NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES
For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act §1862(a)(1)(A) provisions (i.e. “reasonable and necessary”).
Surgical Dressings are covered under the Surgical Dressings Benefit (Social Security Act §1861(s)(5)). The CMS Benefit Policy Manual (IOM 100-02), CH 15, §100 provides interpretive guidance to contractors for the implementation of this provision. The relevant part of the manual section establishes two separate benefit criteria:
- The necessity for and definition of a qualifying wound; and,
- The requirements necessary for any product to be classified as a surgical dressing for purposes of coverage under this benefit.
In order for a beneficiary’s item(s) to be eligible for reimbursement, all benefit requirements discussed below and the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met.
QUALIFYING WOUND
Surgical dressings are covered when a qualifying wound is present. A qualifying wound is defined as either of the following:
- A wound caused by, or treated by, a surgical procedure; or,
- After debridement of the wound, regardless of the debridement technique.
The surgical procedure or debridement must be performed by a treating practitioner 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 (e.g., sharp instrument or laser)
- Mechanical (e.g., irrigation or wet-to-dry dressings)
- Chemical (e.g., topical application of enzymes) or
- Autolytic (e.g., 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 debridement agents themselves are noncovered.
Examples (not all-inclusive) of clinical situations in which dressings are noncovered under the Surgical Dressings benefit are:
- Drainage from a cutaneous fistula which has not been caused by or treated by a surgical procedure; or,
- A Stage 1 pressure ulcer; or,
- A first degree burn; or,
- Wounds caused by trauma which do not require surgical closure or debridement - e.g., skin tear or abrasion; or,
- A venipuncture or arterial puncture site (e.g., blood sample) other than the site of an indwelling catheter or needle.
Claims for surgical dressings used for clinical conditions other than the qualifying wounds as described above will be denied as statutorily non-covered, no benefit.
QUALIFYING DRESSING REQUIREMENTS
Products that are eligible to be classified as a surgical dressing are defined as:
- Primary dressings - Therapeutic or protective coverings applied directly to wounds or lesions either on the skin or caused by an opening to the skin.
- Secondary dressings - Materials that serve a therapeutic or protective function and that are needed to secure a primary dressing. Items such as adhesive tape, roll gauze, bandages, and disposable compression material are examples of secondary dressings.
Some items, such as transparent film, may be used as a primary or secondary dressing.
The following are examples of wound care items which are non-covered under the surgical dressing benefit because they do not meet the statutory definition of a dressing (not all-inclusive):
- Skin sealants or barriers (A6250)
- Wound cleansers (A6260) or irrigating solutions
- Solutions used to moisten gauze (e.g., saline)
- Silicone gel sheets (A6025)
- Topical antiseptics
- Topical antibiotics
- Enzymatic debriding agents
- Gauze or other dressings used to cleanse or debride a wound but not left on the wound
- First-aid type adhesive bandage (A6413)
- Any item listed in the latest edition of the Orange Book (e.g., an antibiotic-impregnated dressing which requires a prescription)
- Surgical stockings (A4490, A4495, A4500, A4510)
- Non-elastic binder for an extremity (A4465)
- Small adhesive bandages (e.g., Band-Aid or similar product) are not primarily used for the treatment of wounds addressed in the Surgical Dressings policy.
These dressings are noncovered under the surgical dressing benefit.
Claims for products that are not able to be used as a primary or secondary dressing on a qualifying wound of the skin or that are composed of materials that do not serve a therapeutic or protective function will be denied as statutorily non-covered, no benefit.
MISCELLANEOUS
If a treating practitioner applies surgical dressings as part of a professional service that is billed to Medicare, the surgical dressings are considered incident to the professional services of the health care practitioner and are not separately payable. Claims for these dressings must not be submitted. Claims for the professional service, which includes the dressings, must be submitted to the local carrier or intermediary. If dressing changes are sent home with the beneficiary, claims for these dressings may be submitted. In this situation, use the place of service corresponding to the beneficiary's residence; Place of Service Office (POS=11) must not be used.
Claims for tape (A4450 and A4452) which are billed without an AW modifier (see Coding Guidelines section) or another modifier indicating coverage under a different policy will be rejected as missing information.
