Ask the PSC MDs

Tuesday, October 31, 2006

New coding changes went into effect for surgical dressings Oct. 1, 2006. These new coding changes, along with findings and issues identified through DME PSC medical review activities, serve as the basis for this article. But first, some background. Coverage of surgical dressings under Medicare's DMEPOS benefit is limited to primary and secondary dressings that are required for treating wounds from a surgical procedure. A licensed physician or other healthcare professional must perform the surgery. Surgical dressings are also covered if they're required for treating a wound after debridement, irrespective of the type of debridement, provided the debridement was reasonable and necessary and performed by a licensed healthcare professional. Surgical dressings are covered for as long as they are needed or medically necessary.
Q. What type of coding should be used when billing for dressings that are slightly larger than 4 square inches?
A. Slightly larger dressings are not functionally different and do not warrant higher reimbursement. The DME PSCs have determined that they should be reimbursed using the "16 square inches or less" codes. A similar determination has been made for dressings that slightly exceed 48 square inches.
Q. What if the wound is not as large as a 4-square-inch dressing, meaning the dressing is slightly larger than the wound?
A. As stated in the LCD for surgical dressings, the dressing size must be appropriate for the wound size. It would not be reasonable or appropriate for the dressing size to be more than 2 inches greater than the actual dimension of the wound. For example, a dressing greater than 16 square inches would not be medically necessary for a wound less than 2 inches across.
Q. Are smaller adhesive dressings covered? If so, how are they coded?
A. Small adhesive bandages (e.g. Band-Aids or similar products) are not primarily used for the treatment of surgical wounds addressed in the surgical dressings policy and, therefore, are not covered under the surgical dressing benefit. If they are used for protecting a dermatologic wound performed in an outpatient setting or a physician's office, they are covered as part of the composite payment for the surgical procedure. If suppliers choose to submit claims for these products, they must be billed with the code A9270 (non-covered item or service).
Q. How often does a surgical dressing need to be changed?
A. Surgical dressings must be tailored to meet the specific needs of an individual patient. The number of changes depends on the character of the wound being treated, the amount of wound drainage, the type of dressing required, how often the wound requires assessment and what stage of healing the wound is in. Dressing needs may change frequently (e.g. weekly) in the early phases of wound treatment and/or with heavily draining wounds.
Composite dressings, foam and hydrocolloid wound covers, and transparent film--when used as secondary dressings--should be changed less than once a day. These dressings are designed to be changed every three to seven days, depending on the character and healing status of the wound. Use of these dressings as primary dressings may not be appropriate if more frequent dressing changes are required. Clinical judgment should be used to avoid their use with primary dressings.
Alginate or other fiber gelling dressing covers are used to treat moderately to highly exudative full thickness wounds (e.g., stage III or IV ulcers). Usual dressing change is up to once per day.
For further details regarding surgical dressings, please refer to the LCD on surgical dressings. If a manufacturer or supplier has a question about the correct coding of a specific product, they should contact the SADMERC for a coding verification review.