Physicians: Are You Ordering Surgical Dressings for Your Patient?

In order for a DME supplier to provide surgical dressings to your patients, there are actions you can take to make sure that all the required supporting medical record documentation is available.

Coverage Criteria Documentation Requirements

Surgical dressings are covered when they are required to treat either of two types of qualifying wounds.

1. A wound caused by a surgical procedure.
2. After the debridement of a wound.

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

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

Products that are eligible to be classified as surgical dressing include both:

• Primary dressings ‒ which are defined as therapeutic or protective coverings that are applied directly to wounds or lesions either on the skin or caused by an opening to the skin; and,
• Secondary dressings ‒ those are defined as materials that serve as a therapeutic or protective function and they are needed to secure a primary dressing.

A new order is needed when a new dressing type is added or if the quantity needs to be increased. A new order is required every three months for each dressing used.

These requirements are included on the SWO.

The SWO must contain the elements below. Help your patients by providing this timely.

• Beneficiary’s name or MBI
• Order date
• Description of the item(s) ordered
• Quantity to be dispensed, if applicable
• Treating practitioner name or NPI
• Treating practitioner’s signature

Clinical information demonstrating the reasonable and necessary requirements, must also be present in the beneficiary’s medical record.

For initial wound evaluations, the treating practitioner's medical record, nursing home, or home care nursing records must specify:

• The type of qualifying wound (see above); and,
• Information regarding the location, number and size of qualifying wounds being treated with a dressing; and,
• Whether the dressing is being used as a primary or secondary dressing or for some noncovered use (e.g., wound cleansing); and,
• Amount of drainage; and,
• The type of dressing (e.g., hydrocolloid wound cover, hydrogel wound filler, etc.); and,
• The size of the dressing (if applicable); and,
• The number/amount to be used at one time; and,
• The frequency of dressing change; and,
• Any other relevant clinical information.

The treating practitioner (or their designee) must update this information monthly. The wound evaluation is required unless there is documentation in the medical record which justifies why an evaluation could not be done within the timeframe, and what other monitoring methods were used to evaluate the beneficiary's need for ongoing use of dressings. Evaluation is expected on a weekly basis for beneficiaries in a nursing facility or for beneficiaries with heavily draining or infected wounds. The evaluation may be performed by a nurse, physician or other health care professional involved in the regular care of the beneficiary. This person must have no financial relationship with the supplier. This prohibition does not extend to treating practitioners who are also the supplier.

The weekly or monthly evaluation must include:

• The type of each wound (e.g., surgical wound, pressure ulcer, burn, etc.),
• Wound(s) location,
• Wound size (length x width) and depth,
• Amount of drainage, and
• Any other relevant wound status information.

Remember, this is the responsibility of the treating practitioner and the documentation needs to be available to the supplier when requested.

The frequency of recommended dressing changes depends on the type and use of the surgical dressing. When combinations of primary dressings, secondary dressings, and wound filler are used, the change frequencies of the individual products should be similar. For purposes of this policy, the product in contact with the wound determines the change frequency. It is not reasonable and necessary to use a combination of products with differing change intervals. For example, it is not reasonable and necessary to use a secondary dressing with a weekly change frequency over a primary dressing with a daily change interval.

The normal refill requirements apply to this policy. Regardless of utilization, no more than a month's supply of dressings may be provided at one time without documentation to support the greater quantities.

For coverage and limitations of these supplies review Surgical Dressings LCD L33831 and Policy Articles A54563 and A55426.

Reviewed 11/21/2024