The following are the examples of situations in which dressings are noncovered under the Surgical Dressings benefit are:
- Drainage from a cutaneous fistula which has not been caused by or treated by a surgical procedure; or
- A Stage I pressure ulcer; or
- A first degree burn; or
- Wounds caused by trauma which do not require surgical closure or debridement – e.g., skin tear or abrasion; or
- A venipuncture or arterial puncture site (e.g., blood sample) other than the site of an indwelling catheter or needle.
Surgical dressing codes billed without modifiers A1-A9 are noncovered under the Surgical Dressings benefit. Certain dressings may be covered under other benefits.
Small adhesive bandages (e.g., Band-Aid or similar product) are not primarily used for the treatment of wounds addressed in the Surgical Dressings policy. Therefore, these dressings are noncovered under the surgical dressing benefit.
A silicone gel sheet (A6025) used for the treatment of keloids or other scars does not meet the definition of the surgical dressing benefit and will be denied as noncovered.
A first-aid type adhesive bandage (A6413) does not meet the definition of the surgical dressing benefit and will be denied as noncovered.
If a physician applies surgical dressings as part of a professional service that is billed to Medicare, the surgical dressings are considered incident to the professional services of the health care practitioner and are not separately payable. Claims for these dressings must not be submitted. Claims for the professional service which includes the dressings must be submitted to the local carrier or intermediary. If dressing changes are sent home with the patient, claims for these dressings may be submitted. In this situation, use the place of service corresponding to the patient’s residence; Place of Service Office (POS=11) must not be used.
The following are examples of wound care items which are noncovered under the surgical dressing benefit: skin sealants or barriers (A6250), wound cleansers (A6260) or irrigating solutions, solutions used to moisten gauze (e.g., saline), silicone gel sheets, topical antiseptics, topical antibiotics, enzymatic debriding agents, gauze or other dressings used to cleanse or debride a wound but not left on the wound. Also, any item listed in the latest edition of the Orange Book (e.g., an antibiotic-impregnated dressing which requires a prescription) is considered a drug and is noncovered under the Surgical Dressings benefit.
Claims for tape (A4450 and A4452) which are billed without an AW modifier (Item furnished in conjunction with a surgical dressing) or another modifier indicating coverage under a different policy will be denied as noncovered.
When dressings are covered under other benefits, there is no separate payment using surgical dressing codes. Payment for any type of dressing in these situations is included in the allowance for other codes. Examples, not all-inclusive, are:
- Dressings used with infusion pumps (covered under the DME benefit) are included in the allowance for code A4221.
- Dressings used with parenteral nutrition (covered under the prosthetic device benefit) are included in the allowance for code B4224.
- Dressings used with gastrostomy tubes for enteral nutrition (covered under the prosthetic device benefit) are included in the allowance for codes B4034-B4036.
- Dressings used with tracheostomies (covered under the prosthetic device benefit) are included in the allowance for code A4625 and A4629.
- Dressings used with dialysis access catheters (covered under the end stage renal disease benefit) are included in the composite rate (outpatient facility dialysis) or payment cap (method 1 home dialysis) paid to the dialysis provider.