When dressings are covered under other Medicare benefits, there is no separate payment using surgical dressing codes. Payment for any type of dressing in these other benefits is included (bundled) in the allowance for applicable supply codes. Examples, not all-inclusive, are:
- Dressings used with infusion pumps (which are covered under the DME benefit) are included in the allowance for code A4221.
- Dressings used with parenteral nutrition (covered under the prosthetic device benefit) are included in the allowance for code B4224.
- Dressings used with gastrostomy tubes for enteral nutrition (covered under the prosthetic device benefit) are included in the allowance for codes B4034, B4035, B4036.
- Dressings used with tracheostomies (covered under the prosthetic device benefit) are included in the allowance for code A4625 and A4629.
- Dressings used with dialysis access catheters (covered under the end stage renal disease benefit) are included in the composite rate (outpatient facility dialysis) or payment cap (method 1 home dialysis) paid to the dialysis provider.
Note that the allowance for items referred to using the term “kit” (e.g. in HCPCS codes A4625, A4629, B4224, B4034, B4035, B4036) includes not only the individual major supply items, but also any gauze, tape, other dressing supplies, etc. necessary for their use. Refer to the applicable LCD and related Policy Article for additional coverage, coding and documentation requirements for these items.
Claims separately billed for dressings that are included in a bundled supply or kit code will be denied as unbundling. (Refer to the CODING GUIDELINES section for additional information)
Gradient compression stockings (A6530, A6533, A6534, A6535, A6536, A6537, A6538, A6539, A6540, A6541, A6544, A6549) are non-covered under the surgical dressing benefit because they do not meet the statutory definition of a dressing; however, they may be considered for coverage under the lymphedema compression treatment items benefit and billed in accordance with CMS Final Rule CMS-1780-F.
LIGHT COMPRESSION BANDAGE (A6448, A6449, A6450), MODERATE/HIGH COMPRESSION BANDAGE (A6451, A6452), SELF-ADHERENT BANDAGE (A6453, A6454, A6455), CONFORMING BANDAGE (A6442, A6443, A6444, A6445, A6446, A6447), PADDING BANDAGE (A6441)
Light compression bandages, self-adherent bandages, and conforming bandages are covered when they are used to hold wound cover dressings in place over any wound type i.e., as a secondary dressing over a qualified wound.
Moderate or high compression bandages, conforming bandages, self-adherent bandages, and padding bandages are covered when they are part of a multi-layer compression bandage system used in the treatment of a venous stasis ulcer that meets the requirements to be a qualified wound.
All of these bandages are non-covered when used for non-qualifying conditions such as, strains, sprains, edema, or situations other than as a dressing for a qualified wound. Claims for items used in these scenarios will be denied as statutorily non-covered, no benefit.
GRADIENT COMPRESSION STOCKINGS/WRAPS (A6531, A6532, A6545)
A gradient compression stocking described by codes A6531 or A6532 or a non-elastic gradient compression wrap described by code A6545 is only covered when it is used in the treatment of an open venous stasis ulcer that meets the qualifying wound requirements described above.
Codes A6531, A6532, and A6545 are non-covered for the following conditions:
- Venous insufficiency without stasis ulcers;
- Prevention of stasis ulcers;
- Prevention of the reoccurrence of stasis ulcers that have healed;
- Treatment of lymphedema in the absence of ulcers.
In these situations, since there is no ulcer, the stockings/wraps do not meet the definition of a surgical dressing, as there is no qualifying wound. Claims for these uses will be denied as non-covered, no benefit.
COMPRESSION BURN GARMENTS (A6501, A6502, A6503, A6504, A6505, A6506, A6507, A6508, A6509, A6510, A6511, A6512, A6513)
Compression burn garments are covered under the Surgical Dressings benefit when they are used to reduce hypertrophic scarring and joint contractures following a burn injury.
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217)
Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The required Face-to-Face Encounter and Written Order Prior to Delivery List is available here.
Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.
If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD prior to delivery, it will be eligible for coverage.
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS
In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.
Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below.
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 required every 3 months for each dressing being used.
When the prescribing practitioner is also the supplier, and is permitted to furnish specific items of DMEPOS, a separate order is not required; however, the medical record must still contain all of the required order elements.
