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Dressing Essentials

Dressing Essentials

INTRODUCTION

This topic provides practice essentials on dressings. It includes summarized information on the main dressing types used in wound management, divided in 3 tables. For each dressing type, refer to its corresponding row on the "Overview" table for clinical information, including function, composition, properties, configuration and need for secondary dressing. For information on application and removal, refer to the "How To" table. For information on HCPCS coding and Medicare coverage, consult the "Coding and Coverage" table. 

When using Dressings Essentials (this topic), it is important to keep in mind that dressing selection is a only a small component of wound management. Without a holistic, individualized patient assessment and plan that addresses the cause(s) of the ulcer, patient concerns and local wound care, efforts and resources may be wasted, as the ulcer will likely not heal.[1][2]

Details on assessment and wound bed preparation will be discussed elsewhere; however it is important to mention that as part of the initial assessment, clinicians should determine if the ulcer is [1][2] :
  • Healable: ulcer has adequate blood supply; causes and existing cofactors, conditions, or medications that could potentially delay healing have been optimized or ideally corrected. In general, for healable wounds, adequate debridement is recommended; dressing types listed on the tables below can be used depending on characteristics of the wound, such as moisture level, presence of local infection and other factors. 
  • Maintenance: ulcer is healable but either healthcare system factors or patient-related issues (e.g., patient adherence) are preventing the ulcer from healing. Maintenance ulcers are typically managed as non-healable ulcers, until unfavorable factors can be mitigated. For maintenance and non-healable ulcers, no debridement or conservative debridement is usually indicated. Antiseptics, and some types of dressings  (e.g, some antimicrobial and/or dry protective dressings) can be used. 
  • Non-healable: ulcer that does not have adequate blood supply to support healing or cause cannot be corrected. Managed as maintenance ulcers.
  • Stalled (has not healed in 6 weeks):  patient and ulcer need to be reassessed, advanced therapies may be indicated.

Debridement can be performed through several methods (e.g. autolytic, surgical, biologic, mechanical, and enzymatic).[3][4] If ongoing debridement is needed, it can be achieved through topical therapies such as collagenase covered with a dressing (enzymatic debridement, see dressing compatibility) or application of an occlusive dressing, which creates a moist wound bed environment facilitating the body’s intrinsic enzymes to break down necrotic or non-viable tissue (autolytic debridement).[3][5] Enzymatic debridement has been shown to result in shorter ulcer time to epithelialization when compared to autolytic debridement.[3][6][7]

The dressing type will change as the needs of the person and their wound change. Dressing choice needs to consider characteristics of the wound, unit costs, clinical effectiveness, ease of use, clinician's and patient's preferences, and indications and contraindications.[8][9][10]

QUICK NAVIGATION

Links provided in the table below can be used for quick navigation within this topic. "Compare brands" links leads to interactive matrices that help choose among brands. 

OVERVIEW

For each dressing type, the table below presents a short summary on description, indications, contraindications and ability to help with autolytic debridement ("autolytic"), reduce bacterial load on wound ("infection"), and help with moisture balance. "Autolytic", "infection" and "moisture balance" activities are classified as  - = no activity, + = minimal activity, ++ = moderate activity, +++ = strong activity. 

* "Infection" relates to the ability of the dressing to reduce bacterial load on wound. While all dressing types may be impregnated with antimicrobial agents (e.g., silver) and thus reduce wound bacterial load, for all dressing types except for "antimicrobial dressings", classification refers to additional intrinsic features that may also contribute towards decreasing bacterial load (e.g, bacterial sequestration by alginates and gelling fibers).[11][2]

Dressing Description

Autolytic

Infection*

Moisture balance Indications Contraindications/ Warnings

Alginate 

[11][2][12]


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Function

  • Moisture absorption 
  • Facilitate autolytic debridement
  • May assist in control of minor bleeding
  • May help decrease bacterial load through bacterial sequestration in gel
  • Fill in dead space

Composition

  • Derived from brown seaweed (biodegradable)

Properties

  • Absorb 20 times its weight
  • Interact with exudate to form a soft gel and maintain a moist environment
  • Conform to the shape of a wound
  • Easy to apply and remove (one piece remova

Configurations

  • Sheet, rope and combinations including silver, gelling fibers, charcoal, honey, hydrocolloid, and hydrogel

Secondary dressing

  • Required

Autolytic

++ 

Infection

Balance

+++

Thickness: 
  • Partial and full-thickness 

Exudate:

  • Moderate to very heavy

Infection:

  • Infected and non-infected

Wound bed:

  • Red (granulating) and yellow (fibrin/slough) 

Tunneling 

 
 

Do not use if:

  • Known sensitivity to alginates
  • Heavy bleeding
  • Hydrogel is being used 

Precaution:

  • Dressing performance may be affected by excessive use of petroleum-based ointments
  • Direct application on dry or lightly exuding wounds may result in excessive adherence to wound. In this case, moisten with saline to help removal. 

