L11449

LCD/NCD Portal

Automated World Health

L11449 SURGICAL DRESSINGS

Region IV

DME Region

Jurisdiction C

08/05/2011

• For any item to be covered by Medicare, it must

o be eligible for a defined Medicare benefit category

o be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member

o Meet all other applicable Medicare statutory and regulatory requirements.

o For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following indications and limitations of coverage and/or medical necessity.

• If the coverage criteria described below are not met, the claim will be denied as not reasonable and necessary.

• For an item to be covered by Medicare, a written signed and dated order must be received by the supplier before a claim is submitted.

o If the supplier bills for an item without first receiving the completed order, the item will be denied as not reasonable and necessary.

• Surgical dressings are covered for as long as they are medically necessary.

o Dressings over a percutaneous catheter or tube (e.g., intravascular, epidural, nephrostomy, etc.) are covered as long as the catheter or tube remains in place and after removal until the wound heals.

 (Refer to Coding Guidelines in the associated Policy Article)

• Surgical dressings used in conjunction with investigational wound healing therapy (e.g., platelet derived wound healing formula) may be covered if all applicable coverage criteria are met based on the number and type of surgical dressings that are appropriate to treat the wound if the investigational therapy were not being used.

• When a wound cover with an adhesive border is being used, no other dressing is needed on top of it and additional tape is usually not required.

o Reasons for use of additional tape must be well documented.

o An adhesive border is usually more binding than that obtained with separate taping and is therefore indicated for use with wounds requiring less frequent dressing changes.

• Use of more than one type of wound filler or more than one type of wound cover in a single wound is rarely medically necessary and the reasons must be well documented.

o An exception is an alginate or other fiber gelling dressing wound cover or a saline, water, or hydrogel impregnated gauze dressing which might need an additional wound cover.

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

• Because composite dressings, foam and hydrocolloid wound covers, and transparent film, when used as secondary dressings, are meant to be changed at frequencies less than daily, appropriate clinical judgment should be used to avoid their use with primary dressings which require more frequent dressing changes.

o When claims are submitted for these dressings for changes greater than once every other day, the quantity in excess of that amount will be denied as not reasonable and necessary.

o While a highly exudative wound might require such a combination initially, with continued proper management the wound usually progresses to a point where the appropriate selection of these products results in the less frequent dressing changes which they are designed to allow.

o An example of an inappropriate combination is the use of a specialty absorptive dressing on top of non-impregnated gauze being used as a primary dressing.

• Dressing size must be based on and appropriate to the size of the wound.

o For wound covers, the pad size is usually about 2 inches greater than the dimensions of the wound.

o For example, a 5 cm x 5 cm (2 in. x 2 in.) wound requires a 4 in. x 4 in. pad size.

• The quantity and type of dressings dispensed at any one time must take into account the current status of the wound(s), the likelihood of change, and the recent use of dressings.

• Dressing needs may change frequently (e.g., weekly) in the early phases of wound treatment and/or with heavily draining wounds.

o Suppliers are also expected to have a mechanism for determining the quantity of dressings that the patient is actually using and to adjust their provision of dressings accordingly.

o No more than a one month's supply of dressings may be provided at one time, unless there is documentation to support the necessity of greater quantities in the home setting in an individual case.

o An even smaller quantity may be appropriate in the situations described above.

• Surgical dressings must be tailored to the specific needs of an individual patient.

o When surgical dressings are provided in kits, only those components of the kit that meet the definition of a surgical dressing, that are ordered by the physician, and that are medically necessary are covered.

• The following are some specific coverage guidelines for individual products when the products themselves are necessary in the individual patient.

o The medical necessity for more frequent change of dressings must be documented in the patient's medical record and submitted with the claim (see Documentation section).

• ALGINATE OR OTHER FIBER GELLING DRESSING (A6196-A6199):

• Alginate or other fiber gelling dressing covers are covered for moderately to highly exudative full thickness wounds (e.g., stage III or IV ulcers)

• Alginate or other fiber gelling dressing fillers for moderately to highly exudative full thickness wound cavities (e.g., stage III or IV ulcers).

• They are not medically necessary on dry wounds or wounds covered with eschar.

• Usual dressing change is up to once per day.

• One wound cover sheet of the approximate size of the wound or up to 2 units of wound filler (1 unit = 6 inches of alginate or other fiber gelling dressing rope) is usually used at each dressing change. It is usually inappropriate to use alginates or other fiber gelling dressings in combination with hydrogels.

