Surgical Dressings

Affected Providers

Treating practitioners and DME suppliers who bill for surgical dressings.

HCPCS & CPT Codes

Local Coverage Determination (LCD): Surgical Dressings (L33831) has the current HCPCS and CPT codes.

Background

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the improper payment rate for surgical dressings is 57.6%, with a projected improper payment amount of $177 million.

We cover surgical dressings under the surgical dressings benefit. You must meet the provisions in LCD L33831. We outline other policy requirements in: 

• Article: Surgical Dressings (A54563)
• Article: Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426).
• National Coverage Determination (NCD): Porcine Skin and Gradient Pressure Dressings (270.5)

Denial Reasons

No documentation accounted for 48.6% of improper payments for surgical dressings during the 2024 reporting period, while insufficient documentation (43.8%), incorrect coding (1.3%), medical necessity (0.4%), and other errors (5.8%) also caused improper payments. “Other” errors include duplicate payment, non-covered or unallowable service, or ineligible Medicare patient errors.

Preventing Denials

Qualifying Wound

We cover surgical dressings for a qualifying wound. A qualifying wound is either:

• A wound caused by, or treated by, a surgical procedure
• A wound after debridement, regardless of debridement technique (examples include, but aren’t limited to, surgical, mechanical, chemical, or autolytic)

Qualifying Dressing

Eligible products classified as surgical dressings include:

• Primary dressings: Therapeutic or protective coverings applied directly to wounds or lesions either on skin or caused by an opening to the skin.
• Secondary dressings: Needed materials that serve a therapeutic or protective role to secure a primary dressing. Examples of secondary dressings include adhesive tape, roll gauze, bandages, and disposable compression material.

• Type of qualifying wounds
• Location, number, and size of qualifying wounds being treated with a dressing
• Whether dressing use is primary or secondary, or for non-covered use (for example, wound cleansing)
• Amount of drainage
• Type of dressing (for example, hydrocolloid wound cover, hydrogel wound filler)
• Number or amount used at 1 time
• Frequency of dressing change
• Any other relevant clinical information

The patient’s medical records must include the clinical information and the reasonable and necessary policy requirements about the type and quantity of surgical dressings, which the treating practitioner (or their designee) must update monthly. We require this evaluation of the patient’s wound unless the medical record documents and justifies why the treating practitioner can’t evaluate within this time frame and documents what other monitoring methods showed the patient’s need for ongoing dressing use.

We expect weekly wound evaluations for patients in a nursing facility or for patients with heavily draining or infected wounds. A nurse, treating practitioner, or other health care provider involved in the patient’s regular care can do the evaluation. This person may have no financial relationship with the supplier. This prohibition doesn’t extend to treating practitioners who are also the supplier.

Weekly or monthly evaluation must include:

• Type of each wound (for example, surgical wound, pressure ulcer, burn)
• Wound location
• Wound size (length X width) and depth
• Amount of drainage
• Any other relevant wound status information

The supplier must document and date the source of this information in their records.

The frequency of recommended dressing changes depends on the type and use of surgical dressing. When providers use combinations of primary dressings, secondary dressings, and wound filler, frequency of changes in individual products should be similar.

For this policy, the product in contact with the wound determines the change frequency. We don’t consider using a combination of products with differing change intervals as reasonable and necessary. For example, it isn’t reasonable and necessary to use a secondary dressing with a weekly change frequency over a primary dressing with a daily change interval. We deny these claims as not reasonable and necessary.

Porcine Skin and Gradient Pressure Dressings

Porcine (pig) skin dressings are covered if reasonable and necessary for the patient as an occlusive dressing for burns, donor sites of a homograft, and decubiti and other ulcers (see NCD 270.5).

Gradient pressure dressings are Jobst elasticized heavy duty dressings that help reduce hypertrophic scarring and joint contractures following burn injury. They’re covered when used for that purpose.

Refill Requirements

For DMEPOS items and supplies provided on a recurring basis, base your billing on prospective, not retrospective use.

Documentation Requirements

To justify payment, you must meet specific requirements when ordering DMEPOS. We require a new order every 3 months for each dressing used.

Example of Improper Payments Due to Insufficient Documentation for Surgical Dressings

A supplier bills the claim for HCPCS code A6203 (Composite dressing, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing) and submits the following documentation per the review contractor’s request:

• Standard written order with correct HCPCS coding
• Treating practitioner’s medical record that has adequate medical necessity information
• Wound evaluation and medical records
• Refill request

What Documentation Was Missing?

The medical records sent to the contractor lacked sufficient information to determine if the patient’s condition met medical necessity coverage criteria.

What Happens Next?

The review contractor completes the claim as an insufficient documentation error, and the Medicare Administrative Contractor recoups payment.

Recommendation

To avoid billing errors and improper payments, the certifying physician must collect and submit all proper documentation in the treating practitioner’s medical record for DMEPOS.