Surgical Dressings (HCPCS A6010, A6196 & A6197) Notification of Service Specific Post-Payment Review

Noridian Jurisdiction D, DME MAC, Medical Review is initiating service specific post-payment medical record review of claims for the following HCPCS codes:

  • A6010: COLLAGEN BASED WOUND FILLER, DRY FORM, STERILE, PER GRAM OF COLLAGEN
  • A6196: ALGINATE OR OTHER FIBER GELLING DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR LESS, EACH DRESSING
  • A6197: ALGINATE OR OTHER FIBER GELLING DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACH DRESSING

Service specific reviews are initiated to prevent improper payments for services which present possible sustained or high-level payment errors. This review is being initiated based on data analysis identifying probable vulnerabilities.

In order to evaluate compliance with Medicare coverage and coding rules, all suppliers having billed Jurisdiction D for the HCPCS codes listed above are subject to review. Suppliers will receive a coversheet identifying the selected claim and a notification letter with instructions for submitting documentation supporting the following information:

  • Treating practitioner's written order
  • Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD), Policy Article, and/or Standard Documentation Requirement Article (A55426) requirements
  • Beneficiary’s medical records (which may include; practitioner medical records, hospital records, nursing home records, home care nursing notes, physical/occupational therapy notes) that support the item(s) provided is/are reasonable and necessary
  • Documentation to support refill request
  • If codes A4649, A6261 or A6262 are billed, the claim must include a narrative description of the item (including size of the product provided), the manufacturer, the brand name or number, and information justifying the medical necessity for the item
  • Any other supporting documentation

Failure to supply the above requested information within 45 days of the letter date will result in initiation of claim adjustments or overpayment recoupments for the undocumented items. The following methods may be used for documentation submission:

In addition to federal laws, regulations, and CMS manuals, the following references will be used in the medical review of the claims and can be accessed on the Noridian website.

  • Local Coverage Determination (LCD) L33831
  • Policy Article A54563
  • Standard Documentation Requirements Article A55426

Additional information, educational opportunities, and training tools related to this product category are available on the Education & Outreach webpage.

Information about post-payment reviews may be found in CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3.

 

Last Updated Fri, 04 Dec 2020 15:40:44 +0000