CODING, COVERAGE AND REIMBURSEMENT

This section currently focuses primarily on Medicare. It may be expanded in the future to include information on private insurers as well.

General

• Overall, compression bandages, wraps and certain gradient compression stockings are considered Surgical Dressings and covered by Medicare part B as long as used on patients with a venous stasis ulcer (VLU) that meet the requirements to be a qualified wound (surgically created or modified, or debrided). These items are only covered if used at the beneficiary's residence (place of service 12) and are not separately payable if items are supplied at physician's office or hospital outpatient department.
• Medicare coverage of compression devices, including compression bandages, is managed by Medicare Administrative Contractors (MAC). Coverage is explained by the:
• Local Coverage Determination (LCD) Surgical Dressings (L33831) [1] , and
• Local Coverage Article: Surgical Dressings - Policy Article (A54563) [2]. 
• The frequency of recommended dressing changes depends on the type and use of the surgical dressing. When combinations of primary dressings, secondary dressings, and wound filler are used, the change frequencies of the individual products should be similar. According to the Surgical Dressings Policy [2] , the product in contact with the wound determines the change frequency. It is not reasonable and necessary to use a combination of products with differing change intervals. For example, it is not reasonable and necessary to use a secondary dressing with a weekly change frequency over a primary dressing with a daily change interval. Such claims will be denied as not reasonable and necessary.
• The following items are covered by Medicare Part B when requirements are met:

Gradient compression wrap

• HCPCS: A6545 GRADIENT COMPRESSION WRAP, NON-ELASTIC, BELOW KNEE, 30-50 MM HG, EACH
• Coverage requirements:
• The gradient compression stockings above are only covered when the patient has an active venous ulcer that has been treated by a physician or other healthcare professional and that required medically necessary debridement.
• Claims for gradient compression stockings used without a qualifying wound or when used for other non-qualifying conditions will be denied as statutorily non-covered, no benefit. Refer to the related Policy Article non-medical necessity coverage and payment rules for information about the statutory benefit requirements
• Frequency of replacement allowed by Medicare:
• 1 unit per leg every 6 months.
• Non-covered conditions:
• Venous insufficiency without stasis ulcers
• Prevention of stasis ulcers
• Prevention of the reoccurrence of stasis ulcers that have healed
• Treatment of lymphedema in the absence of ulcers
• Situations other than as a dressing for a qualified wound (VLU that has been debrided)
• Billing reminders:
• The only products that may be billed with code A6545 (non-elastic compression wrap) are those which have received a written Coding Verification Review from the Pricing, Data Analysis, and Coding (PDAC) contractor and that are posted in the Product Classification List on the PDAC web site
• Billable unit: one unit of service is for one wrap.
• When gradient compression stocking codes A6531 and A6532 or the gradient compression wrap code A6545 are used for an open venous ulcer, the code must be billed with the modifier AW. RT/LT modifiers need to be used to indicate side. Since stockings come in pairs, bill the left and the right stocking on the same claim line using the RT/LT modifiers and 2 units of service. Claims billed without modifiers AW or RT and/or LT will be rejected as incorrect coding. Modifiers A1-A9 are not used with codes A6531 and A6532.

HCPCS Modifiers 

• Modifiers A1-A9 are not used with gradient compression wrap code A6545
• Claims for gradient compression wrap code A6545 without the modifiers below will be rejected by the MAC.
• AW - Item furnished in conjunction with a surgical dressing
• RT – Right side
• LT- Left side

REFERENCES

1. Center for Medicare and Medicaid Services (CMS), et al. Local Coverage Determination for Surgical Dressings (L33831) . Date of publication 2017;.
2. Centers for Medicare and Medicaid Services, et al. Local Coverage Article for Surgical Dressings - Policy Article (A54563) . Date of publication 2015;.

SUBTOPICS