For initial wound evaluations, the treating practitioner’s medical record, nursing home, or home care nursing records must specify:
- The type of qualifying wound (see above); and,
- Information regarding the location, number, and size of qualifying wounds being treated with a dressing; and,
- Whether the dressing is being used as a primary or secondary dressing or for some noncovered use (e.g., wound cleansing); and,
- Amount of drainage; and,
- The type of dressing (e.g., hydrocolloid wound cover, hydrogel wound filler, etc.); and,
- The size of the dressing (if applicable); and,
- The number/amount to be used at one time; and,
- The frequency of dressing change; and,
- Any other relevant clinical information.
Clinical information, which demonstrates that the reasonable and necessary requirements in the policy regarding the type and quantity of surgical dressings provided, must be present in the beneficiary's medical records. This information must be updated by the treating practitioner (or their designee) on a monthly basis. This evaluation of the beneficiary's wound(s) is required unless there is documentation in the medical record which justifies why an evaluation could not be done within this timeframe and what other monitoring methods were used to evaluate the beneficiary's need for ongoing use of dressings.
For beneficiaries in a nursing facility or for beneficiaries with heavily draining or infected wounds, wound evaluations are expected on a weekly basis. The evaluation may be performed by a nurse, treating practitioner or other health care professional involved in the regular care of the beneficiary. This person may have no financial relationship with the supplier. This prohibition does not extend to treating practitioners who are also the supplier.
The weekly or monthly evaluation must include:
- The type of each wound (e.g., surgical wound, pressure ulcer, burn, etc.),
- Wound(s) location,
- Wound size (length x width) and depth,
- Amount of drainage, and
- Any other relevant wound status information.
The source of that information and date obtained must be documented in the supplier's records. 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 modifier A9 (DRESSING FOR NINE OR MORE WOUNDS) 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 non-coverage (e.g., "A6216GY - used for wound cleansing") must be entered in the narrative field of the electronic claim.
When codes A4649, A6261 or A6262 are billed, the claim must include:
- Description of the item or service
- Manufacturer name
- Product name and number
- Supplier Price List (PL) amount
This information must be entered in the narrative field of the electronic claim. Miscellaneous HCPCS codes billed without this information will be return/rejected for missing information.
Claims lines for A4649, A6010, A6011, A6021, A6022, A6023, A6024, A6154, A6196, A6197, A6198, A6199, A6203, A6204, A6205, A6206, A6207, A6208, A6209, A6210, A6211, A6212, A6213, A6214, A6215, A6217, A6218, A6219, A6220, A6221, A6222, A6223, A6224, A6228, A6229, A6230, A6231, A6232, A6233, A6234, A6235, A6236, A6237, A6238, A6239, A6240, A6241, A6242, A6243, A6244, A6245, A6246, A6247, A6248, A6251, A6252, A6253, A6254, A6255, A6256, A6257, A6258, A6259, A6261, A6262, A6266, A6402, A6403, A6404, A6441, A6442, A6443, A6444, A6445, A6446, A6447, A6448, A6449, A6450, A6451, A6452, A6453, A6454, A6455, A6456, A6457 billed without A1-A9 modifiers will be rejected as missing information.
Claims lines for A4450 and A4452 billed without AW and A1-A9 modifiers will be rejected as missing information.
Claim lines for A6531, A6532 and A6545 without an AW modifier (A1-A9 modifiers are not required for these codes) will be rejected for missing information.
CODING GUIDELINES
Products containing multiple materials (excluding basic construction elements such as backing material, adhesive used in borders, binders, preservatives, etc.(not all-inclusive)) are classified as either composite dressings or as multi-component dressings. Impregnated gauze dressing are not included in this classification.
Composite dressings (A6203, A6204, A6205) are products combining physically distinct components into a single dressing that provides multiple functions. These functions must include all of the following:
- A physical (not chemical) bacterial barrier that is present over the entire dressing pad and extends out into the adhesive border,
- An absorptive layer other than an alginate or other fiber gelling dressing, foam, hydrocolloid, or hydrogel, and
- Either a semi-adherent or a non-adherent property over the wound site.