• COMPOSITE DRESSING (A6203-A6205):

• Usual composite dressing change is up to 3 times per week, one wound cover per dressing change.

• CONTACT LAYER (A6206-A6208):

• Contact layer dressings are used to line the entire wound; they are not intended to be changed with each dressing change. Usual dressing change is up to once per week.

• FOAM DRESSING (A6209-A6215):

• Foam dressings are covered when used on full thickness wounds (e.g., stage III or IV ulcers) with moderate to heavy exudate.

• Usual dressing change for a foam wound cover used as a primary dressing is up to 3 times per week.

• When a foam wound cover is used as a secondary dressing for wounds with very heavy exudate, dressing change may be up to 3 times per week. Usual dressing change for foam wound fillers is up to once per day.

• GAUZE, NON-IMPREGNATED (A6216-A6221, A6402-A6404, A6407):

• Usual non-impregnated gauze dressing change is up to 3 times per day for a dressing without a border and once per day for a dressing with a border.

• It is usually not necessary to stack more than 2 gauze pads on top of each other in any one area.

• GAUZE, IMPREGNATED, WITH OTHER THAN WATER, NORMAL SALINE, HYDROGEL, OR ZINC PASTE (A6222-A6224, A6266):

• Usual dressing change for gauze dressings impregnated with other than water, normal saline, hydrogel or zinc paste is up to once per day.

• GAUZE, IMPREGNATED, WATER OR NORMAL SALINE (A6228-A6230):

• There is no medical necessity for these dressings compared to non-impregnated gauze which is moistened with bulk saline or sterile water.

• When these dressings are billed, they will be denied as not reasonable and necessary.

• HYDROCOLLOID DRESSING (A6234-A6241):

• Hydrocolloid dressings are covered for use on wounds with light to moderate exudate.

• Usual dressing change for hydrocolloid wound covers or hydrocolloid wound fillers is up to 3 times per week.

• HYDROGEL DRESSING (A6231-A6233, A6242-A6248):

• Hydrogel dressings are covered when used on full thickness wounds with minimal or no exudate

 (e.g., stage III or IV ulcers).

o Hydrogel dressings are not usually medically necessary for stage II ulcers.

o Documentation must substantiate the medical necessity for use of hydrogel dressings for stage II ulcers (e.g., location of ulcer is sacro-coccygeal area).

o Usual dressing change for hydrogel wound covers without adhesive border or hydrogel wound fillers is up to once per day.

o Usual dressing change for hydrogel wound covers with adhesive border is up to 3 times per week.

• The quantity of hydrogel filler used for each wound must not exceed the amount needed to line the surface of the wound.

o Additional amounts used to fill a cavity are not medically necessary.

o Documentation must substantiate the medical necessity for code A6248 billed in excess of 3 units (fluid ounces) per wound in 30 days.

• Use of more than one type of hydrogel dressing (filler, cover, or impregnated gauze) on the same wound at the same time is not medically necessary.

• SPECIALTY ABSORPTIVE DRESSING (A6251-A6256):

• Specialty absorptive dressings are covered when used for moderately or highly exudative wounds

o (e.g., stage III or IV ulcers).

• Usual specialty absorptive dressing change is up to once per day for a dressing without an adhesive border and up to every other day for a dressing with a border.

• TRANSPARENT FILM (A6257-A6259):

• Transparent film dressings are covered when used on open partial thickness wounds with minimal exudate or closed wounds.

• Usual dressing change is up to 3 times per week.

• WOUND FILLER, NOT ELSEWHERE CLASSIFIED (A6261-A6262):

• Usual dressing change is up to once per day.

• WOUND POUCH (A6154):

• Usual dressing change is up to 3 times per week.

• TAPE (A4450, A4452):

• Tape is covered when needed to hold on a wound cover, elastic roll gauze or non-elastic roll gauze.

• Additional tape is usually not required when a wound cover with an adhesive border is used.

• The medical necessity for tape in these situations must be documented. Tape change is determined by the frequency of change of the wound cover.

• Quantities of tape submitted must reasonably reflect the size of the wound cover being secured.

• Usual use for wound covers measuring 16 square inches or less is up to 2 units per dressing change;

o for wound covers measuring 16 to 48 square inches, up to 3 units per dressing change

o For wound covers measuring greater than 48 square inches, up to 4 units per dressing change.

