Probe unearths high denial rate for dressings

Sunday, August 5, 2007

COLUMBIA, S.C. – A second quarter review of foam dressings revealed denials of nearly all claims billed with the A1 modifier in jurisdictions A and B.

TriCenturion’s probe of payments for A6209-A6214 revealed a denial rate of 99.25% in Jurisdiction A and 98.77% in Jurisdiction B. Of those denials, 71% in Jurisdiction A and 65% in Jurisdiction B were denied as not medically necessary, and 28% and 35%, respectively, were denied for no response.

Providers should probably count on seeing similar reviews of other wound care products in the future, said Maxine Rankin, a registered nurse and clinical training and reimbursement specialist for the Holliston, Mass.-based Invacare Supply Group.

“If they are looking at this with foam dressing, they are probably going to be looking at it with (everything),” said Rankin. “If they found this much of a problem here, it’s just the beginning.”

According to the review, medical necessity for foam dressings lacked supporting documentation. Claims need to include physician orders, which need to show:

• Amount and size of dressing, and frequency of change.
• Monthly wound measurements.
• Duration of need.

The review also found that medical records often failed to support claims because:

• Amount of drainage documented did not support the need for the dressing.
• Wound depth measurement did not indicate full thickness involvement.
• Supplier created forms were submitted as a substitution for the medical record.

Rankin said: “I think what’s happening is dealers have to get more involved with keeping medical records and information. They want to know the dressing is still required, month after month. The only way to do that is to measure the wounds.”