Surgical dressings with a backing that provides a physical bacterial barrier but does not have an adhesive border do not meet the definition of a composite dressing because there is no assurance that it will prevent bacterial access to a wound. These types of dressings are to be coded as specialty absorptive dressings (A6251, A6252, A6253).
Multi-component dressings that are not classified as composite dressings are categorized according to the clinically predominant component. The clinically predominant component is defined based on the proportion of material(s) in the dressing. For example, a dressing that is 60 percent hydrocolloid and 40 percent alginates would be categorized as a hydrocolloid dressing. HCPCS Coding is determined based on the following:
- Products where a single material comprises greater than 50% (by weight) of a product's composition are coded based upon the applicable specific HCPCS code for that material. If a specific HCPCS code does not exist for the predominant component, HCPCS code A4649 is used.
- Products where no single material comprises greater than 50% (by weight) of the composition are coded as A4649.
Composite and multi-component products may not be unbundled and billed as the separate components of the dressing.
Alginate or Other Fiber Gelling Dressings (A6196, A6197 and A6198) are absorbent dressings that manage moderately to highly exudative full thickness wounds (e.g., stage 3 or 4 ulcers), are composed of a multi-layer or multi-component structure with either alginate or gelling fiber as the predominant component. Codes A6196, A6197 and A6198 may be used as either a primary and/or secondary dressing, as determined by the treating practitioner (see Policy Specific Documentation Requirements above). When used as a secondary dressing, the dressing size selected must be appropriate to the size of the wound, taking into account the wound margin(s). For example, a 2 in. x 2 in. wound may require a 4 in. x 4 in. pad size. See below for alginate wound fillers (A6199) used as primary dressings.
Contact layers (A6206, A6207, A6208) are thin non-adherent sheets placed directly on an open wound bed to protect the wound tissue from direct contact with other agents or dressings applied to the wound. They are not absorptive. They are porous to allow wound fluid to pass through for absorption by a separate overlying dressing. They remain on the wound for an extended time while the absorptive dressings are changed.
A foam dressing (A6209, A6210, A6211, A6212, A6213, A6214, A6215) is a sterile, non-linting, absorptive dressing which is made of open cell, medical grade expanded polymer.
Impregnated gauze dressings (A6222, A6223, A6224, A6228, A6229, A6230, A6231, A6232, A6233, A6266, A6456) are woven or non-woven materials into which substances such as iodinated agents, petrolatum, zinc paste, crystalline sodium chloride, chlorhexidine gluconate (CHG), bismuth tribromo (BTP), water, aqueous saline, hydrogel, or other agents have been incorporated into the dressing material by the manufacturer. These codes are not to be used for gauze dressings containing substances that are not recognized as effective dressing materials such as silver, honey, copper, cadexomer iodine, charcoal or other similar materials (not all-inclusive).
Specialty absorptive dressings (A6251, A6252, A6253, A6254, A6255, A6256) are unitized multi-layer dressings that provide (a) either a semi-adherent quality or non-adherent layer, and (b) highly absorptive layers of fibers such as absorbent cellulose, cotton, or rayon. These may or may not have an adhesive border.
A wound pouch (A6154) is a waterproof collection device with a drainable port that adheres to the skin around a wound.
Effective for claims with dates of service on or after June 1, 2013, the only products which may be billed to Medicare using code A6021, A6022, A6023 and A6024 are those for which a written coding verification review (CVR) has been made by the Pricing, Data Analysis, and Coding (PDAC) contractor and subsequently published on the Product Classification List (PCL). Information concerning the documentation that must be submitted to the PDAC for a Coding Verification Request can be found on the PDAC web site or by contacting the PDAC. A PCL with products that have received a coding verification can be found on the PDAC web site. If a product is billed to Medicare using a HCPCS code that requires written CVR, but the product is not on the PCL for that particular HCPCS code, then the claim line will be denied as incorrect coding.
Code A6025 should only be used for gel sheets used for the treatment of keloids or other scars. Hydrogel sheets used in the treatment of wounds are billed with codes A6242, A6243, A6244, A6245, A6246, A6247.
When dressings are covered under other benefits, they may not be billed separately using surgical dressing codes. See Non-Medical Necessity Coverage and Payment Rules section for additional information.
