DMEPOS Mini-Series #5 – Surgical Dressings

Per CMS, for the 2020 reporting period, the improper payment rate for surgical dressings was 67.3% representing $194.9 million. CMS indicated 82.4% of improper payments were due to insufficient documentation. Additional errors were no documentation (1.9%), medical necessity (1.7%), incorrect coding (1.9%) and other (12.2%). Pharmacies need to ensure that the clinical information in the patient’s records proves the dressings are reasonable and necessary as well as what type and quantity of dressing(s) they qualified for. Use the helpful tips and links below to be prepared in case of an audit on surgical dressings.

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Required Documentation for all DMEPOS items, see our April 2021 Newsline for more details
- Standard Written Order (SWO)
- Proof of refill request
- Proof of delivery
- Medical Records

Coverage Criteria for Surgical Dressings
- Medical records must support the surgical dressings are required for one of the following:
  - Treatment of a wound caused by, or treated by, a surgical procedure, OR used after debridement of a wound
  - Initial wound evaluation must include:
    - Type, location, number, and size of qualifying wounds (L x W and depth)
    - Amount of drainage
    - Frequency of dressing change
  - Ongoing wound evaluation (weekly or monthly)
  - Specific dressing coverage criteria (in addition to meeting the criteria for qualifying wound)
  - A new order is needed at least every 3 months for each qualified dressing dispensed, OR sooner if quantity required increases
  - Modifiers (A1-A9) to indicate the number of wounds on which the dressing is being applied
    - If using A9, must also submit actual number of wounds being treated in narrative on electronic claim
  - Please reference the following helpful links for more detail when billing for surgical dressings:

Author
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Jennifer Ottman, CPhT

Analyst at PAAS National^®

I began working at an independent pharmacy in high school and really enjoyed being in the health care field. I provided clinical support to improve patient care and adherence to their medications. I have played a vital role in the pharmacy industry full-time for 23 years. 

I have a Bachelor of Science degree from the University of Wisconsin-River Falls and have been a Certified Pharmacy Technician since 2001. Prior to joining the PAAS team, I was a floating technician, 3rd party district chargeback specialist, and district pharmacy training coordinator. Formerly, I was also an instructor for pharmacy technician certification classes. 

PAAS’ personal, one-on-one connection will help your pharmacy become more successful in dealing with tiresome PBM audits. It is a pleasure knowing that my colleagues and I can help member pharmacies.

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