Gelling Fibers 

[2][11][12][13][14]


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Function

  • Moisture absorption
  • Facilitate autolytic debridement
  • May help decrease bacterial load through bacterial sequestration in gel
  • Does not have hemostatic properties
  • Fill in dead space

Composition

  • Composed primarily of carboxymethylcellulose (CMC), not degradable

Properties

  • Absorb up to 30 times their weight (more than alginate)
  • May provide less risk of maceration compared to alginate due to vertical fluid absorption properties (alginate absorbs laterally)
  • Interact with exudate to form a soft gel and maintain a moist environment
  • Conform to the shape of a wound
  • Easy to apply and remove (one piece removal)

Configurations

  • Sheet, rope and combinations including silver, alginate, and charcoal

Secondary dressing

  • Required

Autolytic

++

Infection

+

Balance

+++

Thickness: 

  • Partial and full-thickness

Exudate:

  • Moderate to very heavy 

Infection:

  • Infected and non-infected

Wound bed:

  • Red (granulating) and yellow (fibrin/slough)

Tunneling 

Do not use if:

  • Known sensitivity to components
  • Active bleeding
  • Hydrogel is being used 

Precaution:

  • Dressing performance may be affected by excessive use of petroleum-based ointments
  • Direct application on dry or lightly exuding wounds may result in excessive adherence to wound. In this case, moisten with saline to help removal. 

Antimicrobials

[1][2][12]


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Function'

  • Reduce bacterial levels
  • May facilitate autolytic debridement (e.g, honey)
  • May help with moisture absorption or donation, depending on underlying dressing material

Composition

  • Antimicrobial agent such as silver, iodides, PHMB, honey or aniline dye, with a vehicle (dressing) for delivery
  • Underlying dressing may be gauze, alginate, foams, or other types

Properties

  • Broad spectrum against bacteria (do not cause bacterial resistance)
  • Silver is activated from the dressing to the wound’s surface based on the amount of exudate and bacteria in the wound

Configurations

  • Sheets, gels, alginates, foams, or paste

Secondary dressing

  • May or may not be required, depending on dressing

Autolytic

Depends on product

Infection

+++

Balance

Depends on product


Infected wounds:

  • NERDS: Nonhealing, increased Exudate, Red and friable tissue, Debris, Smell. Any 3 = local infection
  • STONEES: increased Size, increased Temperature, Os, New breakdown, increased Exudate, increased Erythema/edema (cellulitis), Smell. Any 3 = deep infection

Exudate: 

  • Minimal to high levels, depends on dressing

 

Do not use if:

  • Known sensitivity to any product component

Precaution:

  • May cause stinging or sensitization
    - Silver: may cause staining on wound and intact skin, reduces enzymatic activity of collagenase

Collagen

[2][12][15]

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Function

  • Encourage the deposition and organization of newly formed collagen, create an environment that fosters healing
  • Provide moisture or absorption, depending on the delivery system (underlying dressing type)

Composition

  • Usually formulated with bovine, avian, or porcine collagen (fibrous, insoluble proteins produced by fibroblasts), degradable

Properties

  • Due to its chemotactic properties on wound fibroblasts, collagen stimulates cellular migration and contributes to new tissue development
  • Conform to the shape of a wound
  • Easy to apply and remove
  • Nonadherent

Configurations

  • Sheets, pastes,pads, particles, solutions, and gels

Secondary dressing

  • May or may not be required, depending on dressing

Autolytic

-

Infection

 -

Balance

 -

Thickness:

  • Partial and full-thickness

Exudate:

  • Light to moderate 

Infection

  • Non-infected wounds

Wound bed:

  • red (granulating)

Tunneling wounds

Skin graft donor sites



Do not use if:

  • Known sensitivity to any of the product components
  • Wound is infected, has sinus tracts or excessive exudate
  • Third degree burns
  • Dry, necrotic wounds
  • Active vasculitits

Precaution:

  • Possibility of patient’s cultural issues related to source


Composite 

[2][12][4]

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Function

  • Moisture absorption 
  • Facilitate autolytic debridement
  • Bacterial barrier

Composition

As per Medicare, a composite dressing must have: 

  • A physical (not chemical) bacterial barrier that is present over the entire dressing pad and extends out into the adhesive border (if no adhesive border, not a composite dressing), and
  • An absorptive layer other than an alginate or other fiber gelling dressing, foam, hydrocolloid, or hydrogel,
    and
  • Either a semi-adherent or a non-adherent property over the wound site

Properties

  • Conform to the shape of a wound
  • Easy to apply and remove
  • Bacterial barrier, moisture absorption, autolytic activity and nonadherence to wound in a single product

Configurations

  • Sheets with or without adhesive border

Secondary dressing

  • Not required
  • May be used as primary or secondary

Autolytic

 +

Infection

-

Balance

+++

Thickness:

  • Partial and full-thickness 

Exudate:

  • Minimal to moderate 

Infection:

  • Infected or non-infected wounds

Wound bed: 

  • Red (granulating), yellow (fibrin/slough), black (moist eschar)

Precaution:

  • Use with caution if infection is suspected
  • Require a border of intact skin for anchoring the dressing

Contact Layer

[2][12][4]

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Function

  • Protect wound base from trauma during dressing changes, by lining the entire wound to prevent adhesion of the overlying dressing to the wound
  • Not intended to be changed with each dressing change. They remain on the wound for an extended time while the absorptive dressings are changed
  • No autolytic activity
  • Not absorptive

Composition

  • Composed of a single layer of a woven (polyamide) net that acts as a low-adherence material

Properties

  • Designed to allow wound exudate passes to a secondary dressing
  • May be applied with topical medications, wound fillers, or absorptive dressings
  • Can be used with NPWT for the protection of fragile wound structures
  • Conform to the shape of a wound
  • Easy to apply and remove

Configurations:

  • Sheet; may have oil, hydrocolloid, silicon

Secondary dressing:

  • Required

Autolytic

-

Infection

-

Balance

-

Thickness:

  • Partial and full-thickness

Exudate:

  • Minimal to heavy

Infection:

  • Infected or non-infected wounds

Conditions include:

