Noridian, besides being the Medicare Administrative Contractor (MAC) for Medicare benefits within a specific area of the country, also handles Durable Medical Equipment (DME) benefits for Jurisdiction D. As a DME MAC, Noridian recently issued an “update” on the surgical dressing policy regarding the frequency of dressing changes. What’s strange is that it’s not an update, which leaves me wondering why they wasted their time to post it. I may be paranoid, but the MACs (like Jason Bourne) “don’t do random,” so I’ve been trying to understand why they bothered to post anything.

In part, it says:

“For purposes of this policy, the product in contact with the wound determines the change frequency. It is not reasonable and necessary to use a combination of products with differing change intervals. For example, it is not reasonable and necessary to use a secondary dressing with a weekly change frequency over a primary dressing with a daily change interval…”

Noridian references the Surgical Dressing Local Coverage Determination, which says exactly the same thing, and has said exactly the same thing since at least 2017. In other words, this is nothing new.

Because I am paranoid, I read the LCD for Surgical Dressings again, wondering what I had missed. I made a list (see below) of the change frequency for each dressing category. Since there is no dressing category that must be changed daily or weekly (every category is worded “up to” [once per day, three times per week, seven days]), I must assume that both Noridian and the Surgical Dressing policy are talking about the orders written by a doctor around dressing change frequency for DME products.

Let’s dissect the text I highlighted in yellow:

1. The policy says that the change frequency of the primary dressing (“the product in contact with the wound”) determines the frequency of dressing changes for the wound. OK, so far so good.
2. I understand that when ordering dressings from a DME, a practitioner must specify exactly how often the dressing is to be changed and for how many days total– otherwise the DME doesn’t know how many units to send. In other words, you can’t send a DME order with “as needed” in the frequency. (This is no different than when prescribing a drug – you must specify how often it is to be taken and for how many days). OK, we are still good.
3. I understand that a doctor should not order a product to be changed, for example, “daily” if in fact, it is not covered under the Surgical Dressing policy for daily changes (see frequency information below for each dressing category). OK. That’s clear.
4. Therefore, what the section in yellow must be talking about, is that a doctor should not write an order, for example, for the primary dressing to be changed daily and for the secondary dressing placed over it to be changed less than that (e.g., only three times per week)! In other words, it seems that Noridian has gone to the trouble of emphasizing that doctors should not write stupid DME orders.

I have written a lot about how hard it is for patients to get wound dressings due to what appears to be a nationwide process of draconian audits targeting the DME companies. I’ve seen auditors who, for example, denied payment for a dressing because the doctor described the drainage as “copious” instead of “large” – but the over reach of Medicare auditors is a topic for another day.

Sadly, it’s also true that many practitioners write stupid, contradictory DME orders. Part of the reason is that many practitioners have never read the surgical dressing policy and may have no idea how often Medicare allows a specific product category to be changed -at least if the products are going to be sent by a DME for the patient’s home use. Part of the problem may be that many physicians turn the responsibility for writing the DME orders over to someone else who may or may not know the rules – and then doesn’t bother to read what they signed.

However, even if a practitioner does not know anything about the surgical dressing policy, it should be obvious that if you stack two dressing products on top of each other, the one on the bottom cannot logically be changed more often than the one on the top! C’mon people! While it may be clinically appropriate to change a secondary dressing more often than the primary, you can’t do it the other way around because – seriously do I have to explain this?

I confess that I am secretly worried that auditors will over reach the dressing policy and deny orders because the primary and secondary dressings have different potential change frequencies. Based on the denials I have seen, I have a reason to be paranoid. However, as far as I know, that particular over reach hasn’t happened (yet). At least for now, it appears that Noridian issued an “update” (sic) on their website simply to ask practitioners not to write stupid DME orders. It’s unfortunate (and embarrassing) that such an obvious statement was necessary.

–Caroline

I’ve summarized below the dressing change frequency by product type, per the Surgical Dressing policy, in case you’d like a refresher:

1. Alginate Or Other Fiber Gelling Dressing (A6196-A6199): Dressing change is “up to once per day.”
2. *Collagen Dressing Or Wound Filler (A6010, A6011, A6021-A6024): They can “stay in place up to 7 days.”
3. Composite Dressing (A6203-A6205): Dressing change is “up to 3 times per week.”
4. Contact Layer (A6206-A6208): Dressing change is “up to once per week.”
5. Foam Dressing Or Wound Filler (A6209-A6215): “When a foam wound cover is used as a secondary dressing for wounds with very heavy exudate, dressing change is up to 3 times per week. Dressing change frequency for foam wound fillers is up to once per day.”
6. Gauze, Non-Impregnated (A6216-A6221, A6402-A6404, A6407): “Up to 3 times per day for a dressing without a border and once per day for a dressing with a border.”
7. Hydrocolloid Dressing (A6234-A6241): “up to 3 times per week.”
8. Hydrogel Dressing (A6231-A6233, A6242-A6248): “up to once per day.”
9. Specialty Absorptive Dressing (A6251-A6256): “up to once per day for a dressing without an adhesive border and up to every other day for a dressing with a border.”
10. Transparent Film (A6257-A6259): “up to 3 times per week”
11. Wound Filler, Not Elsewhere Classified (A6261-A6262) “up to once per day”
12. Light Compression Bandage (A6448-A6450), Moderate/High Compression Bandage (A6451, A6452), Self-Adherent Bandage (A6453-A6455), Conforming Bandage (A6442-A6447), Padding Bandage (A6441) “Most compression bandages are reusable. Frequency of replacement would be no more than one per week unless they are part of a multi-layer compression bandage system.”

* Collagens are confusing because “stay in place up to 7 days” does not tell you how often it CAN be changed – and apparently the answer is that it can be changed daily.

Caroline Fife, M.D.

Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/c/carolinefifemd/videos

The opinions, comments, and content expressed or implied in my statements are solely my own and do not necessarily reflect the position or views of Intellicure or any of the boards on which I serve.