01-303 Surgical Dressings Findings of Medical Review

Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, has conducted a post-payment review of claims for Medicare Surgical Dressing services, billed on dates of service from January 1, 2019, through December 31, 2019. Below are the review results:

Project ID Project Title Error Rate
01-303 Surgical Dressings 91%


Medicare provides reimbursement for surgical dressings under the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Benefit. This benefit only provides coverage for primary and secondary surgical dressings used on the skin on specified wound types. 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. Surgical dressings are ranked in the top four categories of the 2019 Comprehensive Error Rate Testing (CERT) Improper Payment Report with an associated improper payment rate of 62.80%.

Reason for Review

The SMRC was tasked with performing claim review on a sample of surgical dressing claims from January 1, 2019, through December 31, 2019. The SMRC conducted medical record reviews in accordance with applicable statutory, regulatory, and sub-regulatory guidance.

Common Reasons for Denial

  • Medical Necessity
    • The medical record documentation contains an error not otherwise specified. The medical record documentation did not show evidence of a qualifying wound, that the wound met the requirements of the qualifying dressing, or that there was a wound evaluation performed. Policy Article A54563 – Surgical Dressings states Surgical Dressings are covered under the Surgical Dressings Benefit (Social Security Act §1861(s)(5)). The CMS Benefit Policy Manual, IOM Pub. 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.
  • No Response to the Documentation Request
    • CMS Internet-Only Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section B/C, requires providers/suppliers to respond to requests for documentation within 45 calendar days of the additional documentation request. The documentation was not submitted or not submitted timely.
  • Medical Records Missing to Support Medical Necessity
    • The treating practitioner’s order, Certificate of Medical Necessity, supplier prepared statement, or the practitioner’s attestation, by itself, does not provide sufficient documentation of medical necessity. Refer to IOM 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.9.


Social Security Act (SSA) Title XVIII

  • SSA § 1815(a). Providers must furnish information.
  • SSA § 1833(e). Payment of Benefits.
  • SSA § 1834(j)(2)(B), (3), (5)(F)(iii). Requirements for Suppliers of Medical Equipment and Supplies.
  • SSA § 1861 (s)(5). Medical and Other Health Services.
  • SSA § 1862(a)(1)(A). Exclusions from Coverage and Medicare as Secondary Payer.
  • SSA § 1879(a)(1), (g)(2). Limitations on Liability of Beneficiary Where Medicare Claims are Disallowed.

Code of Federal Regulations (CFR) Title 42

  • CFR § 410.38. Durable medical equipment: Scope and conditions.
  • CFR § 414.200. Payment for Durable Medical Equipment and Prosthetic and Orthotic Devices.
  • CFR § 424.5. Basic Conditions.
  • CFR § 424.516, Subpart f. Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare program.
  • CFR § 424.535. Revocation of enrollment in the Medicare program.

IOM Medicare Benefit Policy Manual, 100-02

  • Ch. 15, Section 100. Surgical Dressings, Splints, Casts, and Other Devices Used for Reductions of Fractures and Dislocations.

Medicare National Coverage Determinations Manual, 100-03

  • Ch. 1, Section 270.4. Treatment of Decubitus Ulcers.
  • Ch. 1, Section 270.5. Porcine Skin and Gradient Pressure Dressings.

Medicare Claim Processing Manual, 100-04

  • Ch. 20, Section 10.2. Coverage Table for DME Claims.
  • Ch. 20, Section 100. General Documentation Requirements.

IOM, Medicare Program Integrity Manual, Publication 100-08

  • Ch. 3, Section Additional Documentation Request Required and Optional Elements.
  • Ch. 3, Section No Response or Insufficient Response to Additional Documentation Requests.
  • Ch. 3, Section Signature Requirements.
  • Ch. 4, Section 4.26. Supplier Proof of Delivery Documentation Requirements.
  • Ch. 4, Section 4.26.1. Proof of Delivery and Delivery Methods.
  • Ch. 4, Section 4.26.3. Proof of Delivery Requirements for Recently Eligible Medicare FFS Beneficiaries.
  • Ch. 5, Section 5.2. Rules Concerning Orders.
  • Ch. 5, Section 5.7. Documentation in the Patient’s Medical Record.
  • Ch. 5, Section 5.8. Supplier Documentation.
  • Ch. 13, Section 13.5.4. Reasonable and Necessary Provisions in LCDs.

Local Coverage Determinations

  • L33831. Surgical Dressings. Effective October 1, 2015.

Local Coverage Articles

  • A54563. Surgical Dressings-Policy Article. Effective October 1, 2015.
  • A55426. Standard Documentation Requirements for All Claims Submitted to DME MACs. Effective January 1, 2017.

Last Updated Oct 10, 2022