01-136 Surgical Dressings Notification of Medical Review
Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of claims for Medicare Durable Medical Equipment (DME) billed on dates of service from January 1, 2023, through December 31, 2024. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.
Background
Surgical dressings are covered under the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Benefit. Coverage is provided for primary and secondary surgical dressings used on the skin on qualifying wound types such as a wound caused by, or treated by, a surgical procedure or after debridement of the wound. Types of surgical dressings include, but are not limited to, alginate or other fiber gelling dressing, collagen or wound filling dressing, and foam filling dressing. The relevant part of the surgical dressings benefit establishes two separate benefit criteria:
- The necessity for and definition of a qualifying wound
- The requirements necessary for any product to be classified as a surgical dressing.
In the 2023 Comprehensive Error Rate Testing (CERT) Improper Payment Report, surgical dressings had an associated improper payment rate of 62.1%. Prior work done by the Supplemental Medical Review Contractor (SMRC) demonstrated a claim error rate of 91%.
Reason for Review
The SMRC is tasked to perform data analysis and conduct medical record reviews on surgical dressing claims billed with dates of service January 1, 2023, through December 31, 2024. The SMRC will conduct medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.
Claim Sample Detail
| HCPCS | Description |
|---|---|
| A6010 | Collagen based wound filler, dry form, sterile, per gram of collagen |
| A6011 | Collagen based wound filler, gel/paste, per gram of collagen |
| A6021 | Collagen dressing, sterile, size 16 sq. in. or less, each |
| A6022 | Collagen dressing, sterile, size more than 16 sq. in. but less than or equal to 48 sq. in., each |
| A6023 | Collagen dressing, sterile, size more than 48 sq. in., each |
| A6024 | Collagen dressing wound filler, sterile, per 6 inches |
| A6196 | Alginate or other fiber gelling dressing, wound cover, sterile, pad size 16 sq. in. or less, each dressing |
| A6197 | Alginate or other fiber gelling dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each dressing |
| A6198 | Alginate or other fiber gelling dressing, wound cover, sterile, pad size more than 48 sq. in., each dressing |
| A6199 | Alginate or other fiber gelling dressing, wound filler, sterile, per 6 inches |
| A6209 | Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
| A6210 | Foam dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing |
| A6211 | Foam dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing |
| A6212 | Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing |
| A6213 | Foam dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing |
| A6214 | Foam dressing, wound cover, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing |
| A6215 | Foam dressing, wound filler, sterile, per gram |
Access related project details below.
Documentation Requirements
Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review.
Providers/suppliers are requested to submit each of the Documentation Requirements outlined below, if and as applicable to the claim on review.
- Please Note: The supplier or provider is responsible for obtaining all documentation from the ordering/referring provider to ensure medical necessity criteria have been met.
- Standard Written Order (SWO).
- Dispensing Order, if applicable.
- Beneficiary’s medical records (which may include practitioner medical records, hospital records, nursing home records, home care nursing notes, physical/occupational therapy notes) that support the item(s) provided is/are reasonable and necessary.
- Operative/procedure report.
- History and Physical reports (include medical history and current list of medications).
- Medical record documentation to support national and local requirements.
- Evaluation and wound care assessments within the previous 30 days.
- Wound care notes.
- Documentation of the request for refill.
- DME Documentation of continued Need.
- Proof of Delivery.
- Any other supporting/pertinent documentation.
- All medical record documentation must have at least two identifiers to include, at a minimum, the beneficiary’s name, and date of service.
- Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC).
- If an electronic health record is utilized, include your facility’s process of how the electronic signature is created. Include an example of how the electronic signature displays once signed by the physician.
- Providers/suppliers are encouraged to review the documentation prior to submission, to ensure that signature information is available when authenticity is not conclusively documented. Please include a signature log or signature attestation for any missing or illegible signature within the medical record.
- If Medical record documentation submitted via esMD: Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation.
References
Social Security Act (SSA) Title XI
- §1135 Authority to Waive Requirements During National Emergencies
Social Security Act (SSA) Title XVIII
- §1815(a) Payment to Providers of Services
- §1833(e), (P) Payment of Benefits
- §1834(a)(7)(C)(i), (ii) and (iii) Replacement of Items
- §1834(i)(1)(A)(B), 2(A)(B), (3), (5)(A)(D) Special Payment Rules for Particular Items and Services
- §1861(n), (s)(5) Miscellaneous Provisions
- §1862(a)(1)(A) Exclusions from Coverage and Medicare as Secondary Payer
- §1879(a)(1), (2), (h) (1-3) Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
- §1893(f)(7)(A)(B) (i-iv), (h)(4)(B) Medicare Integrity Program
Code of Federal Regulations (CFR) Title 42
- §410.3 Supplementary Medical Insurance (SMI) Benefits
- §411.15 Exclusions from Medicare and Limitations on Medicare Payment
- §413.1 Subpart A, Introduction and General Rules
- §414.200 Purpose
- §424.5 Basic Conditions
- §424.516(P) Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare program.