Wound fillers are primary dressings placed into open wounds to eliminate dead space, absorb exudate, or maintain a moist wound surface.
Wound fillers come in hydrated forms (e.g., pastes, gels), dry forms (e.g., powder, granules, beads), or other forms such as rope, spiral, pillows, etc. For certain materials, unique codes have been established - i.e., collagen wound filler (A6010, A6011, A6024), alginate or other fiber gelling wound filler (A6199), foam wound filler (A6215), hydrocolloid wound filler (A6240, A6241), hydrogel wound filler (A6248), and non-impregnated packing strips (A6407). Wound fillers made of recognized dressing materials, not falling into any of these categories are coded as A6261 or A6262. Wound fillers comprised of substances that are not recognized as effective dressing materials are coded as A9270.
The units of service for wound fillers are 1 gram, 1 fluid ounce, 6-inch length, or one yard depending on the product. If the individual product is packaged as a fraction of a unit (e.g., 1/2 fluid ounce), determine the units billed by multiplying the number dispensed times the individual product size and rounding to the nearest whole number. For example, if eleven (11) 1/2 oz. tubes of a wound filler are dispensed, bill 6 units (11 x 1/2 = 5.5; round to 6).
For some wound fillers, the units on the package do not correspond to the units of the code. For example, some pastes or gels are labeled as grams (instead of fluid ounces), some wound fillers are labeled as cc. or ml. (instead of fluid ounces or grams), and some are described by linear dimensions (instead of grams). In these situations, the supplier must contact the manufacturer to determine the appropriate conversion factor or unit of service, which corresponds to that used by the code narrative.
Wound covers are flat dressing pads that may serve as either primary or secondary dressings. A wound cover with adhesive border has an integrated cover and distinct adhesive border designed to adhere tightly to the skin. In order to be billed using a "with adhesive border" code, the adhesive border must be present along all sides of the dressing and must be proportionate to the size of the dressing pad. All dressing types that utilize an adhesive border should be sized to appropriately account for the wound margin(s) to avoid tissue damage.
Some wound covers are available both without and with an adhesive border. For wound covers with an adhesive border, the code to be used is determined by the pad size, not by the outside adhesive border dimensions. For example, a hydrocolloid dressing with outside dimensions of 6 in. x 6 in. has a 4 in. x 4 in. pad surrounded by a 1 in. border on each side and is correctly coded as A6237, "... pad size 16 sq. inch or less..."
A first-aid type adhesive bandage (e.g., Band-Aid or similar product) is a wound cover with a pad size of less than 4 square inches. It must be billed with code A6413.
For products with features that go beyond the usual scope of surgical dressings (e.g., a large wound cover with a slit in the middle and a plastic pouch which covers the dressing and is intended to protect an indwelling venous catheter), the coding determination will be based on the dominant component that falls under the Surgical Dressings benefit category and that is appropriate for the management of the wound itself.
Gauze or gauze-like products are typically manufactured as a single piece of material folded into a several ply gauze pad. Coding must be based on the functional size of the pad as it is commonly used in clinical practice.
For all dressings, if a single dressing is divided into multiple portion/pieces, the code and quantity billed must represent the originally manufactured size and quantity.
Impregnated dressings that are listed in the FDA Orange Book must be billed using code A9270 and must not be billed using codes A6222, A6223, A6224, A6231, A6232, A6233, or A6266.
Elastic bandages are those that contain fibers of rubber (latex, neoprene), spandex, or elastane. Roll bandages that do not contain these fibers are considered non-elastic bandages even though many of them (e.g., gauze bandages) are stretchable. Codes A6442, A6443, A6444, A6445, A6446, A6447 describe roll gauze-type bandages made either of cotton or of synthetic materials such as nylon, viscose, polyester, rayon, or polyamide. These bandages are stretchable, but do not contain elastic fibers. These codes include short-stretch bandages.
Codes A6448, A6449, A6450 describe ACE-type elastic bandages. Codes A6451 and A6452 describe elastic bandages that produce moderate or high compression that is sustained typically for one week. They are commonly included in multi-layer compression bandage systems. Suppliers billing these new codes must be able to provide, upon request, documentation from the manufacturer verifying that the performance characteristics specified in the code narratives have been met.
