Updates to Surgical Dressing Documentation Requirements

AMERX Health Care provides you with extensive resources that include everything you need for perfect documentation to ensure compliance when dispensing surgical dressings.  The majority of this guidance comes from the DMEMAC Surgical Dressings LCD and the DMEMAC Surgical Dressing Policy Article.  On December 3, 2019, the DMEMACs released some additional guidance in the form of an article titled, “Physicians! Are You Ordering Surgical Dressings For Your Patients?”

When Should I Create New Orders?

The need to create a new order when the dressing type is changed or when a new dressing type is added has been covered in this space before.  A new order is also required if the quantity of dressings being used increases.  Even with no change to dressing type or quantity, a new order is required every three months while a dressing is still being used.

Include in Your Progress Notes...

In addition to the extensive documentation requirements we already knew about, this new article instructs us to document why and how the selected dressing(s) are being used.  For example, "Foam was selected to help handle the heavy exudate this ulcer is putting out.”  Furthermore, we are instructed to document whether the dressing will be used as a primary or secondary dressing.  We cannot assume that the primary versus secondary distinction can be drawn from the products ordered or the manner in which they are intended to be used.  We must spell out if the dressing(s) ordered are being used as a primary or secondary dressing, and if we order both, we must designate which is primary and which is secondary.

Frequency of Evaluation

As long as the patient is receiving surgical dressings, a wound evaluation must be performed by the treating physician at least once a month.  At a minimum, this evaluation should include documentation of the wound type, location, size, and drainage amount.

DISCLAIMER: The information provided here is intended to educate health care providers regarding compliance for ICD, CPT, and HCPCS coding. The information provided does not guarantee reimbursement and is accurate to the best of our knowledge at the time of this publication. Coding guidelines can change and we encourage you to stay up to date. The existence of a code does not guarantee payment.

About the Author

Dr. Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC

Dr. Lehrman is in private practice in Fort Collins, CO and operates Lehrman Consulting, LLC. 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. He is a Fellow of the American Academy of Podiatric Practice Management and an Expert Panelist on Codingline. In his role as a Consultant to the APMA Health Policy and Practice Department, Dr. Lehrman serves as an advisor to the APMA Coding Committee and the APMA MACRA Task Force. Dr. Lehrman sits on the board of directors of both the American Professional Wound Care Association and the American Society of Podiatric Surgeons. He is also on the editorial advisory board of the journal WOUNDS.

Read More by Dr. Lehrman →

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