• LIGHT COMPRESSION BANDAGE (A6448-A6450), MODERATE/HIGH COMPRESSION BANDAGE (A6451, A6452),SELF-ADHERENT BANDAGE (A6453-A6455), CONFORMING BANDAGE (A6442-A6447), PADDING BANDAGE (A6441):

• Most compression bandages are reusable.

o Usual frequency of replacement would be no more than one per week unless they are part of a multi-layer compression bandage system.

• Conforming bandage dressing change is determined by the frequency of change of the selected underlying dressing.

• GRADIENT COMPRESSION WRAP (A6545):

• Coverage of a non-elastic gradient compression wrap (A6545) is limited to one per 6 months per leg.

• Quantities exceeding this amount will be denied as not reasonable and necessary.

• Refer to Policy Article for statement concerning noncoverage if the ulcer has healed.

Coding Information

Bill Type Codes:

• Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.

• Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type.

• Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Revenue Codes:

• Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service.

• In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination.

• Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

CPT/HCPCS Codes

• The appearance of a code in this section does not necessarily indicate coverage.

HCPCS MODIFIERS:

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

HCPCS CODES:

A4450 TAPE, NON-WATERPROOF, PER 18 SQUARE INCHES

A4452 TAPE, WATERPROOF, PER 18 SQUARE INCHES

A4461 SURGICAL DRESSING HOLDER, NON-REUSABLE, EACH

A4463 SURGICAL DRESSING HOLDER, REUSABLE, EACH

A4465 NON-ELASTIC BINDER FOR EXTREMITY

A4490 SURGICAL STOCKINGS ABOVE KNEE LENGTH, EACH

A4495 SURGICAL STOCKINGS THIGH LENGTH, EACH

A4500 SURGICAL STOCKINGS BELOW KNEE LENGTH, EACH

A4510 SURGICAL STOCKINGS FULL LENGTH, EACH

A4649 SURGICAL SUPPLY; MISCELLANEOUS

A6010 COLLAGEN BASED WOUND FILLER, DRY FORM, STERILE, PER GRAM OF COLLAGEN

A6011 COLLAGEN BASED WOUND FILLER, GEL/PASTE, PER GRAM OF COLLAGEN

A6021 COLLAGEN DRESSING, STERILE, SIZE 16 SQ. IN. OR LESS, EACH

A6022 COLLAGEN DRESSING, STERILE, SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACH

A6023 COLLAGEN DRESSING, STERILE, SIZE MORE THAN 48 SQ. IN., EACH

A6024 COLLAGEN DRESSING WOUND FILLER, STERILE, PER 6 INCHES

A6025 GEL SHEET FOR DERMAL OR EPIDERMAL APPLICATION, (E.G., SILICONE, HYDROGEL, OTHER), EACH

A6154 WOUND POUCH, EACH

A6196 ALGINATE OR OTHER FIBER GELLING DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR LESS, EACH DRESSING

A6197 ALGINATE OR OTHER FIBER GELLING DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACH DRESSING

A6198 ALGINATE OR OTHER FIBER GELLING DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ. IN., EACH DRESSING

A6199 ALGINATE OR OTHER FIBER GELLING DRESSING, WOUND FILLER, STERILE, PER 6 INCHES

A6203 COMPOSITE DRESSING, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

A6204 COMPOSITE DRESSING, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

A6205 COMPOSITE DRESSING, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

A6206 CONTACT LAYER, STERILE, 16 SQ. IN. OR LESS, EACH DRESSING

A6207 CONTACT LAYER, STERILE, MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACH DRESSING

A6208 CONTACT LAYER, STERILE, MORE THAN 48 SQ. IN., EACH DRESSING

A6209 FOAM DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING

A6210 FOAM DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING

A6211 FOAM DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING

A6212 FOAM DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

A6213 FOAM DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

A6214 FOAM DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

A6215 FOAM DRESSING, WOUND FILLER, STERILE, PER GRAM

A6216 GAUZE, NON-IMPREGNATED, NON-STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING

A6217 GAUZE, NON-IMPREGNATED, NON-STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING

A6218 GAUZE, NON-IMPREGNATED, NON-STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING

A6219 GAUZE, NON-IMPREGNATED, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

