documentation does not contain a valid standard written order (SWO). Refer to Standard Documentation Requirements A55426. 6.29%
7. The medical records do not show that the Collagen dressing is being used on full thickness wound, a wound with light to moderate exudate, or on a wound that has stalled or has not progressed towards a healing goal. 4.57%
8. The medical records do not show that the Composite dressing is being used to cover moderately to highly exudative wounds. 4.57%
9. The medical records do not include an evaluation of the wounds performed on a monthly basis or justification for why they could not be evaluated monthly and what other methods were used to evaluate the need for the dressings. 4.00%
10. The medical records received lack sufficient information concerning the beneficiary’s condition to determine if medical necessity coverage criteria were met. 3.43%

*The total percentage will be greater than 100% because some claims were denied for multiple reasons.
**The error rate included is an overall average for the supplier specific reviews as a part of the Targeted Probe and Educate program. This is not meant to represent an overall error rate for the HCPCS code or policy under medical record review.

*CGS is the Jurisdiction B and C Durable Medical Equipment Medicare Administrative Contractor (DME MAC) providing services to the states/territories of Alabama, Arkansas, Colorado, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Michigan, Minnesota, Mississippi, New Mexico, North Carolina, Ohio, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, U.S. Virgin Islands, Virginia, West Virginia and Wisconsin. CGS is also the Jurisdiction 15 A/B Medicare Administrative Contractor (MAC) providing claims payment and services for Medicare Part A and Part B for the states of Kentucky and Ohio and Home Health & Hospice services for the states of Colorado, Delaware, D.C., Iowa, Kansas, Maryland, Missouri, Montana, Nebraska, North Dakota, Pennsylvania, South Dakota, Utah, Virginia, West Virginia and Wyoming.

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