What Is Happening
There have been multiple recent incidences of surgical dressing payment denial based on an auditor’s finding that four weeks of conservative treatment was needed prior to dispensing surgical dressings.
Why It’s Happening
The need to have attempted four weeks of conservative treatment before dispensing surgical dressings is NOT a Medicare requirement. The need to have attempted four weeks of conservative treatment before dispensing surgical dressings is NOT listed in the Durable Medical Equipment Medicare Administrative Carrier (DMEMAC) coverage policies. This is, instead, a requirement that some third-party payers have related to skin substitute products and cellular and/or tissue-based products for wounds. This requirement is unrelated to the provision of surgical dressings.
What To Do About It
The following information may be helpful if you need to discuss such a denial with an auditor or third party payer representative:
The DMEMAC Local Coverage Determination for Surgical Dressings is here:
Medical Coverage Determination
The DMEMAC Local Coverage Article for Surgical Dressings is here:
These are the only two policies that govern coverage of surgical dressings for Medicare beneficiaries and neither include anything about the duration of wound care needed before surgical dressings are a covered service. There is no Medicare reference that lists four weeks of conservative treatment as a requirement for coverage of surgical dressings and, therefore, this is not a requirement that can be enforced.
It is also recommended that providers communicate with their medical malpractice carrier and administrative defense carrier when upon receiving any request for documentation.