A6220 GAUZE, NON-IMPREGNATED, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

A6221 GAUZE, NON-IMPREGNATED, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

A6222 GAUZE, IMPREGNATED WITH OTHER THAN WATER, NORMAL SALINE, OR HYDROGEL, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING

A6223 GAUZE, IMPREGNATED WITH OTHER THAN WATER, NORMAL SALINE, OR HYDROGEL, STERILE, PAD SIZE MORE THAN 16 SQ. IN., BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING

A6224 GAUZE, IMPREGNATED WITH OTHER THAN WATER, NORMAL SALINE, OR HYDROGEL, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING

A6228 GAUZE, IMPREGNATED, WATER OR NORMAL SALINE, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING

A6229 GAUZE, IMPREGNATED, WATER OR NORMAL SALINE, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING

A6230 GAUZE, IMPREGNATED, WATER OR NORMAL SALINE, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING

A6231 GAUZE, IMPREGNATED, HYDROGEL, FOR DIRECT WOUND CONTACT, STERILE, PAD SIZE 16 SQ. IN. OR LESS, EACH DRESSING

A6232 GAUZE, IMPREGNATED, HYDROGEL, FOR DIRECT WOUND CONTACT, STERILE, PAD SIZE GREATER THAN 16 SQ. IN., BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACH DRESSING

A6233 GAUZE, IMPREGNATED, HYDROGEL, FOR DIRECT WOUND CONTACT, STERILE, PAD SIZE MORE THAN 48 SQ. IN., EACH DRESSING

A6234 HYDROCOLLOID DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING

A6235 HYDROCOLLOID DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING

A6236 HYDROCOLLOID DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING

A6237 HYDROCOLLOID DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

A6238 HYDROCOLLOID DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

A6239 HYDROCOLLOID DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

A6240 HYDROCOLLOID DRESSING, WOUND FILLER, PASTE, STERILE, PER OUNCE

A6241 HYDROCOLLOID DRESSING, WOUND FILLER, DRY FORM, STERILE, PER GRAM

A6242 HYDROGEL DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING

A6243 HYDROGEL DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING

A6244 HYDROGEL DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING

A6245 HYDROGEL DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

A6246 HYDROGEL DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

A6247 HYDROGEL DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

A6248 HYDROGEL DRESSING, WOUND FILLER, GEL, PER FLUID OUNCE

A6250 SKIN SEALANTS, PROTECTANTS, MOISTURIZERS, OINTMENTS, ANY TYPE, ANY SIZE

A6251 SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING

A6252 SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING

A6253 SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING

A6254 SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

A6255 SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

A6256 SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

A6257 TRANSPARENT FILM, STERILE, 16 SQ. IN. OR LESS, EACH DRESSING

A6258 TRANSPARENT FILM, STERILE, MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACH DRESSING

A6259 TRANSPARENT FILM, STERILE, MORE THAN 48 SQ. IN., EACH DRESSING

A6260 WOUND CLEANSERS, ANY TYPE, ANY SIZE

A6261 WOUND FILLER, GEL/PASTE, PER FLUID OUNCE, NOT OTHERWISE SPECIFIED

A6262 WOUND FILLER, DRY FORM, PER GRAM, NOT OTHERWISE SPECIFIED

A6266 GAUZE, IMPREGNATED, OTHER THAN WATER, NORMAL SALINE, OR ZINC PASTE, STERILE, ANY WIDTH, PER LINEAR YARD

A6402 GAUZE, NON-IMPREGNATED, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING

A6403 GAUZE, NON-IMPREGNATED, STERILE, PAD SIZE MORE THAN 16 SQ. IN. LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING

A6404 GAUZE, NON-IMPREGNATED, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING

A6407 PACKING STRIPS, NON-IMPREGNATED, STERILE, UP TO 2 INCHES IN WIDTH, PER LINEAR YARD

A6410 EYE PAD, STERILE, EACH

A6411 EYE PAD, NON-STERILE, EACH

A6412 EYE PATCH, OCCLUSIVE, EACH

A6413 ADHESIVE BANDAGE, FIRST-AID TYPE, ANY SIZE, EACH

A6441 PADDING BANDAGE, NON-ELASTIC, NON-WOVEN/NON-KNITTED, WIDTH GREATER THAN OR EQUAL TO THREE INCHES AND LESS THAN FIVE INCHES, PER YARD

