Last Modified: 7/21/2020
Location: FL, PR, USVI
Business: Part B
Revised July, 2020
In order for a durable medical equipment (DME) supplier to provide surgical dressings to your patients, there are actions you can take to make sure that all the required supporting medical record documentation is available.
Medicare requires the patient's medical record to show that the number and type of surgical dressing is medically necessary according to the coverage criteria below.
Surgical dressings are covered when they are required to treat a qualifying wound. There are only two types of qualifying wounds:
1. A wound caused by a surgical procedure that was performed by a treating physician or other qualified health professional.
2. After the debridement of a wound. Some examples of the types of debridement where treatment would be necessary are for:
• Surgical – either through sharp instrument or laser
• Mechanical – irrigation or wet-to-dry dressings
• Chemical – topical application of enzymes
• Autolytic – application of occlusive dressings to an open wound
Be aware that the debridement agents used are not covered under this policy.
In addition to having a qualifying wound, the coverage criteria are also determined by the requirements necessary for any product to be classified as a surgical dressing for purposes of coverage under this benefit.
Surgical dressings must be tailored to the specific needs of an individual beneficiary. Dressing size must be based on and appropriate to the size of the wound.
For wound covers, the pad size is usually about 2 inches greater than the dimensions of the wound. The quantity and type of dressings dispensed must take into account the current status of the wound, the likelihood of change, and the recent use of dressings.
When surgical dressings are provided in kits, only those components of the kit that meet the definition of a surgical dressing, that are ordered by the physician, and that are medically necessary are covered. The allowance for items referred to using the term "kit" includes not only the individual major supply items, but also any gauze, tape, or other dressing supplies necessary for their use.
Products that are eligible to be classified as a surgical dressing include both:
• Primary dressings – which are defined as therapeutic or protective coverings that are applied directly to wounds or lesions either on the skin or caused by an opening to the skin; and,
• Secondary dressings – those are defined as materials that serve a therapeutic or protective function and they are needed to secure a primary dressing.
Dressings that are not used as primary or secondary on a qualifying wound that do not serve a therapeutic or protective function will be denied as statutorily non-covered – no benefit.
A new order is needed when a new dressing is added or if the quantity needs to be increased. A new order is also required every 3 months for each dressing used.
These requirements are included on the standard written order (SWO). You will likely receive this document from the Durable Medical Equipment, Prosthetic, Orthotic and Supplies (DMEPOS) supplier and it will need to be reviewed, signed, dated, and returned to them before they can submit their claim to Medicare.
The SWO must contain the elements below. Help your patient by providing this timely.
• Beneficiary's name or Medicare Beneficiary Identifier (MBI)
• Order date
• Description of the item(s) ordered
• Quantity to be dispensed, if applicable
• Treating practitioner name or NPI
• Treating practitioner's signature
Information defining the number of surgical/debrided wounds being treated with a dressing, the reason for dressing use (e.g., surgical wound, debrided wound, etc.), and whether the dressing is being used as a primary or secondary dressing or for some noncovered use (e.g., wound cleansing) must be available to the supplier from the physician, nursing home, or home care nursing records.
Clinical information, which demonstrates that the reasonable and necessary requirements in the policy regarding the type and quantity of surgical dressings provided, must also be present in the beneficiary's medical records.
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.
This information must be updated by the treating physician (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. Evaluation is expected on a weekly basis for beneficiaries in a nursing facility or for beneficiaries with heavily draining or infected wounds. The evaluation may be performed by a nurse, physician or other health care professional involved in the regular care of the beneficiary. This person must 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.
Remember that this is the responsibility of the treating practitioner and the documentation needs to be available to the supplier when requested.
The frequency of recommended dressing changes depends on the type and use of the surgical dressing. When combinations of primary dressings, secondary dressings, and wound filler are used, the change frequencies of the individual products should be similar. For purposes of this policy, the product in contact with the wound determines the change frequency. It is not reasonable and necessary to use a combination of products with differing change intervals. For example, it is not reasonable and necessary to use a secondary dressing with a weekly change frequency over a primary dressing with a daily change interval.
Dressing needs may change frequently in the early phases of wound treatment with heavily draining wounds. Suppliers need to monitor the beneficiary’s usage and adjust their provision of dressings accordingly.
The normal refill requirements apply to this policy. Regardless of utilization, no more than a month's supply of dressings may be provided at one time without documentation to support the greater quantities.
DME MAC Jurisdiction A
(CT, DE, MA, ME, MD, NH, NJ, NY, PA, RI, VT, District of Columbia)
DME MAC Jurisdiction C
(AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, SC, TN, TX, VA, WV, Puerto Rico, U.S. Virgin Islands)
DME MAC Jurisdiction D
(AK, AZ, CA, HI, ID, IA, KS, MO, MT, NE, NV, ND, OR, SD, UT, WA, WY, American Samoa, Guam, Northern Mariana Islands)
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