CODING, COVERAGE AND REIMBURSEMENT

Coverage

• Overall, compression bandages, wraps and certain gradient compression stockings are covered by Medicare part B as long as used on patients with an ulcer that meet the requirements to be a qualified wound (surgically created or modified, or debrided). These items are only separately reimbursed by Medicare if used at the beneficiary's residence (place of service 12); they are not reimbursable as a separate item if 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. For purposes of this policy, 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: 

Tubular Dressing

• HCPCS: A6457 - TUBULAR DRESSING WITH OR WITHOUT ELASTIC, ANY WIDTH, PER LINEAR YARD
• Coverage requirements:
• Tubular dressings are only covered when they are used as a primary or secondary dressing over wound that meet the statutory requirements for a qualifying wound (surgically created or modified, or debrided).
• Claims for tubular dressings 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: same as primary dressing

• Non-covered conditions:
• Strains, sprains, edema,
• Situations other than as a dressing for a qualified wound (surgically created or modified, or debrided).
• Drainage from a cutaneous fistula which has not been caused by or treated by a surgical procedure; or,
• A Stage I pressure ulcer; or
• A first degree burn; or
• Wounds caused by trauma which do not require surgical closure or debridement - e.g., skin tear or abrasion; or,
• A venipuncture or arterial puncture site (e.g., blood sample) other than the site of an indwelling catheter or needle.
• Billing reminders:
• Medicare billable unit for tubular dressings is "per yard".
• When billing Medicare, check number of yards per dressing as described by manufacturer and indicate number of units (i.e., yards) to be used during the period for which supplies are being requested. As per Medicare Policy: "For all dressings, if a single dressing is divided into multiple portion/pieces, the code and quantity billed must represent the originally manufactured size and quantity".

HCPCS Modifiers:

• Claims for tubular dressings without the A1-A9 modifiers below will be rejected by the MAC. 
• Modifiers A1 – A9 have been established to indicate that a particular item is being used as a primary or secondary dressing on a surgical or debrided wound and to indicate the number of wounds on which that dressing is being used. The modifier number must correspond to the number of wounds on which the dressing is being used, not the total number of wounds treated. For example, if the beneficiary has four (4) wounds but a particular dressing is only used on two (2) of them, the A2 modifier must be used with that HCPCS code
• A1 – Dressing for one wound 
• A2 – Dressing for two wounds 
• A3 – Dressing for three wounds 
• A4 – Dressing for four wounds 
• A5 – Dressing for five wounds 
• A6 – Dressing for six wounds 
• A7 – Dressing for seven wounds 
• A8 – Dressing for eight wounds 
• A9 – Dressing for nine wounds 
• AW – Item furnished in conjunction with a surgical dressing 
• EY – No physician or other licensed health care provider order for this item or service 
• GY – Item or service statutorily noncovered or does not meet the definition of any Medicare benefit 
• LT – Left side 
• RT – Right side
• If the dressing is not being used as a primary or secondary dressing on a surgical or debrided wound, do not use modifiers A1-A9. When dressings are provided in noncovered situations (e.g., use of gauze in the cleansing of a wound or intact skin), a GY modifier must be added to the code and a brief description of the reason for non-coverage included - e.g., "A6216GY - used for wound cleansing."

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