A6442 CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, NON-STERILE, WIDTH LESS THAN THREE INCHES, PER YARD

A6443 CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, NON-STERILE, WIDTH GREATER THAN OR EQUAL TO THREE INCHES AND LESS THAN FIVE INCHES, PER YARD

A6444 CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, NON-STERILE, WIDTH GREATER THAN OR EQUAL TO 5 INCHES, PER YARD

A6445 CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, STERILE, WIDTH LESS THAN THREE INCHES, PER YARD

A6446 CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, STERILE, WIDTH GREATER THAN OR EQUAL TO THREE INCHES AND LESS THAN FIVE INCHES, PER YARD

A6447 CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, STERILE, WIDTH GREATER THAN OR EQUAL TO FIVE INCHES, PER YARD

A6448 LIGHT COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, WIDTH LESS THAN THREE INCHES, PER YARD

A6449 LIGHT COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, WIDTH GREATER THAN OR EQUAL TO THREE INCHES AND LESS THAN FIVE INCHES, PER YARD

A6450 LIGHT COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, WIDTH GREATER THAN OR EQUAL TO FIVE INCHES, PER YARD

A6451 MODERATE COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, LOAD RESISTANCE OF 1.25 TO 1.34 FOOT POUNDS AT 50% MAXIMUM STRETCH, WIDTH GREATER THAN OR EQUAL TO THREE INCHES AND LESS THAN FIVE INCHES, PER YARD

A6452 HIGH COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, LOAD RESISTANCE GREATER THAN OR EQUAL TO 1.35 FOOT POUNDS AT 50% MAXIMUM STRETCH, WIDTH GREATER THAN OR EQUAL TO THREE INCHES AND LESS THAN FIVE INCHES, PER YARD

A6453 SELF-ADHERENT BANDAGE, ELASTIC, NON-KNITTED/NON-WOVEN, WIDTH LESS THAN THREE INCHES, PER YARD

A6454 SELF-ADHERENT BANDAGE, ELASTIC, NON-KNITTED/NON-WOVEN, WIDTH GREATER THAN OR EQUAL TO THREE INCHES AND LESS THAN FIVE INCHES, PER YARD

A6455 SELF-ADHERENT BANDAGE, ELASTIC, NON-KNITTED/NON-WOVEN, WIDTH GREATER THAN OR EQUAL TO FIVE INCHES, PER YARD

A6456 ZINC PASTE IMPREGNATED BANDAGE, NON-ELASTIC, KNITTED/WOVEN, WIDTH GREATER THAN OR EQUAL TO THREE INCHES AND LESS THAN FIVE INCHES, PER YARD