  • Painful wounds
  • Skin tears
  • Skin grafts and skin substitutes (e.g. Apligraft, Dermagraf)
  • Skin grafts donor sites
  • Surgical incisions
  • Radiated skin
  • 1st and 2nd degree burns


Do not use if:

  • Known sensitivity to product components (e.g, silicone, if present)
  • Stage 1 pressure injuries
  • Third degree burn
  • Dry or necrotic ulcers
  • Viscous exudate

Foam

[2][12][14][4]

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Function

  • Moisture absorption
  • Bacterial barrier (if occlusive backing)
  • Fill in dead space (if filler)

Composition

  • Non-adherent or adherent polyurethane
  • May be manufactured with other materials such as oil, hydrocolloid, silicon, antimicrobial agents (e.g, silver)
  • May have occlusive backing (bacterial barrier)

Properties

  • Non-linting and absorbent, may have various levels of thickness
  • May have non-adherent layer that allows non-traumatic removal
  • May have other properties such as low tack, antimicrobial action or pain control, depending on product
  • Easy to apply and remove

Configurations

  • Sheet, pads, pillow (cavity) dressings
  • With or without adhesive border

Secondary dressing

  • May be required, depending on dressing
  • May be used as primary for absorption and insulation, or as secondary for wounds with packing

Autolytic

-

Infection

-

Balance

+++

Thickness:

  • Partial and full-thickness 

Exudate:

  • Light to heavy, depending on product

Infection:

  • Infected or non-infected wounds, depending on product

Wound bed:

  • As primary: red (granulating), yellow (fibrin/slough) if used with enzymatic debrider 



Do not use if:

  • Occlusive dressing should not be used on heavily exudative or infected wounds
  • As primary on dry, necrotic black ulcers

Precaution:

  • May macerate periwound skin if become saturated

Gauze

[4][16]

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Function

  • Moist saline gauze: fill in dead space, mechanical debridement
  • Impregnated with other substances: fill in dead space, may keep wound moist. May be antimicrobial if impregnated with antimicrobial agents

Composition

  • Comprised of woven or nonwoven rayon, polyester, cotton or viscose
  • Typically manufactured as a single piece of material folded into a several ply gauze pad
  • May be non-impregnated or impregnated with substances such as iodinated agents, petrolatum, zinc paste, crystalline sodium chloride, chlorhexadine gluconate (CHG), bismuth tribromophenate (BTP), water, aqueous saline, hydrogel, or other agents  

Properties

  • Non-woven dressings result in stronger pads with improved fluid wicking properties, compared to woven dressings
  • Highly permeable, relatively non-occlusive: may desiccate wound beds with minimal exudate
  • No autolytic activity. When used as wet-to-dry dressings, result in non-selective debridement, which may disrupt newly formed tissue and cause pain upon dressing removal.
  • Not absorptive

Configurations

  • Sheet, rope, rolls, squares
  • With or without adhesive border

Secondary dressing

  • Required if no adhesive border or if manufacturer recommends it 
  • Non impregnated gauze can be primary or secondary dressing
  • Impregnated gauze most often primary dressing

 

Autolytic

+++

(wet to dry)

Infection

-


Balance

+/-

Thickness:

  • Partial and full-thickness 
    Exudate
  • Minimal to heavy exudate, depending on product

Infection:

  • Infected or non-infected wounds, depending on product 

Wound bed:

  • Non-adherent gauze as primary: dry, non-healable black (eschar), red (granulating)

 

Precaution:

  • May desiccate wounds with minimal exudate
  • When cut, woven gauze can leave fibers in the wound, which may act as a foreign body and perpetuate inflammation
  • While these dressings are inexpensive, they require frequent changing and ultimately incur higher cost due to care time and the volume of product used 


Hydrocolloid

[2][12][14][4][16]

[17]

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Function

  • Moisture maintenance
  • Facilitate autolytic debridement
  • Reduce wound pain
  • Bacterial barrier

Composition

  • Occlusive or semi-occlusive dressing with a film outer layer and sodium carboxymethylcellulose, gelatin, pectin, elastomers, and adhesives
  • Forms a yellow, malodorous gel on the wound surface, promoting moist wound healing (may be mistaken by infection). Some may leave residues or adhere to the periwound skin

Properties

  • If transparent, allow observation of the healing process
  • Conform to the shape of a wound

Configurations

  • Sheet, paste wafers, powders
  • With or without adhesive border

Secondary dressing

  • Required if no adhesive border or if manufacturer recommends it
  • May be used as primary or secondary dressings
  • May be used as secondary dressing over an alginate when the drainage is moderate, or over a hydrogel to further facilitate autolysis.

Autolytic

+++

Infection

+/-

Balance

++

Thickness:

  • Partial and full-thickness 

Exudate:

  • Light to moderate exudate

Infection:

  • Non-infected wounds

Wound bed:

  • Black eschar with adequate blood supply, yellow (fibrin/slough), red (granulating) 

Conditions include:

  • Initial debridement of venous ulcers, especially if wound is dry, with fibrinous slough


Do not use if: 

  • Heavy exudate, sinus tracts, infections
  • Fragile periwound skin: may cause maceration
  • Exposed tendon or bone
  • 3rd degree burns
  • Vasculitis
  • Hypergranulation
  • Sensitivity to product components
  • Stable, intact black eschar on heel
  • Dry black eschar with unknown or inadequate blood supply

Precaution:

  • Do not use if dressing needs to be changed more than every 3 days
  • Use with caution on wounds that require frequent inspection (e.g, diabetic foot ulcers due to increased risk of infection)