- §424.57(c)(12) Special Payment Rules for Items Furnished by DMEPOS Suppliers and Issuance of DMEPOS Supplier Billing Privileges
Federal Register
- Final Rule Volume 85, No. 66, Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID–19 Public Health Emergency. Effective March 1, 2020. Retrieved from 2020-06990.pdf (govinfo.gov)
- Interim Final Rule with Comments (IFC) 85 FR 19230. Revisions in Response to the COVID-19 Public Health Emergency. CMS-1744-IFC. Effective March 1, 2020. Retrieved from CMS-1744-IFC
Internet Only Manual (IOM), Medicare Benefit Policy Manual (MBPM), Pub. 100-02
- Ch. 15, §100 Surgical Dressings, Splints, Casts, and Other Devices Used for Reductions of Fractures and Dislocations
- Ch. 16 General Exclusion from Coverage
Internet Only Manual (IOM), Medicare Claims Processing Manual (MCPM), Pub. 100-04
- Ch. 1 General Billing Requirements
- Ch. 20 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)
- Ch. 30, §50 Advance Beneficiary Notice of Non-coverage (ABN)
Internet Only Manual (IOM), Medicare Program Integrity Manual (MPIM), Pub. 100-08
- Ch. 3 Verifying Potential Errors and Taking Corrective Actions
- Ch. 4, §4.7.3.1 Supplier Proof of Delivery Documentation Requirements
- Ch. 4, §4.7.3.1.1 Proof of Delivery and Delivery Methods
- Ch. 4, §4.7.3.1.2 Exceptions
- Ch. 4, §4.7.3.1.3 Proof of Delivery Requirements for Recently Eligible Medicare FFS Beneficiaries
- Ch. 5, §5.2 Rules Concerning DMEPOS Orders/Prescriptions
- Ch. 5, §5.7 Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs
- Ch. 5, §5.8 Physician Assistant Rules Concerning Orders and CMNs
- Ch. 5, § 5.9 Documentation in the Patient’s Medical Record
- Ch. 5, §5.11 Evidence of Medical Necessity
- Ch. 13, §13.5.4 Reasonable and Necessary Provisions in LCDs
CMS Coding Policies
- National Correct Coding Initiative Edits (NCCI). NCCI Policy Manual for Medicare Services. Effective January 1, 2023-December 31, 2024
Local Coverage Determination (LCDs)
- L33831 Surgical Dressings
Local Coverage Articles (LCAs)
- A54563 Surgical Dressing- Policy Article
- A55426 Standard Documentation Requirements for All Claims Submitted to DME MACs
Other
- American Medical Association (AMA), Current Procedural Terminology (CPT). CPT® (Current Procedural Terminology) | AMA
- American Academy of Professional Coders (AAPC). Medical Coding – Medical Billing – Medical Auditing – AAPC
- CMS. Coronavirus Disease (COVID-19) Emergency Declaration Blanket Waivers for Health Care Providers. Updated November 29, 2021. COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers (cms.gov)
- CMS. COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing. Updated January 7, 2021. COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing (cms.gov)
- CMS. 2023 Medicare Fee-for-Service Supplemental Improper Payment Data. Updated December 7, 2023. Retrieved from 2023 Medicare Fee-for-Service Supplemental Improper Payment Data
- CMS. MLN Matters. Standard Elements for DMEPOS Order, and Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and Written Orders Prior to Delivery and, or Prior Authorization Requirements. January 12, 2022. Retrieved from SE20007 – MLN Matters
- Comprehensive Error Rate Testing (CERT). 2023 Medicare Fee-for Service Supplemental Improper Payment Data. December 7, 2023. Retrieved from 2023 Medicare Fee-for-Service Supplemental Improper Payment Data | CMS
- CMS.MLN Matters. Refillable DMEPOS Documentation Requirements. Effective date January 1, 2024. Retrieved from MM13480-MLN Matters
Last Updated Mar 25, 2025