Medicare PART B Surgical Dressings Benefit Category Explained
by Glenda Motta RN, MPH
Medicare contractors recently issued a reminder regarding the use of surgical dressings for Medicare beneficiaries. Apparently, not everyone realizes that not ALL wounds are eligible for surgical dressing reimbursement. So, here is a refresher course.
Surgical dressings are limited to primary and secondary dressings required for treatment of a wound caused by, or treated by, a surgical procedure that has been performed by a physician or other health care professional to the extent permissible under State law.
In addition, surgical dressings required after debridement of a wound are covered, irrespective of the type of debridement, as long as the debridement was reasonable and necessary and performed by a health care professional acting within the scope of his/her legal authority when performing this function.
Debridement of a wound may be any type (examples are not all-inclusive): surgical (e.g., sharp instrument or laser), mechanical (e.g., irrigation or wet-to-dry dressings), chemical (e.g., topical application of enzymes), or autolytic (e.g., application of occlusive dressings to an open wound).
Dressings used for mechanical debridement to cover chemical debriding agents or to cover wounds to allow autolytic debridement are covered, although the agents themselves are non-covered under this policy.
Thus, not all wounds are eligible for coverage because at least one of the two following statutory requirements must be met:
- The wound must be surgically created or surgically modified; or,
- The wound must require debridement.
The DME MAC Surgical Dressings Local Coverage Determination and related Policy Article includes the following examples of situations (not all-inclusive) in which dressings are excluded from coverage under this benefit:
- Drainage from a cutaneous fistula which has not been caused or treated by a surgical procedure;
- Stage I pressure ulcers;
- First degree burns;
- Wounds caused by trauma which do not require surgical closure or debridement (e.g., skin tear or abrasion);
- A venipuncture or arterial puncture site other than the site of an indwelling catheter or needle.
Some other possibilities include: friction tears, cuts, ruptured bullae, self-inflicted wounds, or moisture-acquired skin defects unless they are either (a) caused by or the result of a surgery or (b) documented in the medical record to have required surgical debridement.
Also, it is important to note that many wound care items are non-covered under the surgical dressing benefit: skin sealants or barriers; wound cleansers or irrigating solutions; solutions used to moisten gauze (e.g., saline), silicone gel sheets, topical antiseptics, topical antibiotics, enzymatic debriding agents, gauze or other dressings used to cleanse or debride a wound but not left on the wound. In addition, any item listed in the latest edition of the Orange Book (e.g., an antibiotic-impregnated dressing which requires a prescription) is considered a drug and is non-covered under the Surgical Dressings benefit.
If a dressing is covered under another benefit, there is no separate payment using surgical dressing codes. Examples (not all-inclusive) are:
- Dressings used with infusion pumps (covered under the DME benefit) are included in the allowance for code A4221.
- Dressings used with parenteral nutrition (covered under the prosthetic device benefit) are included in the allowance for code B4224.
- Dressings used with gastrostomy tubes for enteral nutrition (covered under the prosthetic device benefit) are included in the allowance for codes B4034-B4036.
- Dressings used with tracheostomies (covered under the prosthetic device benefit) are included in the allowance for codes A4625 and A4629.
- Dressings used with dialysis access catheters (covered under the end stage renal disease benefit) are included in the composite rate (outpatient facility dialysis) or payment cap (method 1 home dialysis) paid to the dialysis provider.
Lastly, when a wound meets the eligibility requirement, surgical dressings are covered for as long as they are medically necessary. However, neither a physician’s order nor a CMN (Certificate of Medical Necessity) nor a DIF (Durable Medical Equipment Regional Carrier Information Form) nor a supplier prepared statement nor a physician attestation by itself provides sufficient documentation of medical necessity. There must be information in the patient’s medical record that supports the medical necessity for the item and substantiates the answers on the CMN or DIF or information on a supplier prepared statement or physician attestation.
For more information, refer to the entire Local Coverage Article for Surgical Dressings – Policy Article published by your appropriate DME MAC.
About The Author
Glenda Motta RN, MPH is a reimbursement consultant and wound care expert, publishing over 125 articles and books, serving as the President of the WOCN (1987-1989), and founding GM Associates, Inc., a healthcare marketing and reimbursement firm.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.