Hydrogel

[2][12][14][4][16]

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Function

  • Moisture addition
  • Facilitate autolytic debridement
  • Fills dead space (amorphous, impregnated gauzes)
  • May reduce wound pain

Composition

  • Viscous polymers with high water content (~80%)
  • May contain other materials depending on the manufacturer

Properties

  • Easy to apply and remove
  • Conform to the shape of a wound
  • Non-adherent so they do not harm the wound bed or surrounding skin

Configurations

  • Amorphous gels, impregnated gauzes or sheet dressings.
  • Sheets with or without adhesive border

Secondary dressing

  • Amorphous and impregnated dressings require secondary dressing
  • Sheets may be primary or secondary dressings

Autolytic

++

Infection

+/-

Balance

++

Thickness:

  • Partial and full-thickness 

Exudate:

  • None to minimal exudate

Infection:

  • Non-infected and infected wounds

Wound bed:

  • Black eschar with adequate blood supply, yellow (fibrin/slough) 

Do not use if: 

  • Heavy exudate
  • 3rd degree burns
  • Sensitivity to product components
  • Stable, intact black eschar on heel
  • Dry black eschar with unknown or inadequate blood supply
     

Precaution:

  • May be difficult to secure
  • Some may cause periwound skin maceration



Specialty Absorptive

[2][12][14][4][16]

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Function

  • Moisture absorption

Composition
As per Medicare, specialty absorptive dressings are unitized multi-layer dressings that provide:

  • (a) either a semi-adherent or non-adherent layer, and 
  • (b) highly absorptive layers of fibers such as absorbent cellulose, cotton, or rayon

Other absorptive polymers 

Properties

  • Highly absorptive
  • Easy to apply and remove
  • Non-adherent so they do not harm the wound bed or surrounding skin

Configurations

  • Sheet
  • With or without border

Secondary dressing

  • Required if no adhesive border or if manufacturer recommends it
  • May be primary or secondary dressings

Autolytic

-

Infection

-

Balance

+++

Thickness:

  • Partial and full-thickness 

Exudate:

  • Moderate to heavy exudate

Infection:

  • Non-infected and infected wounds

Wound bed:

  • Red (granulating), yellow (fibrin/slough), black (necrotic)


Precaution:

  • As a primary dressing, may not be appropriate for wounds with undermining

Transparent Film

[2][12][14][4][16]

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Function

  • Moisture maintenance
  • Facilitate autolytic debridement
  • Bacterial barrier

Composition

  • Semipermeable adhesive polyurethane sheet 
  • Impermeable to water molecules and bacteria, but allow vapor to cross the barrier, thus maintaining moist healing environment to promote granulation

Properties

  • Flexible and good for wounds on difficult anatomical sites (e.g, joints, toes) 
  • Allow for wound observation
  • Not absorptive
  • Generally inexpensive
  • May bathe or showe

Configurations

  • Film 

Secondary dressing

  • Not required
  • May be used as primary or secondary dressing

Autolytic

+

Infection

-

Balance

-

Thickness:

  • Partial thickness 

Exudate:

  • None to minimal exudate

Infection:

  • Non-infected wounds

Wound bed:

As secondary dressing for:

  • Red (granulating), yellow (fibrin/slough), black (necrotic)

Conditions include:

  • Primary dressing for partial thickness wounds with minimal or no exudate
  • Prevent or manage stage 1 pressure injury

Do not use (as primary dressing) if:

  • Infected wounds
  • Wounds with moderate to heavy drainage, as it is not absorptive and may cause maceration
  • Fragile periwound skin
  • Full thickness wounds
  • 3rd-degree burn

Precaution

  • Should not be used on wounds that require frequent dressing changes, as it can last for several days without needing replacement
  • May be difficult to apply and handle
    - May dislodge in high-friction areas

Wound Fillers

[2][12][14][4][16]

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Function

  • Fill in dead space
  • Moisture absorption or maintenance, depending on underlying material
  • May facilitate autolytic debridement, depending on underlying material

Composition

  • Depends on underlying material. Can be made of collagen, alginate or other fiber gelling, foam, hydrocolloid, hydrogel, non-impregnated packing strips and other dressing materials.

Properties

  • Easy to apply and remove
  • Depends on underlying material

Configurations

  • Hydrated forms (e.g., pastes, gels), dry forms (e.g., powder, granules, beads), or other forms such as rope, spiral, pillows, etc. 

Secondary dressing

  • Required
  • Used as primary dressing
     

Autolytic

Depends on product

Infection

Depends on product

Balance

Depends on product

Thickness:

  • Partial and full thickness 

Exudate:

  • Light to moderate exudate

Infection:

  • Non-infected and infected wounds, depending on dressing

Conditions include:

  • Wounds that need packing to fill dead space (cavity, undermining, etc)

  • Depends on specific product and underlying material
  • Generally contraindicated for use on wounds with no or minimal exudate
  • 3rd-degree burns 

HOW TO

The table below illustrates generic methods for application and removal of the different dressing types. Always follow manufacturers' recommendations as there might be variations among product brands within the same dressing type. Instructions for certain dressing types (e.g., foam, would filler) vary widely among product brands and thus a generic application or removal method is not presented here.