When multi-layer compression bandage systems are used for the treatment of a venous stasis ulcer, each component is billed using a specific code for the component - e.g., moderate or high compression bandages (A6451, A6452), conforming bandages (A6443, A6444), self-adherent bandages (A6454), padding bandages (A6441), zinc paste impregnated bandage (A6456).
For the compression stocking codes A6531 and A6532, one unit of service is generally for one stocking. However, if a manufacturer has a product consisting of two components that are designed to be worn simultaneously on the same leg, the two components must be billed as one claim line with one unit of service – e.g., a product that consists of an unzippered liner and a zippered stocking.
The only products that may be billed using code A6545 (non-elastic compression wrap) are those for which a written CVR has been made by the PDAC contractor and subsequently published on the PCL. Information concerning the documentation that must be submitted to the PDAC for a Coding Verification Request can be found on the PDAC web site or by contacting the PDAC. A PCL with products that have received a coding verification can be found on the PDAC web site. If a product is billed to Medicare using a HCPCS code that requires written CVR, but the product is not on the PCL for that particular HCPCS code, then the claim line will be denied as incorrect coding.
Modifiers A1-A9 have been established to indicate that a particular HCPCS code is being used as a primary or secondary dressing on a qualifying surgical or debrided wound. Modifiers A1-A9 are used to indicate the number of qualifying wounds on which a specific dressing HCPCS code is being used.
The modifier number must correspond to the number of qualifying wounds on which the dressing HCPCS code is being used, not the total number of wounds treated.
Modifiers A1-A9 are not used with codes A6531 and A6532.
Example Scenarios:
- September 1 Dressing Shipment: Beneficiary has two wounds that require two different categories of dressings, A61XX (max allowance of 30 per month) and A62XX (max allowance of 12 per month)
- Supplier should bill:
- A61XX A1 UOS = 30
- A62XX A1 UOS = 12
- September 15 Dressing Shipment: Beneficiary has a new wound that requires one of the same categories of dressings as another wound (A61XX – max allowance of 30 per month)
- Supplier should supply and bill 15 units (to last for the next 2 weeks) and should append the A2 modifier because this dressing category is now used on 2 wounds. NOTE: The modifier number corresponds to the number of wounds on which the dressing is being used, not the total number of wounds treated.
- October 1 Dressing Shipment: Beneficiary still has three wounds: two require A61XX (max allowance of 60 per month) and one requires A62XX (max allowance of 12 per month)
- Supplier should bill:
- A61XX A2 UOS = 60
- A62XX A1 UOS = 12
If the dressing is not being used as a primary or secondary dressing on a surgical or debrided wound, do not use modifiers A1-A9. When dressings are provided in noncovered situations (e.g., use of gauze in the cleansing of a wound or intact skin), a GY modifier must be added to the code and a brief description of the reason for non-coverage included - e.g., "A6216GY - used for wound cleansing."
When tape codes A4450 and A4452 are used with surgical dressings, they must be billed with the AW modifier (in addition to the appropriate A1-A9 modifier). When gradient compression stocking codes A6531 and A6532 or the gradient compression wrap code A6545 are used for an open venous stasis ulcer, the code must be billed with the AW modifier (but not an A1-A9 modifier). For this policy, codes A4450, A4452, A6531, A6532, and A6545 are the only codes for which the AW modifier may be used.
The RT and/or LT modifiers must be used with codes A6531, A6532, and A6545 for gradient compression stockings and wraps. Effective for claims with dates of service (DOS) on or after 3/1/2019, when the same code for bilateral items (left and right) is billed on the same date of service, bill each item on two separate claim lines using the RT and LT modifiers and 1 unit of service (UOS) on each claim line. Do not use the RTLT modifier on the same claim line and billed with 2 UOS. Claims billed without modifiers RT and/or LT, or with RTLT on the same claim line and 2 UOS, will be rejected as incorrect coding.
When dressing codes are billed for items covered under another benefit (e.g., gauze for a continent ostomy which is covered under the prosthetic device benefit) claims must be billed according to the documentation requirements specified in the applicable policy (see Ostomy Supplies policy for details).
Suppliers should contact the PDAC contractor for guidance on the correct coding of these items.
