Practitioners who participate in the surgical dressing program can dispense high quality wound care products directly to their patients. Examples of surgical dressings include collagen, calcium alginate, foam, gauze, hydrocolloids, hydrogel, and compression garments.
Advantages
Dispensing the products a patient needs to care for their wounds directly to the patient eliminates the need for the patient to deal with a pharmacy to get these products. This is an advantage to participation in the surgical dressing program because, often, the travel to the pharmacy is a barrier to the patient getting the wound care products they need. Eliminating the pharmacy also eliminates the possibility of the item the practitioner ordered being substituted or changed to something less efficacious by the pharmacy.
Compliance
There are MACs for Part B services and MACs for durable medical equipment (DME). As surgical dressings are a form of DME, the compliance guidelines for surgical dressings dispensed to Medicare beneficiaries are provided by the DME MACs, CGS Administrators, LLC and Noridian Healthcare Solutions, LLC. Non-Medicare third party payers may have their own coverage policies, but most non-Medicare third party payers that provide this benefit use the same guidelines that are provided by the DME MACs. This article shares the guidelines of the DME MACs.
Umbrella Requirements:
Surgical dressings are covered for Medicare beneficiaries if:
- The dressing(s) are medically necessary
- The exudate quantity of the wound(s) to be treated is documented
- Debridement of the wound to be treated was medically necessary and it was debrided, or the surgical dressings are to be used in the treatment of an ulcer caused by or treated by a surgical procedure
Medical Necessity
The presence and documentation of medical necessity is a requirement that applies to all medical services and supplies when submitting for payment to a third party payer. This applies to all evaluation and management services, all procedures, and all supplies, including surgical dressings. When dispensing surgical dressings, the documentation must clearly illustrate the medical necessity of the dressings. There are many situations in which surgical dressings are medically necessary. Just some include a wound in a compromised patient, a wound complicated by arterial disease, and a wound complicated by malnutrition. There are many others.
An example of a portion of a progress note that clearly demonstrates the medical necessity of collagen powder is:
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This is a chronic ulcer. This ulcer is not demonstrating signs that lead me to believe it will heal if current treatment continues and advanced healing options are not instituted. Ulcers of this nature have a high rate of failure to heal, and high rates of infection, amputation, other morbidity, and even mortality associated with them. Therefore, advanced treatment in the form of collagen powder is medically necessary and indicated in an effort to heal this chronic ulcer and prevent amputation. Collagen was selected as this wound is stalled and not progressing toward the goal of healing the way it should be. I expect the collagen to attract monocytes and fibroblasts, act as a sacrificial substrate for MMPs, and ultimately provide a matrix for tissue and vessel growth. |
Primary and Secondary Surgical Dressings
There is no cure for lymphedema. However, it can be managed when the appropriate tools are employed. When lymphedema is appropriately managed, the risks of the complications listed above occurring are significantly decreased.
Extermit-EASE changes all of that with a revolutionary design that makes it much easier for patients to apply, remove, and tolerate. Extremit-EASE combines a zipper and bungees with large tabs to make independent application and adjustment easy for patients to achieve—even if they suffer from dexterity issues. Patients appreciate the lightweight, air permeable fabric allowing for hours of comfortable wear with less sweat, fewer hot spots, and less pistoning.
Another study[1] demonstrated the marked difference in compliance with compression when the Extermit-EASE is used. This study truly tested the improvement when Extremit-EASE is selected over other options by only including patients with venous insufficiency or lymphedema who had failed treatment with standard compression because they could not tolerate it. On a scale of 1-5, with 1 being “very difficult” and 5 being “very easy,” patients in the study ranked “ease of application” with the more traditional compression garment as 1.74 versus 4 with Extremit-EASE. On a scale of 1-5, with 1 being “very uncomfortable” and 5 being “very comfortable,” patients in the study ranked “comfort” with the more traditional compression garment as 1.91 versus 4.17 with Extremit-EASE. The patients in this study were able to wear the Extremit-EASE almost twice as many hours per day as they did the more traditional option. Better compliance by patients with the treatment they need results in better results for them and better outcomes for medical practices[2].
If dispensing multiple products at the same time, as in the case of an AmerX® Wound Care Kit, each product should be accounted for and this designation of primary versus secondary use should be made for each product. This could be accomplished with a sentence such as, “The collagen powder in this kit will be used as a primary dressing and the bordered gauze in this kit will be used as a secondary dressing.”
For assistance in determining the primary or secondary designation of AmerX dressings, this summary may be helpful:
HELIX-3 Collagen – Primary
AmerX Foam Dressing – Primary or secondary
AmerX Calcium Alginate Dressing – Primary or secondary
AmerX Gauze Dressing – Secondary
Amerigel® Hydrogel Wound Dressing – Primary
AmerX Hydrocolloid Dressing – Primary or secondary
EXTREMIT-EASE® Compression Garment- Secondary
“Exudate” Versus “Drainage”
The coverage for many surgical dressings is, in part, dependent on the volume of exudate. Some coverage requirements include:
Foam: Moderate to heavy exudate
Calcium Alginate: Light to Moderate exudate
Hydrogel: Minimal or no exudate
Collagen: Light to moderate exudate, or wounds that have stalled or have not progressed toward a healing goal.
Product Requirements
In addition to the umbrella requirements listed above, each product type has its own documentation requirements for coverage:
Collagen: Must document medical necessity and one or more of:
The wound is full thickness
The wound has light to moderate exudate
The wound has stalled or has not progressed toward a healing goal
Foam: Must document medical necessity, the wound has moderate to heavy exudate, and the wound is full thickness.