Dressing Application Removal

Alginates
[11][2][12]


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  • Cleanse with saline or other wound cleanser, dry peri-wound skin
  • Cut dressing to cover wound, ensure overlap by 1 cm onto the periwound skin. May fold dressing if heavy exudate
  • Heavy exudates: apply directly to wound base & change daily initially
  • For cavities, sinus tract or undermining: lightly pack one piece (where possible) of ribbon, leave visible tail for easy removal
  • Apply secondary dressing such as gauze, to maintain a moisture balanced wound environment
  • Alginate gels in contact with exudate and absorbs its color. Using forceps, remove dressing in one piece. If forceps unavailable, may remove with gloved forefinger and thumb using a 2x2 gauze. Gently irrigate with saline to flush residual dressing from wound bed
  • If dressing is dry and hard to remove, saturate it with sterile saline or sterile water and allow liquid to soak into the dressing until dressing is soft

Gelling Fibers

[2][11][12][13][14]

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  • Cleanse with saline or other wound cleanser, dry periwound skin
  • Cut dressing to cover wound, ensure overlap by 2 cm onto the periwound skin
  • Heavy exudates: apply directly to wound base & change daily initially
  • For cavities, sinus tract or undermining: lightly pack one piece (where possible) of ribbon, leave visible tail for easy removal
  • Apply secondary dressing such as gauze, to maintain a moisture balanced wound environment

  • Gelling fibers gel in contact with exudate and absorbs its color. Using forceps, remove dressing in one piece. If forceps unavailable, may remove with gloved forefinger and thumb using a 2x2 gauze. Gently irrigate with saline to flush residual dressing from wound bed
  • If dressing is dry and hard to remove, saturate it with sterile saline or sterile water and allow liquid to soak into the dressing until dressing is soft

Antimicrobials

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Varies, follow manufacturers’ instructions

Varies, follow manufacturers’ instructions

Collagen

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Varies, follow manufacturers’ instructions Varies, follow manufacturers’ instructions

Composite

[2][12][4][18]

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  • Cleanse with saline or other wound cleanser, dry periwound skin
  • Choose a size so that dressing overlaps intact periwound skin by 2 cm. Do not cut to fit
  • Remove the first tab from the underside of the dressing.
  • Adhere the exposed adhesive side on one side of the wound.
  • Remove the second tab and adhere the rest of the dressing over the wound.

  • Gently lift one corner of the dressing.
  • Roll it away from the wound while holding the skin away.
  • Gently lift the other corners and pull upwards until the dressing completely peels off.

Contact Layer

[2][12][4][18] 

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  • Cleanse with saline or other wound cleanser, dry periwound skin
  • Moisten gloves with sterile solution to prevent silicone from adhering to gloves
  • Cut dressing to cover wound, ensure overlap by at least 2 cm onto the periwound skin
  • Apply directly to wound base as a single layer, with no folding, tacky side to the wound
  • Remove remaining protective film, smooth it in place to obtain a good seal
  • If more than one piece is needed, overlap margins of dressings but make sure holes are not blocked
  • Apply secondary dressing, to maintain a moisture balanced wound environment

Should not be changed in every dressing change. Secondary dressing may be changed and contact layer left up to 7 days

  • Remove secondary dressing
  • Lift one corner of the contact layer and peel back from the wound

Foam

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Varies, follow manufacturers’ instructions Varies, follow manufacturers’ instructions

Gauze

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Varies, follow manufacturers’ instructions Varies, follow manufacturers’ instructions

Hydrocolloid

[12][18][19]

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  • Cleanse with saline or other wound cleanser, dry periwound skin 
  • Choose a size so that dressing overlaps intact periwound skin by 3 cm
  • Warm the dressing between your hands
  • Remove part of the white release paper, being careful to minimize finger contact with the adhesive surface.
  • Hold the adhesive side of the dressing over the wound. Align the dressing with the center of the wound. Gently apply the center part of the dressing in a rolling motion. Smooth into place
  • Remove the "bottom" white release paper while rolling the dressing in place - but don't stretch it.
  • Use tape to secure edges if needed
  • Gently mold the dressing into place for 30-60 seconds.

TIPS: 

  • May curl at edges and can be difficult to apply to ulcer base, may apply to primary dressing (e.g gauze, foam, alginate, gelling fibers), then apply both to ulcer.
  • Recommended re-assessment in 48-72h of first application. 

  • Gently lift one corner of the dressing.
  • Roll it away from the wound while holding the skin away.
  • Gently lift the other corners and pull upwards until the dressing completely peels off.

Hydrogel

[12][18][19]

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Amorphous gel, impregnated gauze:

  • Cleanse or irrigate,
  • Apply skin prep to periwound, allow to dry,
  • Fill wound with gel bed 5mm thick or impregnated gauze with gel.
  • Cover with secondary dressing (gauze, foam or transparent film dressing).

Sheet:

  • Cut to wound size and apply sticky side to wound. 
  • Cover with secondary dressing.

TIPS:

  • if hydrogel impregnated gauze is unavailable, may use plain non-woven gauze impregnated with hydrogel gel

Amorphous gel:

Flush with saline or water
Impregnated gauze: 

  • Gently remove dressing, then flush with saline or water

Sheet: 

  • Gently remove dressing away from wound

Specialty Absorptive

[12][18][19]

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Varies, follow manufacturers’ instructions Varies, follow manufacturers’ instructions

Transparent Film

[12][18][19]

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  • Cleanse with saline or other wound cleanser, dry periwound skin 
  • Choose a size so that dressing overlaps intact periwound skin by 2 cm. May cut to fit
  • Remove the first tab from the underside of the dressing.
  • Position dressing over the wound, press it down gently around the perimeter of the wound
  • Remove the second tab and adhere the rest of the dressing over the wound. Peel back tab of the outer surface if present
  • Smooth dressing out firmly from the center toward the edges
  • Gently lift off one edge of dressing and pull it away from wound, in the direction of hair growth
  • Remove immediately if there’s skin irritation, leakage or loosening of the film, or if it begins to roll up at the corners. 

