Surgical dressings are the subject of a new widespread prepay review by National Government Services, the Jurisdiction B DME MAC. This is a 100 percent prepay review of medical necessity for claims submitted with the HCPCS codes A6209-A6214 from multiple providers, according to a notice from the DME MAC.
After an initial probe, NGS discovered that a large number of providers are submitting claims for surgical foam dressings when the wound does not qualify for this type of dressing and/or frequency of dressing changes.
If you provide these dressings, you need to verify that your documentation meets Medicare's coverage criteria requirements and is in your files prior to billing. To prove the medical necessity for these claims, you will need the following:
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Signed and dated detailed written physician's order that includes the type of dressing, the size of the dressing, the number/amount to be used at one time, the frequency of dressing change and the expected duration of need.
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Documentation defining the number of wounds being treated with a dressing.
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Documentation of evaluation of the wound(s) during the month prior to the date of service on the claim that includes: the type of each wound (e.g., surgical wound, pressure ulcer, burn, etc.); location, size (length × width in cm) and depth; amount of drainage and/or any other relevant information. These records must be obtained from the physician, nursing home, home care nurse or outpatient centers. The source of that information must be documented.
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Proof of delivery to verify that the beneficiary received the dressings.
Ensuring that your documentation meets the coverage criteria set forth by Medicare and other payers requires proper and ongoing training of your billing, intake and medical documentation team. Review the LCD requirements with your team for the products you provide to make certain you have compliant documentation, not only for your surgical dressing claims but for all of your company's claims.
Based on claims adjudicated for Medicare and processed for Remit DATA customers, HCPCS codes A6209-A6214 had a combined denial rate of 13.8 percent in the second quarter of 2009.
Read more Working Down Denials columns.
Sarah Hanna is a reimbursement consultant and vice president of ECS Billing & Consulting, Tiffin, Ohio, and specializes in proper billing protocols, Medicare coverage guidelines and billing office procedures. You can reach her at 419/448-5332 or sarahhanna@bright.net.
