Surgical Dressings Quarterly Results of Targeted Probe and Educate Review
The Jurisdiction D, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS code(s) A6021, A6212, A6196 and A6197. The quarterly edit effectiveness results from January 2019 through March 2019 are as follows:
Based on dollars, the overall claim potential improper payment rate is 82%.
Top Denial Reasons
- Documentation does not support coverage criteria
- Refill request documentation is incomplete or missing elements
It is important for suppliers to be familiar with the documentation requirements and utilization parameters as outlined in the Surgical Dressings Local Coverage Determination (LCD) L33831, Policy Article A54563 [PDF] and Standard Documentation Requirements Article A55426.
Suppliers can also review specific policy resources for Surgical. There, you will find, information related to proper documentation requirements including a physician letter, documentation checklists, and FAQs.
Suppliers can also review a specific policy Documentation Checklist for Surgical Dressings.
Noridian provides education via supplier webinars, training opportunities, and presentations.
Information about probe/error validation reviews may be found in CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3.
Information defining the number of surgical/debrided wounds being treated with a dressing, the reason for dressing use (e.g., surgical wound, debrided wound, etc.), and whether the dressing is being used as a primary or secondary dressing or for some noncovered use (e.g., wound cleansing) must be obtained from the physician, nursing home, or home care nurse. The source of that information and date obtained must be documented in the supplier's records.
Current clinical information which supports the reasonableness and necessity of the type and quantity of surgical dressings provided must be present in the patient's medical records. Evaluation of a patient's wound(s) must be performed at least on a monthly basis unless there is documentation in the medical record which justifies why an evaluation could not be done within this timeframe and what other monitoring methods were used to evaluate the patient's need for dressings. Evaluation is expected on a more frequent basis (e.g., weekly) in patients in a nursing facility or in patients with heavily draining or infected wounds. The evaluation may be performed by a nurse, physician or other health care professional. This evaluation must include the type of each wound (e.g., surgical wound, pressure ulcer, burn, etc), its location, its size (length x width in cm.) and depth, the amount of drainage, and any other relevant information.
This information must be available upon request.
Surgical dressings are covered when either of the following criteria are met:
- They are required for the treatment of a wound caused by, or treated by, a surgical procedure; or
- They are required after debridement of a wound.
For DMEPOS products that are supplied as refills to the original order, suppliers must contact the beneficiary prior to dispensing the refill and not automatically ship on a pre-determined basis, even if authorized by the beneficiary. Suppliers must have documentation, available upon request, to demonstrate contact with the beneficiary to ensure that the refilled item remains reasonable and necessary, existing supplies are approaching exhaustion, and to confirm any changes/modifications to the order prior to delivery or shipment of the product. For delivery of refills, the supplier must deliver the DMEPOS product no sooner than 10 calendar days prior to the end of usage for the current product. This is regardless of which delivery method is utilized. DME MACs shall allow for the processing of claims for refills delivered/shipped prior to the beneficiary exhausting his/her supply.
Suppliers must not dispense a quantity of supplies exceeding a beneficiary's expected utilization. Suppliers must stay attuned to changed or atypical utilization patterns on the part of their clients.
Suppliers must verify with the prescribing physician that any changed or atypical utilization is warranted.
Refill intervals are noted in the applicable policies. Regardless of utilization, a supplier must adhere to the refill interval(s) noted in the applicable policy.
Items delivered without a valid, documented refill request will be denied as not reasonable and necessary.
For items that the beneficiary obtains in-person at a retail store, the signed delivery slip or a copy of the itemized sales receipt is sufficient documentation of a request for refill.
For items that are delivered to the beneficiary, documentation of a request for refill must be either a written document received from the beneficiary or a contemporaneous written record of a phone conversation/contact between the supplier and beneficiary. The refill request must occur and be documented before shipment. A retrospective attestation statement by the supplier or beneficiary is not sufficient.
The refill record must include:
- Beneficiary's name or authorized representative if different from the beneficiary
- A description of each item that is being requested
- Date of refill request
- For consumable supplies i.e., those that are used up (e.g., ostomy or urological supplies, surgical dressings, etc.) the supplier must assess the quantity of each item that the beneficiary still has remaining to document that the amount remaining will be nearly exhausted on or about the supply anniversary date.
For non-consumable supplies i.e., those more durable items that are not used up but may need periodic replacement (e.g., PAP and RAD supplies) the supplier must assess whether the supplies remain functional, providing replacement (a refill) only when the supply item(s) is no longer able to function. The supplier must document the functional condition of the item(s) being refilled in sufficient detail to demonstrate the cause of the dysfunction that necessitates replacement (refill).
This information must be kept on file and be available upon request.
Last Updated Jun 27, 2019