Wound Filler

[12][18][19]

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Varies, follow manufacturers’ instructions Varies, follow manufacturers’ instructions

CODING AND COVERAGE

The information in the table below is derived from the most recent Centers for Medicare & Medicare Services (CMS, or "Medicare") Surgical Dressing Policy and Local Coverage Determination.[18][4] For more details see Medicare Coverage Guidelines below. Healthcare Common Procedure Coding System (HCPCS) Codes are standardized code sets used by Medicare and other health insurance providers in supplies and procedures coverage and reimbursement. HCPCS can be checked with manufacturers or on the Medicare Pricing, Data Analysis and Coding (PDAC) website. [20] 

  HCPCS (*) Medicare Coverage Medicare Frequency of Change

 Alginates

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A6196—pad size <16 in2
A6197—pad size >16 in2 but <48 in2
A6198—pad size >48 in2 
A6199—wound filler, per 6″ (15 cm)

Covered for:

  • Full thickness
  • Moderate to heavy exudate

Not covered for:

  • Dry wounds
  • Wounds covered with eschar

Note:

  • When alginate is used as a primary dressing, a secondary dressing is also covered 

Once a day (1 sheet or up to 12 inches of filler)

Gelling Fibers

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Same as for Alginate

A6196—pad size <16 in2
A6197—pad size >16 in2 but <48 in2
A6198—pad size >48 in2 
A6199—wound filler, per 6″ (15 cm)

Covered for:

  • Full thickness
  • Moderate to heavy exudate

Not covered for:

  • Dry wounds
  • Wounds covered with eschar 

Note:

  • When gelling fiber is used as a primary dressing, a secondary dressing is also covered 
Once a day (1 sheet or up to 12 inches of filler)

Antimicrobials

 

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There are no specific HCPCS for antimicrobial dressings. HCPCS depends on underlying dressing type (e.g., alginate, foam, etc)

Medicare does not have coverage guidelines specifically for antimicrobial dressings. Coverage is determined by underlying dressing type (e.g., alginate, foam, etc)

Medicare does not have coverage guidelines specifically for antimicrobial dressings. Coverage is determined by underlying dressing type (e.g., alginate, foam, etc)

Collagen

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A6021 - pad size < 16 in2                       
A6022—pad size > 16 in2 but < 48 in2 
A6023—pad size > 48 in2
A6010—wound filler, dry form, per gram of collagen 
A6011—wound filler, gel/paste, per gram of collagen 
A6024—wound filler, per 6” (15 cm)

Covered for:

  • Full thickness wounds (e.g., stage III or IV ulcers)
  • Wounds with light to moderate exudate, or
  • Wounds that have stalled or have not progressed toward a healing goal. 

Not covered for:

  • Wounds with heavy exudate, third-degree burns, or when an active vasculitis is present

Once every 7 days

Composite

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A6200—pad size ≤ 16 in2 
A6201—pad size > 16 in2 but ≤ 48 in2 
A6202—pad size > 48 in2 
A6203—pad size ≤ 16 in2 
A6204—pad size > 16 in2 but ≤ 48 in2 
A6205—pad size > 48 in2



Covered for:

  • Moderately to highly exudative wounds. 

Notes:

  • May be denied if used with a hydrogel as Medicare considers composite dressing an absorptive dressing
  • If dressing with adhesive border or if dressing with impervious backing layer is used, Medicare will typically not cover tape or a secondary dressing on top of it

3 times per 7 days (1 wound cover per change)

Contact Layer

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A6206 - pad size ≤ 16 in2 
A6207 - pad size > 16 in2 but ≤ 48 in2 
A6208—pad size > 48 in2

Covered for:

  • To line the entire wound to prevent adhesion of the overlying dressing to the wound

Not covered: 

  • When used with any dressing that has a non-adherent or semi-adherent layer as part of the dressing.

Once every 7 days

Foam

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Without an adhesive border: 

  • A6209—pad size ≤ 16 in2 
  • A6210—pad size > 16 in2 but ≤ 48 in2 
  • A6211—pad size > 48 in2
  • With an adhesive border: 
  • A6212—pad size ≤16 in2 
  • A6213—pad size > 16 in2 but ≤ 48 in2 
  • A6214—pad size > 48 in2 
  • Wound fillers: 
  • A6215—per gram

Covered for:

  • Full thickness wounds (e.g., stage III or IV ulcers) with moderate to heavy exudate. 

Note:

  • If dressing with adhesive border or if dressing with impervious backing layer is used, Medicare will typically not cover tape or a secondary dressing on to of it

Not covered:

  • When used with any dressing that has a non-adherent or semi-adherent layer as part of the dressing.
As a wound cover, primary or secondary: up to 3 times per week.  
As a wound filler: 1 time/ day

Gauze

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Gauze, Non-Impregnated (A6216-A6221, A6402-A6404, A6407)
Gauze, Impregnated, With Other Than Water, Normal Saline, Hydrogel, Or Zinc Paste (A6222-A6224,A6266)"

Covered:

  • Gauze, impregnated with other than water, normal saline, hydrogel or zinc paste

Not covered:

  • Gauze, Impregnated, Water Or Normal Saline (A6228-A6230)

Note:

  • Medicare covers a secondary dressing when primary dressing is a impregnated gauze dressing.
  • If dressing with adhesive border or if dressing with impervious backing layer is used, Medicare will typically not cover tape or a secondary dressing on top of it
  • Gauze or other dressings used to cleanse or debride a wound but not left on the wound
  • Non-impregnated gauze dressing: It is usually not reasonable and necessary to stack more than 2 gauze pads on top of each other in any one area