Calcium Alginate: Must document medical necessity, the wound has moderate to heavy exudate, and the wound is full thickness.
Hydrogrel: Must document medical necessity, the wound has zero to light exudate, and the wound is full thickness.
Hydrocolloid: Must document medical necessity and the wound has light to moderate exudate.
More Documentation Requirements
The documentation created when surgical dressings are dispensed should also include:
- Ulcer location
- Ulcer type
- Ulcer Stage
- Ulcer length, width, and depth
- Type of surgical dressing(s) dispensed
- Dressing size(s)
- Number of dressings dispensed
- Number of wounds being treated
- Frequency of surgical dressing changes
- Anticipated duration of surgical dressing requirement
If a kit is dispensed with multiple surgical dressing types, then these documentation requirements must be met for each dressing included in the kit.
All these items listed above must be documented in the progress note even if they are also documented in the Proof of Delivery and / or Standard Written Order.
Updated Information
The DME MAC Surgical Dressings policies require that the clinical information that demonstrates the medical necessity of dispensed surgical dressings be updated on a monthly basis if the patient is using the product(s) for more than one month. If the patient who has received surgical dressings is in a nursing facility or if the patient has a heavily draining or infected wound, this update must be performed weekly. In this situation, the update may be performed by the prescribing / dispensing physician, a nurse, or any health care professional that is involved in the regular care of the patient.
This monthly (or weekly) required evaluation should include:
- Wound type(s)
- Wound(s) location
- Wound(s) size
- Wound(s) drainage
- Any other relevant wound status information
Choosing the Proper Dressing Size
When dispensing surgical dressings, the dressing size should be selected based on the size of the ulcer being treated. From a clinical standpoint, the dressing should cover the entire ulcer. Practitioners should choose the smallest size of the needed dressing that will still cover the entire ulcer.
Proof of Delivery
As surgical dressings are a form of DME, a Proof of Delivery form must be completed when surgical dressings are dispensed. This proof of delivery may be needed to substantiate reimbursement. It may be requested by DME MACs, recovery auditors, supplemental medical review contractors, or Comprehensive Error Rate Testing (CERT) medical review contractors. This Proof of Delivery must be maintained by the supplier for seven years from the date of service. The Proof of Delivery must include:
- Patient name
- Address where item was delivered (i.e. practice address)
- Description of the item
- Quantity delivered
- Patient or designee signature
- Date delivered
The description of the item can be a narrative description of the item, the item’s HCPCS code, the item’s HCPCS code descriptor, and/or the item’s brand name / model number.
When surgical dressings are delivered directly, the patient or a designee who is accepting the item on behalf of the patient must sign the proof of delivery. A designee can be someone with any relationship to the patient such as a neighbor or friend. The designee may not be the supplier themselves, an employee of the supplier, or anyone that has a financial interest in the delivery of the item. When a designee accepts the item on behalf of the patient, the relationship of the designee to the patient must be noted on the delivery slip. Furthermore, if the designee signs for the item, and their signature is not legible, their name should be printed below it.
Standard Written Order
When surgical dressings are supplied, the supplier must maintain a Standard Written Order (SWO) for the dressings supplied. This requirement used to be for a “Detailed Written Order,” but that changed to a SWO as of January 1, 2020. The required elements of the SWO include:
- Beneficiary’s name or Medicare Beneficiary Identifier (MBI)
- Order date
- General description of the item – The description can be either a general description (e.g., wheelchair or hospital bed), a HCPCS code, a HCPCS code narrative, or a brand name/model number
- Quantity to be dispensed
- Treating practitioner name or National Provider Identifier (NPI)
- Treating practitioner’s signature
In the case that the prescribing practitioner is also the supplier, a separate SWO is not required if all the required elements of the SWO are documented in the medical record.
Conclusion
When surgical dressings are delivered directly, the patient or a designee who is accepting the item on behalf of the patient must sign the proof of delivery. A designee can be someone with any relationship to the patient such as a neighbor or friend. The designee may not be the supplier themselves, an employee of the supplier, or anyone that has a financial interest in the delivery of the item. When a designee accepts the item on behalf of the patient, the relationship of the designee to the patient must be noted on the delivery slip. Furthermore, if the designee signs for the item, and their signature is not legible, their name should be printed below it.
[1] https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33831&ContrID=140[2] https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=54563[3] https://med.noridianmedicare.com/web/jddme/topics/documentation/standard-written-order
Dr. Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC, CPMA
Dr. Lehrman is a podiatrist practicing in Fort Collins, CO and operates Lehrman Consulting, LLC which provides consultation services regarding coding, compliance and documentation. Dr. Lehrman is a Certified Professional Coder and Certified Professional Medical Auditor. He serves as a staff liaison at the AMA CPT® Editorial Panel meetings where CPT codes are created, edited, and deleted. He is a Diplomate of the American Board of Foot and Ankle Surgery, Fellow of the American Society of Podiatric Surgeons, and is recognized as a “Master” by the American Professional Wound Care Association. Dr Lehrman is a Fellow of the American Academy of Podiatric Practice Management, Past Director of the American Professional Wound Care Association Board of Directors, and is a Past Chairman of the Board of the American Society of Podiatric Surgeons. Dr. Lehrman is also on the editorial advisory board of the journal WOUNDS.
