ATTENTION MEMBERS!
AAWC Alert
Brought to you by the AAWC Wound Care Specialty Council
CMS Review – Foam Dressings
The National Government Services -Jurisdiction B Medical Review Department

Medicare Surgical Foam Dressings – Prepayment Review Update

The National Government Services Jurisdiction B Medical Review department recently conducted a prepayment review for surgical foam dressings (HCPCS A6209 – A6214). This is a widespread random selection of submitted claims from multiple suppliers which are reviewed for medical necessity.
A total of 4,080 target services were reviewed and 3,795 (93.01 percent) of that total were denied. In this review, a wide variety of issues were found. The top issues and educational information on said issues are as follows:
 

• No response to the request for medical records:  It is expected that the patientʹs medical records will reflect the need for the care provided. The patientʹs medical records include the physicianʹs 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.

• Wound description was not present or did not meet the coverage criteria for a surgical foam dressing: Foam dressings are covered when used on full thickness wounds (e.g., stage III or IV ulcers) with moderate to heavy exudate.

 

• Excessive units of service (UOS) billed: 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. 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 medically necessary. Usual dressing change for a foam wound cover used as a primary dressing is up to three 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 three times per week. Usual dressing change for foam wound fillers is up to once per day.

It is important for suppliers to be familiar with the documentation requirements and utilization parameters as outlined in the surgical dressings LCD and policy article. Please ensure when submitting additional documentation requests that all supporting medical necessity documentation is provided and respond in a timely manner. The Surgical Dressings LCD on the National Government Services Web site at www.NGSMedicare.com Web site.