Noridian Healthcare Solutions, LLC, (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare and Medicaid (CMS), has conducted post-payment review of claims for Medicare Durable Medical Equipment (DME) billed on dates of service from January 1, 2023, through December 31, 2024. Below are the review results:

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 was tasked to perform data analysis and conducted medical record reviews on surgical dressing claims billed with dates of service January 1, 2023, through December 31, 2024. The SMRC conducted medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.

Common Reasons for Denial

• Documentation Did Not Support Medical Necessity
  • Refer to Social Security Act (SSA) 1862(a)(1)(A), Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual (MPIM), Chapter 15, Section 100, Publication 100-08, Medicare Program Integrity Manual (MPIM), Chapter 3, Section 3.6.2.2. The documentation submitted did not support the medical necessity criteria for the qualifying dressing(s) ordered as listed in coverage requirements.
• No Valid Wound Evaluation
  • Refer Social Security Act (SSA) 1862(a)(1)(A), Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 100, Local Coverage Determination (LCD) L33831 Surgical Dressings, Local Coverage Article (LCA) A54563 Surgical Dressings-Policy Article. The documentation submitted did not support the required elements of the wound evaluation.
• Non-Response to the Additional Documentation Request (ADR)
  • Refer to Social Security Act (SSA) Title XVIII, Section 1815(a), 1833(e), & 1862(a)(1)(A). No documentation was received in response to the ADR letter.

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 Feb 6, 2026