Even though Medicare's surgical dressing local coverage determination (LCD) has existed for more than 20 years, it appears that wound care providers have forgotten the documentation rules, do not know the documentation rules, or have become lazy with their documentation to justify the medical necessity of surgical dressings used in the home by Medicare patients. A recent widespread prepayment probe review of alginate surgical dressings was conducted by one of the Durable Medical Equipment (DME) Medicare Administrative Contractors (MAC) and exemplifies this documentation issue. Believe it or not, 92% of the claims submitted for alginate surgical dressings were denied because of inadequate documentation. That is costly to, and often disastrous for, the wound care patients who need to change their dressings at home in-between visits to their qualified healthcare professional's (QHP's) (eg, MD, DO, DPM, NP, PA, CNS) office or to the hospital-based outpatient wound care department. These patients paid their Medicare Part B premiums and should have paid only 20% of the Medicare Part B allowable rate for their surgical dressings. Unfortunately 92% of the patients had to pay 100% of the Medicare Part B allowable rate because of their wound care professionals' inadequate documentation. Because wound care professionals do not want to prevent their patients from obtaining their rightful Medicare benefits, now is a good time to carefully review the documentation requirements of the surgical dressing LCD.
But first, let's look at the reasons 92% of the claims were denied:
* Wound debridement was not seen in the documentation.
* Documentation did not support moderate-high exudative full-thickness (Stage III-IV) wounds.
* Wound evaluation was missing type, location, size, depth, or drainage amount.
* Order did not specify quantity to be used at one time.
* Order did not specify dressing change frequency.
* No medical records were submitted when requested.
Next let's look at pertinent general documentation checklists that are based on Chapter 3 of the Medicare Supplier's Manual. Note: The guidelines that were not followed by the recent widespread prepayment probe review are underlined.
Written order prior to delivery should include
[check mark] beneficiary name
[check mark] physician name
[check mark] date of the order and the start date (if applicable)
[check mark] detailed description of the item(s)
[check mark] prescribing practitioner's National Provider Identifier
[check mark] physician signature
[check mark] signature date
[check mark] date stamp indicating supplier's date of receipt for written order prior to delivery on or before date of delivery
Dispensing order should include
[check mark] description of item(s)
[check mark] beneficiary name
[check mark] physician name
[check mark] date of order and start date (if applicable)
[check mark] physician signature (if written order) or supplier signature (if verbal order)
Detailed written order should include
[check mark] beneficiary name
[check mark] physician name
[check mark] date of order and start date (if different from date of order)
[check mark] detailed description of item(s)
[check mark] physician signature and signature date
Detailed written order for items provided on a periodic basis should include
[check mark] item(s) to be dispensed
[check mark] dosage or concentration (if applicable)
[check mark] route of administration (if applicable)
[check mark] frequency of use
[check mark] duration of infusion (if applicable)
[check mark] quantity to be dispensed
[check mark] number of refills (if applicable)
Now let's look at the pertinent surgical dressing LCD (L33831) requirements that were not fully met by the documentation supporting medical necessity for the denied alginate claims:
Alginate or other fiber gelling dressing (A6196-A6199)
Alginate or other fiber gelling dressing covers are covered for moderately to highly exudative full-thickness wounds (eg, Stage III or IV ulcers) and alginate or other fiber gelling dressing fillers for moderately to highly exudative full-thickness wound cavities (eg, Stage III or IV ulcers). They are not medically necessary on dry wounds or wounds covered with eschar. Usual dressing change is up to once per day. One wound cover sheet of the approximate size of the wound or up to 2 units of wound filler (1 unit = 6 inches of alginate or other fiber gelling dressing rope) is usually used at each dressing change. It is usually inappropriate to use alginates or other fiber gelling dressings in combination with hydrogels.
Documentation Requirements
Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider." It is expected that the patient's medical records will reflect the need for the care provided. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals, and test reports. This documentation must be available upon request.
An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request. Items billed before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code.
