01-303 Surgical Dressings Notification of Medical Review

Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of claims for Medicare Surgical Dressings billed on dates of service from January 1, 2019 through December 31, 2019. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.

Background

Medicare provides reimbursement for surgical dressings under the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Benefit. This benefit only provides coverage for primary and secondary surgical dressings used on the skin on specified wound types. Types of surgical dressings include but are not limited to, alginate or other fiber gelling dressing, collagen or wound filling dressing and foam filling dressing. Surgical dressings are ranked in the top four categories of the 2019 Comprehensive Error Rate Testing (CERT) Improper Payment Report with an associated improper payment rate of 62.80%.

Reason for Review

The SMRC is tasked with performing claim review on a sample of surgical dressing claims from January 1, 2019 through December 31, 2019. The SMRC will conduct medical record reviews in accordance with applicable statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

HCPCS
All Surgical Dressing HCPCS as found in L33831 Surgical Dressings

A4649, A6010, A6011, A6021, A6022, A6023, A6024, A6154, A6196, A6197, A6198, A6199, A6203, A6204, A6205, A6206, A6207, A6208, A6209, A6210, A6211, A6212, A6213, A6214, A6215, A6217, A6218, A6219, A6220, A6221, A6222, A6223, A6224, A6228, A6229, A6230, A6231, A6232, A6233, A6234, A6235, A6236, A6237, A6238, A6239, A6240, A6241, A6242, A6243, A6244, A6245, A6246, A6247, A6248, A6251, A6252, A6253, A6254, A6255, A6256, A6257, A6258, A6259, A6261, A6262, A6266, A6402, A6403, A6404, A6441, A6442, A6443, A6444, A6445, A6446, A6447, A6448, A6449, A6450, A6451, A6452, A6453, A6454, A6455, A6456, A6457

Access related project details below.

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review. Documentation requested has been made specific to assist the provider in collecting and submitting pertinent information to decrease provider burden.

  1. Detailed Written Order
  2. Dispensing Order, if applicable
  3. DME Documentation of continued need and use
  4. Beneficiary’s medical records (which may include; practitioner medical records, hospital records, nursing home records, home care nursing notes, physical/occupational therapy notes) that support the item(s) provided is/are reasonable and necessary
  5. Operative/procedure report
  6. History and Physical reports (include medical history and current list of medications)
  7. Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD), Policy Article, and Standard Documentation Requirement Article (A55426) requirements
  8. Wound care assessment and supporting documentation
  9. Wound care notes
  10. Beneficiary’s compliance, and response to treatment
  11. Documentation of the request for refill
  12. Supplier beneficiary information forms
  13. Proof of Delivery
  14. If 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
  15. Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
  16. List of all non-standard abbreviations or acronyms used, including definitions
  17. Advance Beneficiary Notice
  18. If medical record documentation is submitted via esMD; Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
  19. Any other supporting documentation

References/Resources

  • Social Security Act (SSA) Title XVIII, Section 1815(a). Providers must furnish information.
  • SSA, Title XVIII, Section 1833(e). Payment of Benefits
  • SSA, Title XVIII, Section 1834(j)(2)(B), (3), (5)(F)(iii). Requirements for Suppliers of Medical Equipment and Supplies.
  • SSA, Title XVIII, Section 1861 (s)(5). Medical And Other Health Services.
  • SSA, Title XVIII, 1862(a)(1)(A). Exclusions from Coverage and Medicare as Secondary Payer.
  • SSA Title XVIII, Sections 1879(a)(1), (g)(2). Limitations on Liability of Beneficiary Where Medicare Claims are Disallowed.
  • Code of Federal Regulations (CFR) Title 42, Section 410.38. Durable medical equipment: Scope and conditions.
  • CFR, Title 42, Section 414.200. Payment for Durable Medical Equipment and Prosthetic and Orthotic Devices.
  • CFR, Title 42, Section 424.5. Basic Conditions.
  • CFR, Title 42, Section 424.516, Subpart f. Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare program.
  • CFR, Title 42, Section 424.535. Revocation of enrollment in the Medicare program.
  • Medicare Benefit Policy Manual (MBPM), Publication 100-02, Chapter 15, Section 100. Surgical Dressings, Splints, Casts, and Other Devices Used for Reductions of Fractures and Dislocations.
  • Medicare National Coverage Determinations (NCD) Manual, Publication 100-03, Chapter 1, Section 270.4. Treatment of Decubitus Ulcers.
  • Medicare NCD Manual, Publication 100-03, Chapter 1, Section 270.5. Porcine Skin and Gradient Pressure Dressings.
  • Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 20, Section 10.2. Coverage Table for DME Claims.
  • MCPM, Publication 100-04, Chapter 20, Section 100. General Documentation Requirements.
  • Medicare Program Integrity Manual (MPIM), Publication 100-08, Chapter 3, Section 3.2.3.4. Additional Documentation Request Required and Optional Elements.
  • MPIM, Publication 100-08, Chapter 3, Section 3.2.3.8. No Response or Insufficient Response to Additional Documentation Requests.
  • MPIM, Publication 100-08, Chapter 3, Section 3.3.2.4. Signature Requirements.
  • MPIM, Publication 100-08, Chapter 4, Section 4.26. Supplier Proof of Delivery Documentation Requirements.
  • MPIM, Publication 100-08, Chapter 4, Section 4.26.1. Proof of Delivery and Delivery Methods.
  • MPIM, Publication 100-08, Chapter 4, Section 4.26.3. Proof of Delivery Requirements for Recently Eligible Medicare FFS Beneficiaries.
  • MPIM, Publication 100-08, Chapter 5, Section 5.2. Rules Concerning Orders.
  • MPIM, Publication 100-08, Chapter 5, Section 5.7. Documentation in the Patient’s Medical Record.
  • MPIM, Publication 100-08, Chapter 5, Section 5.8. Supplier Documentation.
  • MPIM, Publication 100-08, Chapter 13, Section 13.5.4. Reasonable and Necessary Provisions in LCDs.
  • Local Coverage Determination (LCD) L33831. Surgical Dressings. Effective October 1, 2015.
  • Local Coverage Article (LCA) A54563. Surgical Dressings-Policy Article. Effective October 1, 2015.
  • LCA A55426. Standard Documentation Requirements for All Claims Submitted to DME MACs. Effective January 1, 2017.

Last Updated Nov 23, 2021