  • Non-impregnated gauze, without border: up to 3 times per day
  • Non-impregnated gauze, with border: once per day
  • Gauze impregnated with other than water, normal saline, hydrogel or zinc paste: up to once per day

Hydrocolloid

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Without an adhesive border: 

  • A6234—pad size <16 in2 
  • A6235—pad size >16 in2 but <48 in2 
  • A6236—pad size >48 in2

With an adhesive border:

  • A6237—pad size <16 in2
  • A6238—pad size >16 in2 but <48 in2 
  • A6239—pad size >48 in2

Wound fillers: 

  • A6240—paste, per fluid ounce 
  • A6241—dry form, per gram

Covered:

  • Light to moderate exudate

Note:

  • If dressing with adhesive border or if dressing with impervious backing layer is used, Medicare will typically not cover tape or a secondary dressing on top of it 
     


Frequency of replacement

  • Up to 3 times a week

Hydrogel

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Without an adhesive border: 

  • A6242—pad size < 16 in2 
  • A6243—pad size > 16 in2 but ≤ 48 in2
  • A6244—pad size > 48 in

With an adhesive border:

  • A6245—pad size < 16 in2
  • A6246—pad size > 16 in2 but ≤ 48 in2 
  • A6247—pad size > 48 in2

Wound fillers:

  • A6248—gel, per fluid ounce 

Gauze dressings impregnated with hydrogel without an adhesive border:

  • A6231—pad size < 16 in2
  • A6232—pad size > 16 in2 but ≤ 48 in2
  • A6233—pad size > 48 in2

Covered for:

  • Full thickness wounds (e.g., stage III or IV ulcers) with minimal or no exudate.
  • Secondary dressing for a hydrogel impregnated gauze is covered

Not covered for: 

  • Stage I, II pressure injury/ulcers.

Note:

  • Not covered when more than one type of hydrogel dressing (filler, cover, or impregnated gauze) is used on the same wound
  • Not covered when another absorptive dressing is used on the same wound at the same time (e.g., hydrogel and alginate).
  • If dressing with adhesive border or if dressing with impervious backing layer is used, Medicare will typically not cover tape or a secondary dressing on top of it 

  • Without adhesive border or hydrogel wound fillers: up to once per day.
  • With adhesive border: up to 3 times per week.

Note: 

  • The quantity of hydrogel filler used for each wound must not exceed the amount needed to line the surface of the wound. Additional amounts used to fill a cavity are not reasonable and necessary. Maximum utilization of code A6248 is 3 units (fluid ounces) per wound in 30 days.

Specialty Absorptive

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Without an adhesive border: 

  • A6251—pad size <16 in2 
  • A6252—pad size >16 in2 but <48 in2 
  • A6253—pad size >48 in2 

With an adhesive border:

  • A6254—pad size <16 in2 
  • A6255—pad size >16 in2 but ≤48 in2 
  • A6256—pad size >48 in2

Covered for:

  • Moderately or highly exudative full thickness wounds (e.g., stage III or IV ulcers).

Notes:

  • It is not appropriate to use combinations of a hydrating dressing on the same wound at the same time as an absorptive dressing (e.g., hydrogel and alginate)

Without an adhesive border: up to once per day 
With an adhesive border: up to every other day 

Transparent Film

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A6257—pad size <16 in2 
A6258—pad size >16 in2 but ≥48 in2
A6259—pad size >48 in2

Covered for: 

  • Open partial thickness wounds with minimal exudate or closed wounds

Up to 3 times per week

Wound Filler

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  • For certain materials, Medicare established unique codes - i.e., collagen wound filler (A6010, A6011, A6024), alginate or other fiber gelling wound filler (A6199), foam wound filler (A6215), hydrocolloid wound filler (A6240, A6241), hydrogel wound filler (A6248), and non-impregnated packing strips (A6407)
  • Wound fillers made of recognized dressing materials, not falling into any of these categories are coded as A6261 or A6262.
  • Wound fillers comprised of substances that are not recognized as effective dressing materials are coded as A9270

Covered for:

  • Coverage is based upon the characteristics of the underlying material(s) (e.g, see coverage for collagen, alginate, etc)

  • Frequency is based upon the characteristics of the underlying material(s) (e.g, see coverage for collagen, alginate, etc)
  • For A6261 or A6262: once a day


Medicare Coverage Guidelines

Information below is a summary based on the Surgical Dressing Policy Article [4]

Qualifying Wound Requirements

Surgical dressings are covered when a qualifying wound is present. A qualifying wound is defined as either of the following:

  • A wound caused by, or treated by, a surgical procedure; or,
  • A wound that requires debridement, regardless of the debridement technique.

The surgical procedure or debridement must be performed by a physician or other healthcare professional to the extent permissible under State law. Debridement of a wound may be any type of debridement (examples given are not all-inclusive):

  • Surgical (e.g., sharp instrument or laser)
  • Mechanical (e.g., irrigation or wet-to-dry dressings)
  • Enzymatic
  • Autolytic (e.g., application of occlusive dressings to an open wound).

Qualifying Dressing Requirements

Products that are eligible to be classified as a surgical dressings include both:

  • Primary dressings – Defined as therapeutic or protective coverings applied directly to wounds or lesions either on the skin or caused by an opening to the skin; and,
  • Secondary dressings – Defined as materials that serve a therapeutic or protective function and that are needed to secure a primary dressing.
Claims for products that are not able to be used as a primary or secondary dressing on a qualifying wound of the skin or that are composed of materials that do not serve a therapeutic or protective function will be denied as statutorily non-covered, no benefit.

