Improper Payment Reasons

Durable Medical Equipment (DME) suppliers of Surgical Dressings and physicians submit claims for surgical dressings and CMS covers it under the surgical dressings benefit i.e., SSA Section 1861[s][5]. CMS recently published Medicare Fee-for-Service (FFS) improper payment rate for surgical dressings for the 2020 reporting period. For this reporting period, the improper payment rate for surgical dressings was 67.3 percent, with a projected improper payment amount of over $194.9 million. For the 2020 reporting period, insufficient documentation accounted for 82.4 percent of improper payments for surgical dressings. Additional types of errors for surgical dressings in the 2020 reporting period were no documentation (1.9 percent), medical necessity (1.7 percent), incorrect coding (1.9 percent), and other (12.2 percent). 

Avoiding Improper Payments

All claims billed to Medicare require a written order or prescription from the treating practitioner as a condition for payment. The written order or prescription must meet the requirements outlined for the Standard Written Order (SWO). Billing guidelines would require you to communicate an SWO to the supplier before claim submission. Certain items of Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS), require a Written Order Prior to Delivery (WOPD) of the item(s) to the patient.

Billing guidelines for surgical dressings would require an SWO containing all the following elements:

• Patient’s name or Medicare Beneficiary Identifier (MBI)
• Order Date
• General description of item:
  • Description can be either a general description (for example, wheelchair or hospital bed), an HCPCS code, an HCPCS code narrative, or a brand name and model number
  • For equipment: Besides the description of the base item, the SWO may include all concurrently ordered options, accessories, or other features separately billed or require an upgraded code (list each separately)
  • For supplies: Besides a description of the base item, the DMEPOS order or prescription may include all concurrently ordered supplies separately billed (list each separately)
• Dispensed quantity, if applicable
• Treating practitioner name or National Provider Identifier (NPI)
• Treating practitioner’s signature

This Medicare coverage guidance applies to surgical dressing claims:

• Medicare covers surgical dressings when a qualifying wound is present. Medicare defines a qualifying wound as either:
  • The wound caused by, or treated by, a surgical procedure
  • After debridement of wound, regardless of debridement technique (examples include, but aren’t limited to, surgical, mechanical, chemical, or autolytic)

Eligible products classified as surgical dressings include:

• 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: Needed materials that serve therapeutic or protective roles to secure a primary dressing. Examples of secondary dressings include items such as adhesive tape, roll gauze, bandages, and disposable compression material.

For first wound evaluations, the treating practitioner’s medical record, nursing home, or home care nursing records must specify:

• Type of qualifying wound 
• Location, number, and size of qualifying wounds being treated with a dressing
• Whether dressing use is primary or secondary or for some non-covered use (for example, wound cleansing)
• Amount of drainage
• Type of dressing (for example, hydrocolloid wound cover, hydrogel wound filler)
• Size of dressing (if applicable)
• Number or amount used at 1 time
• Frequency of dressing change
• Any other relevant clinical information

Other Guidelines

Medicare requires clinical information that proves reasonable and necessary requirements in the policy on the type and quantity of surgical dressings provided in the patient’s medical records. Medicare requires the treating practitioner (or their designee) to update this information monthly. Medicare requires this evaluation of the patient’s wound(s) unless there’s documentation in the medical record that justifies why the treating practitioner can’t conduct an evaluation within this timeframe and what other uses of monitoring methods evaluated the patient’s need for ongoing dressing usage.

Medicare expects weekly wound evaluations for patients in a nursing facility or for patients with heavily draining or infected wounds. A nurse, treating practitioner, or other health care professional involved in the regular care of the patient can do the evaluation. This person may have no financial relationship with the supplier. This prohibition doesn’t extend to treating practitioners who are also the supplier. The weekly or monthly evaluation must include:

• Type of each wound (for example, surgical wound, pressure ulcer, burn)
• Wound(s) location
• Wound size (length X width) and depth
• Amount of drainage
• Any other relevant wound status information

Medicare requires the supplier to document the source of that information and data obtained in the supplier’s records. The frequency of recommended dressing changes depends on the type and use of surgical dressing. When health care professionals use combinations of primary dressings, secondary dressings, and wound filler, the change frequencies of individual products should be similar.

For purposes of this policy, the product in contact with the wound decides to change frequency. Medicare doesn’t consider using a combination of products with differing change intervals as reasonable and necessary. For example, it isn’t reasonable and necessary to use a secondary dressing with weekly change frequency over a primary dressing with daily change interval. Medicare will deny claims as not reasonable and necessary.

MedicalBillersandCoders (MBC) is a leading revenue cycle company providing complete medical billing services. For any assistance required for DME services, contact us at [email protected]/ 888-357-3226

Reference: Medicare Provider Compliance for Surgical Dressings