Correct Coding and Coverage of Oral Suspensions used in the Treatment of Oral Mucosal Injures - JA DME

Joint DME MAC Publication

In recent years, several products have come to market for use by beneficiaries with oral mucosal injuries. These products, Mugard Mucoadhesive (AMAG Pharmaceuticals, Inc.), Gelclair (DARA BioSciences Inc.), and similar products claim to adhere to the injured mucosal surface providing protection. These oral suspensions are used in the treatment of oral mucosal injuries caused by a variety of underlying illnesses and treatments. The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) Medical Directors have evaluated these products for coverage.

Medicare is a defined benefit program. In order for any item to be eligible for payment, the item must first be eligible for inclusion into one of the statutorily established benefit categories. The Medicare Surgical Dressings Benefit provides the definition of covered dressings that are eligible for dressing reimbursement. CMS Internet Only Manual (IOM), Publication 100-02, Benefit Policy Manual, Chapter 15, Section 100 says, in relevant part:

Surgical dressings are limited to primary and secondary dressings required for the treatment of a wound…

Primary dressings are therapeutic or protective coverings applied directly to wounds or lesions either on the skin or caused by an opening to the skin. Secondary dressing materials that serve a therapeutic or protective function and that are needed to secure a primary dressing are also covered. (Emphasis added)

This benefit limits coverage to wounds of the skin. Treatments used for injuries to the oral mucosa are not eligible for coverage under this benefit as oral mucosa is not skin. It is a different tissue type and thus is excluded from this benefit.

Although these products may serve a beneficial purpose in the treatment of oral mucosal injuries, there is no coverage available under the Surgical Dressings benefit for these items. There is no other benefit category under which Medicare coverage might be possible. Claims submitted to the DME MACs for these products must use HCPCS code:

• A9270 - NON-COVERED ITEM OR SERVICE

For questions about correct coding, contact the Pricing, Data Analysis, and Coding contractor (PDAC) at (877) 735-1326 during the hours of 8:30 a.m. to 4 p.m. CT, Monday through Friday, or e-mail the PDAC by completing the DME PDAC Contact Form.