Place of Service

  • If a physician applies surgical dressings as part of a professional service that is billed to Medicare, the surgical dressings are considered incident to the professional services of the health care practitioner and are not separately payable. Claims for these dressings must not be submitted. Claims for the professional service, which includes the dressings, must be submitted to the local carrier or intermediary. 
  • If dressing changes are sent home with the beneficiary, claims for these dressings may be submitted. In this situation, use the place of service (POS) corresponding to the beneficiary's residence (POS=12)
Official reprint from WoundReference® woundreference.com ©2018 Wound Reference, Inc. All Rights Reserved
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NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.

REFERENCES

  1. Sibbald RG, Goodman L, Woo KY, Krasner DL, Smart H, Tariq G, Ayello EA, Burrell RE, Keast DH, Mayer D, Norton L, Salcido RS et al. Special considerations in wound bed preparation 2011: an update©. Advances in skin & wound care. 2011;volume 24(9):415-36; quiz 437-8.
  2. Gary Sibbald R, Goodman L, Reneeka P et al. Wound bed preparation 2012. Journal of cutaneous medicine and surgery. 2013;volume 17 Suppl 1():S12-22.
  3. Waycaster C, Milne CT et al. Clinical and economic benefit of enzymatic debridement of pressure ulcers compared to autolytic debridement with a hydrogel dressing. Journal of medical economics. 2013;volume 16(7):976-86.
  4. Centers for Medicare and Medicaid Services, et al. Local Coverage Article for Surgical Dressings - Policy Article (A54563) . 2015;.
  5. Atkin L, Rippon M et al. Autolysis: mechanisms of action in the removal of devitalised tissue. British journal of nursing (Mark Allen Publishing). 2016;volume 25(20 Suppl):S40-S47.
  6. Milne CT, Ciccarelli A, Lassy M et al. A comparison of collagenase to hydrogel dressings in maintenance debridement and wound closure. Wounds : a compendium of clinical research and practice. 2012;volume 24(11):317-22.
  7. Gilligan AM, Waycaster CR, Bizier R, Chu BC, Carter MJ, Fife CE et al. Comparative Effectiveness of Clostridial Collagenase Ointment to Medicinal Honey for Treatment of Pressure Ulcers. Advances in wound care. 2017;volume 6(4):125-134.
  8. Moore, Zena E H; Webster, Joan et al. Dressings and topical agents for preventing pressure ulcers. Cochrane Database of Systematic Reviews. 2013;.
  9. Hingorani, Anil; LaMuraglia, Glenn M; Henke, Peter; Meissner, Mark H; Loretz, Lorraine; Zinszer, Kathya M; Driver, Vickie R; Frykberg, Robert; Carman, Teresa L; Marston, William; Mills, Jose... et al. The management of diabetic foot: A clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine. Journal of Vascular Surgery. 2016;volume 63(2 Suppl):3S-21S.
  10. Robson, Martin C; Cooper, Diane M; Aslam, Rummana; Gould, Lisa J; Harding, Keith G; Margolis, David J; Ochs, Diane E; Serena, Thomas E; Snyder, Robert J; Steed, David L; Thomas, David R; Wie... et al. Guidelines for the treatment of venous ulcers. Wound Repair and Regeneration. 2006;volume 14(6):649-662.
  11. Karen A. Gibbs, et al. Absorptive Dressings: Alginates and Hydrofibers Advances in Wound Care: Volume 1. 2017;.
  12. Cathy Thomas Hess RN BSN CWOCN. Clinical Guide to Skin and Wound Care (Clinical Guide: Skin & Wound Care) 7th ed. LWW. 2012;.
  13. Gupta S, Andersen C, Black J, de Leon J, Fife C, Lantis Ii JC, Niezgoda J, Snyder R, Sumpio B, Tettelbach W, Treadwell T, Weir D, Silverman RP et al. Management of Chronic Wounds: Diagnosis, Preparation, Treatment, and Follow-up. Wounds : a compendium of clinical research and practice. 2017;volume 29(9):S19-S36.
  14. Stephen Thomas. (Thomas S, ed.) et al. Surgical Dressings and Wound Management. Great Britain: Medetec Publications. 2010;.
  15. Fleck CA, Simman R et al. Modern collagen wound dressings: function and purpose. The journal of the American College of Certified Wound Specialists. 2011;volume 2(3):50-4.
  16. Livingston, Matthew; Wolvos, Tom et al. Scottsdale Wound Management Guide. A Comprehensive Guide for the Wound Care Clinician Malvern, PA: HMP Communications, LLC. 2015;volume 2():.
  17. Joseph McCulloch PhD PT CWS FACCWS FAPTA, ; Luther C. Kloth MS PT CWS FACCWS FAPTA, et al. Wound Healing: Evidence-Based Management (Contemporary Perspectives in Rehabilitation) . 2010;.
  18. Center for Medicare and Medicaid Services (CMS), et al. Local Coverage Determination for Surgical Dressings (L33831) . 2015;.
  19. Nancy Slone Rivera, MS, ANP-C, CWON, CFCN, and Stephanie C. Wu, DPM, MSc et al. Keys To Effective Wound Dressing Selection . 2017;.
  20. Noridian Healthcare Solutions, et al. Noridian PDAC Medicare Pricing, Data and Coding - Search for codes or fees . 2017;.
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