A6457 TUBULAR DRESSING WITH OR WITHOUT ELASTIC, ANY WIDTH, PER LINEAR YARD

A6501 COMPRESSION BURN GARMENT, BODYSUIT (HEAD TO FOOT), CUSTOM FABRICATED

A6502 COMPRESSION BURN GARMENT, CHIN STRAP, CUSTOM FABRICATED

A6503 COMPRESSION BURN GARMENT, FACIAL HOOD, CUSTOM FABRICATED

A6504 COMPRESSION BURN GARMENT, GLOVE TO WRIST, CUSTOM FABRICATED

A6505 COMPRESSION BURN GARMENT, GLOVE TO ELBOW, CUSTOM FABRICATED

A6506 COMPRESSION BURN GARMENT, GLOVE TO AXILLA, CUSTOM FABRICATED

A6507 COMPRESSION BURN GARMENT, FOOT TO KNEE LENGTH, CUSTOM FABRICATED

A6508 COMPRESSION BURN GARMENT, FOOT TO THIGH LENGTH, CUSTOM FABRICATED

A6509 COMPRESSION BURN GARMENT, UPPER TRUNK TO WAIST INCLUDING ARM OPENINGS (VEST), CUSTOM FABRICATED

A6510 COMPRESSION BURN GARMENT, TRUNK, INCLUDING ARMS DOWN TO LEG OPENINGS (LEOTARD), CUSTOM FABRICATED

A6511 COMPRESSION BURN GARMENT, LOWER TRUNK INCLUDING LEG OPENINGS (PANTY), CUSTOM FABRICATED

A6512 COMPRESSION BURN GARMENT, NOT OTHERWISE CLASSIFIED

A6513 COMPRESSION BURN MASK, FACE AND/OR NECK, PLASTIC OR EQUAL, CUSTOM FABRICATED

A6530 GRADIENT COMPRESSION STOCKING, BELOW KNEE, 18-30 MMHG, EACH

A6531 GRADIENT COMPRESSION STOCKING, BELOW KNEE, 30-40 MMHG, EACH

A6532 GRADIENT COMPRESSION STOCKING, BELOW KNEE, 40-50 MMHG, EACH

A6533 GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 18-30 MMHG, EACH

A6534 GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 30-40 MMHG, EACH

A6535 GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 40-50 MMHG, EACH

A6536 GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 18-30 MMHG, EACH

A6537 GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 30-40 MMHG, EACH

A6538 GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 40-50 MMHG, EACH

A6539 GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 18-30 MMHG, EACH

A6540 GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 30-40 MMHG, EACH

A6541 GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 40-50 MMHG, EACH

A6544 GRADIENT COMPRESSION STOCKING, GARTER BELT

A6545 GRADIENT COMPRESSION WRAP, NON-ELASTIC, BELOW KNEE, 30-50 MM HG, EACH

A6549 GRADIENT COMPRESSION STOCKING/SLEEVE, NOT OTHERWISE SPECIFIED

A9270 NON-COVERED ITEM OR SERVICE

Documentations Requirements

• Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider". It is expected that the patient's medical records will reflect the need for the care provided.

o The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.

• An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request.

o Items billed before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code.

• The order must specify

o The type of dressing (e.g., hydrocolloid wound cover, hydrogel wound filler, etc.)

o the size of the dressing (if appropriate)

o the number/amount to be used at one time (if more than one)

o the frequency of dressing change

o The expected duration of need.

• A new order is needed if a new dressing is added or if the quantity of an existing dressing to be used is increased.

o A new order is not routinely needed if the quantity of dressings used is decreased.

o However a new order is required at least every 3 months for each dressing being used even if the quantity used has remained the same or decreased.

• Information defining the number of surgical/debrided wounds being treated with a dressing, the reason for dressing use (e.g., surgical wound, debrided wound, etc.), and whether the dressing is being used as a primary or secondary dressing or for some noncovered use (e.g., wound cleansing) must be obtained from the physician, nursing home, or home care nurse.

o The source of that information and date obtained must be documented in the supplier's records.

• Current clinical information which supports the reasonableness and necessity of the type and quantity of surgical dressings provided must be present in the patient's medical records.

o Evaluation of a patient's wound(s) must be performed at least on a monthly basis unless there is documentation in the medical record which justifies why an evaluation could not be done within this timeframe and what other monitoring methods were used to evaluate the patient's need for dressings.

o Evaluation is expected on a more frequent basis (e.g., weekly) in patients in a nursing facility or in patients with heavily draining or infected wounds.

o The evaluation may be performed by a nurse, physician or other health care professional.

o This evaluation must include

 The type of each wound (e.g., surgical wound, pressure ulcer, burn, etc.)

 its location

 Its size (length x width in cm.) and depth

 the amount of drainage

 Any other relevant information.

• This information must be available upon request.

• When surgical dressings are billed, the appropriate modifier (A1 “A9, AW, EY, or GY) must be added to the code when applicable.

o If A9 is used, information must be submitted with the claim indicating the number of wounds.

o If GY is used, a brief description of the reason for non-coverage (e.g., "A6216GY - used for wound cleansing") must be entered in the narrative field of the electronic claim.

• When codes A4649, A6261 or A6262 are billed, the claim must include a narrative description of the item (including size of the product provided), the manufacturer, the brand name or number, and information justifying the medical necessity for the item.

o This information must be entered in the narrative field of the electronic claim.

• Refer to the Supplier Manual for more information on documentation requirements.

Appendices

• The staging of pressure ulcers used in this policy is as follows:

• Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

o The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

• Stage I

o Intact skin with non-blanchable redness of a localized area usually over a bony prominence.

o Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.

• Stage II

o Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.

o May also present as an intact or open/ruptured serum-filled blister.

• Stage III

o Full thickness tissue loss.

o Subcutaneous fat may be visible but bone, tendon or muscle is not exposed.

o Slough may be present but does not obscure the depth of tissue loss.

o May include undermining and tunneling.