The order must specify (a) the type of dressing (eg, hydrocolloid wound cover, hydrogel wound filler, and so on), (b) the size of the dressing (if appropriate), (c) the number/amount to be used at one time (if more than one), (d) the frequency of dressing change, and (e) the expected duration of need.
A new order is needed if a new dressing is added or if the quantity of an existing dressing to be used is increased. A new order is not routinely needed if the quantity of dressings used is decreased. However, a new order is required at least every 3 months for each dressing being used even if the quantity used has remained the same or decreased.
Information defining the number of surgical/debrided wounds being treated with a dressing, the reason for dressing use (eg, surgical wound, debrided wound, and so on), and whether the dressing is being used as a primary or secondary dressing or for some noncovered use (eg, 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 that 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 that 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 (eg, weekly) in patients in a skilled nursing facility or in patients with heavily draining or infected wounds. The evaluation may be performed by a nurse, physician, or other healthcare professional. This evaluation must include the type of each wound (eg, surgical wound, pressure ulcer, burn, and so on), 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.
When surgical dressings are billed, the appropriate modifier (A1-A9, AW, EY, or GY) must be added to the code when applicable. If A9 is used, information must be submitted with the claim indicating the number of wounds. If GY is used, a brief description of the reason for noncoverage (eg, "A6216GY-used for wound cleansing") must be entered in the narrative field of the electronic claim.
If you have not reviewed the Surgical Dressing LCD or if you need a refresher, visit: http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=338.
This particular surgical dressing LCD also has an attached Article A52491: http://www.cms.gov/medicare-coverage-database/details/article-details.aspx?artic.
The pertinent documentation guidelines found in this Article are as follows:
* Surgical dressings are covered when either of the following criteria are met:
[white circle] They are required for the treatment of a wound caused by, or treated by, a surgical procedure; or
[white circle] They are required after debridement of a wound.
* The surgical procedure or debridement must be performed by a physician or other healthcare professional to the extent permissible under state law. Debridement of a wound may be any type of debridement (examples given are not all-inclusive): surgical (eg, sharp instrument or laser), mechanical (eg, irrigation or wet-to-dry dressings), chemical (eg, topical application of enzymes), or autolytic (eg, application of occlusive dressings to an open wound). Dressings used for mechanical debridement to cover chemical debriding agents or to cover wounds to allow for autolytic debridement are covered, although the agents themselves are noncovered.
Now that you have read Medicare's surgical dressing documentation requirements, I am sure you will agree that the LCD and attached Article provided clear documentation guidelines. To make matters worse, during the prepayment probe review, many DME suppliers did not provide the requested medical records-most likely because they knew the medical records did not include the required documentation. Remember that failure to respond to requests for additional documentation is in violation of supplier standard number 28, found in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual Publication 100-08, Medicare Program Integrity Manual, Chapter 15, which states "Under 42 CFR [S]424.516(f)(1), a provider or supplier that furnishes covered ordered items of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS); clinical laboratory; imaging services; or covered ordered/certified home health services is required to maintain documentation for 7 years from the date of service, and upon the request of CMS or a Medicare contractor, provide access to that documentation."
Summary
In order to prevent our wound care patients from incurring costs that rightfully would be paid by their Medicare Part B insurance, if only their medical record justified the medical necessity for the surgical dressings that they must change at home, QHPs should take the time to review the entire Surgical Dressing LCD and attached Article. Although the Surgical Dressing LCD and attached Article does not directly affect the Medicare payment for most QHPs (except those who also have a separate DME supplier number), it is an important guideline that has been in place for many years and that should guide QHPs' documentation for these dressings that are vital to wound care patients. Once you read the LCD, you will be able to easily adjust your documentation to provide the DME MACs with the medical necessity for each category of surgical dressing your patients require.
Together, healthcare practitioners should make a goal of never making the patients pay 100% for their essential surgical dressings when they should pay only 20%. Personally speaking, I know for sure that my mother would stop using her surgical dressings if she had to pay 100% of the costs. She is 98 years old, has paid into Medicare Part B for many years, and deserves to receive those benefits now, when she needs them most.