Article Detail - JD DME

Article retired due to content incorporation into the applicable Local Coverage Determination or related Policy Article.

Posted November 09, 2012

Recently questions have arisen regarding the use of surgical dressings for Medicare beneficiaries. Surgical dressings are afforded limited coverage by Medicare as defined in the Centers for Medicare & Medicaid Services (CMS) Benefit Policy Manual (Internet-only Manual, Publ. 100-2). Chapter 15, Section 100 of the Benefit Policy Manual provides details for coverage of surgical dressings under this benefit:

Surgical dressings are limited to primary and secondary dressings required for the treatment of a wound caused by, or treated by, a surgical procedure that has been performed by a physician or other health care professional to the extent permissible under State law. In addition, surgical dressings required after debridement of a wound are also covered, irrespective of the type of debridement, as long as the debridement was reasonable and necessary and was performed by a health care professional acting within the scope of his/her legal authority when performing this function. Surgical dressings are covered for as long as they are medically necessary.

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. Items such as adhesive tape, roll gauze, bandages, and disposable compression material are examples of secondary dressings. Elastic stockings, support hose, foot coverings, leotards, knee supports, surgical leggings, gauntlets, and pressure garments for the arms and hands are examples of items that are not ordinarily covered as surgical dressings. Some items, such as transparent film, may be used as a primary or secondary dressing.

As a result of this restrictive language, not all wounds are eligible for surgical dressing reimbursement. To be eligible for coverage, at least one of the two following key statutory requirements must be met:

1) The wound must be surgically-created or surgically-modified; or,

2) The wound requires debridement.

The DME MAC Surgical Dressings Local Coverage Determination and related Policy Article provides additional examples of situations (not all-inclusive) in which dressings are statutorily excluded from coverage under the Surgical Dressings benefit:

a. Drainage from a cutaneous fistula which has not been caused by or treated by a surgical procedure; or,

b. A Stage I pressure ulcer; or,

c. First degree burn; or,

d. Wounds caused by trauma which do not require surgical closure or debridement - e.g., skin tear or abrasion; or,

e. A venipuncture or arterial puncture site (e.g., blood sample) other than the site of an indwelling catheter or needle.

There must be sufficient information in the beneficiary's medical record regarding the wound(s) (e.g., etiology, size, depth, tunneling/undermining, exudate/escar characteristics, prior treatments) to allow the DME MAC's review staff to determine that the wound(s) meet the applicable statutory coverage criteria. In some instances, it may be clinically appropriate to utilize a particular dressing to treat a wound; however, unless the statutory benefit category requirements for surgical dressings described above are met, Medicare coverage for the surgical dressing is precluded. Claims for surgical dressings that do not meet the statutory benefit requirements will be denied as non-covered (no benefit).

Note that if the above statutorily-excluded dressings are billed to Medicare, they must have appended a GY modifier, indicating no Medicare benefit. This statutory exclusion and need for a GY modifier also applies to dressings used for similar situations such as abrasions, cuts, friction tears, ruptured bullae, self-inflicted wounds, "moisture-acquired skin defects" and similar wounds unless they are either (a) caused by or the result of a surgery or (b) documented in the record to have required surgical debridement.

Gradient compression stockings merit additional caution. According to CMS, gradient compression stockings that serve a therapeutic or protective function and that are needed to secure a primary dressing may be covered as surgical dressings. The gradient stocking must be proven to deliver compression greater than 30 mm Hg. and less than 50 mm Hg. In addition to these requirements, the basic benefit category requirement of use to treat a surgically-created or surgically-treated wound must still be met. Consequently, Medicare limits the coverage and reimbursement of gradient compression stockings to the following situation:

• The beneficiary must have an open venous stasis ulcer that has been treated by a physician or other healthcare professional requiring medically necessary debridement. [Emphasis added]
• Additionally, CMS provides guidance on situations where gradient compression stockings are non-covered:
• Venous insufficiency without stasis ulcers
• Prevention of stasis ulcers
• Prevention of the reoccurrence of stasis ulcers that have healed
• Treatment of lymphedema in the absence of ulcers

When a covered gradient compression stocking is provided to a patient with an open venous stasis ulcer, the modifier AW (item furnished in conjunction with a surgical dressing) must be appended or the claim will be denied as a non-covered service.

Finally, note that many of the citations above reference documentation of treatment by the physician or other healthcare professional. Suppliers are reminded that the CMS Program Integrity Manual (Internet-only Manual, Chapter 5) in Section 5.7 states (in part):

However, neither a physician's order nor a CMN nor a DIF nor a supplier prepared statement nor a physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician or supplier. There must be information in the patient's medical record that supports the medical necessity for the item and substantiates the answers on the CMN (if applicable) or DIF (if applicable) or information on a supplier prepared statement or physician attestation (if applicable).

Suppliers should refer to the Surgical Dressings LCD and related Policy Article for additional coverage, coding and documentation requirements.