The Surgical Dressing Policy: Still Alive and Well

  More times than we’d like to acknowledge, we have encountered new patients in our practice who either are covering their open wounds with paper towels, mini-pads or tissue because they simply couldn’t afford even gauze and tape for coverage, or even more disconcerting, have gone from using the most basic gauze dressings to more advanced dressings and expressed concern at the costs they have incurred over time simply because they had not been informed that either their insurance or their Medicare Part B plan would have provided coverage.

  The uninsured patient is a challenge that does require some creativity, and is not the focus of this article. The patient who may have been receiving care from their primary provider who sent the patient off to the pharmacy with a prescription for an over the counter antibiotic ointment, gauze and tape can be forgiven; but a patient who has been discharged from a long term care facility, a home health agency or previously cared for in another wound clinic? Well, shame on us.

  The Surgical Dressing Policy is alive and well. And though it is Medicare Part B coverage we are referring to, many, or actually most insurance carriers have coverage for the dressings in a similar fashion. But beware: if you call an insurance company customer service line you will likely be referred to their Durable Medical Equipment (DME) provider, then when calling the DME provider, you will likely be informed that they don’t provide dressings. If we stop there, the patients will not get their dressings. Oddly enough, we have found that it is the Part B Providers themselves who have the best information as to which plans they provide coverage for, and if they aren’t the provider, they know who is. So again, it’s that time consuming social work part of the care that we provide rearing its ugly head, but the end result is the patient getting the supplies they need to carry out the plan of care that we are setting up.

  The aim of our article is not to attempt to explain every nitty gritty detail of the coverage policy. That is definitely Kathleen Schaum’s domain. (To self-examine your knowledge of the policy, see Kathleen’s article, Can You Pass the Surgical Dressing Ordering and Documentation Test? Advances in Skin & Wound Care: March 2011;Volume 24,Issue 3, pp 112—117). Our goal rather is to resurrect awareness of the policy and discuss using it day-to-day for the better of our patients.

  In April of 1994, the Durable Medical Equipment Regional Carriers, contractors for the Healthcare Financing Administration (HCFA, now CMS, the Center for Medicare and Medicaid Services), made a landmark policy change that enabled access for Medicare Part B recipients to obtain advanced wound care products under the Surgical Dressing Policy. This change was the culmination of a tremendous amount of collaborative effort on the part of the Health Industry Manufacturers Association (HIMA), led by Marcia Nusgart, the International Association of Enterostomal Therapy (IAET, now WOCN), led by Glenda Motta, the National Pressure Ulcer Advisory Panel (NPUAP), led by Diane Krasner and countless other interested parties. Through many workgroups and meetings, the result was a policy which was fair and actually generous and resulted in a huge benefit for wound care patients in the US covered by Medicare Part B.

  There have been changes over the years, but the policy is still intact, and since there continues to be new products coming to the market, there is a mechanism in place to apply for coding and coverage. It may sound easy, but there is definitely hard work involved. Marcia Nusgart, MPh, is still a guiding force in these efforts, as Executive Director of the Coalition of Wound Care Manufacturers, as well as the Alliance of Wound Care Stakeholders. “The policy change in 1994 was certainly landmark and enabled clinicians to obtain quality dressings for their patients. There continues to be ongoing efforts made by our group to stay abreast of potential changes related to policy updates, policy language and product category additions to allow our members to respond in a timely manner”. (Visit this link for an insert www.todayswoundclinic.com/surgical-dressing-policy-still-alive-and-well).

  Surgical dressings are covered when they are medically necessary for the treatment of a wound caused by or treated by a surgical procedure or when debridement of a wound is medically necessary. The surgical procedure or debridement must be performed by a physician or other healthcare professional to the extent permissible under State law. Debridement of a wound may be any type of debridement (examples given are not all-inclusive): surgical (eg, sharp instrument or laser), mechanical (eg, irrigation or wet-to-dry dressings), chemical (eg, topical application of enzymes), or autolytic (eg, application of occlusive dressings to an open wound). Dressings used for mechanical debridement, as secondary dressings over chemical debriding agents, or to create a wound environment to allow for autolytic debridement are covered although the agents themselves are non-covered. Dressings over a percutaneous catheter or tube (eg, intravascular, epidural, nephrostomy, etc) are covered as long as the catheter or tube remains in place and after removal until the wound is closed.

  Surgical dressings include both primary dressings (ie, therapeutic or protective coverings applied directly to wounds or lesions either on the skin or caused by an opening to the skin) and secondary dressings (ie, materials that serve a therapeutic or protective function and that are needed to secure a primary dressing). There are however, various “rules” or utilization guidelines that must be adhered to when ordering for a patient. The basic utilization guidelines are found in the chart attached, but there are additional guidelines to keep in mind (these are examples only, see coverage policy for full details):

    1. When a wound cover with an adhesive border is being used, no other dressing is needed on top of it and additional tape is usually not required. Reasons for use of additional tape must be well documented. An adhesive border is usually more binding than that obtained with separate taping and is therefore indicated for use with wounds requiring less frequent dressing changes.

    2. Use of more than one type of wound filler or more than one type of wound cover in a single wound is rarely medically necessary and the reasons must be well documented. An exception is an alginate or other fiber gelling dressing wound cover or a saline, water, or hydrogel impregnated gauze dressing which might need an additional wound cover.

    3. It may not be appropriate to use some combinations of a hydrating dressing on the same wound at the same time as an absorptive dressing (eg, hydrogel and alginate).

    4. 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.

    5. Dressings provided must be used to treat the wound. Gauze and saline used to clean the wound, skin protectants, etc are not provided in the policy.

  Finding a Part B Provider can be accomplished easily through an Internet search. There are several that provide to patients nationally (eg, Central Medical Solutions, Inc. [CMSI], Edgepark Medical Supplies, National Rehab, Advance Tissue Management, CCS Medical) and there are many that supply more regionally or locally. Most of these companies will provide pre-printed forms to make ordering easier which is just one step in assuring compliance with the program. There are important points to keep in mind as we work with these companies:

  • When a decision is made on a plan of care for the patient, there must be a written order in the patient’s medical record as to need for the dressings, the type, amount and frequency. Additionally the wound assessment detailing type of wound, measurements, amount of exudate, tissue type and surgical procedure or debridement must also be documented separately from the order form.

  • The patient must sign the order form acknowledging that they are aware that this order is being placed for them, that there may be a co-payment necessary, and that their protected health information will be shared to place the order. Ask the patient if they have utilized a company before to ascertain if they are already receiving product from a particular company or have a preference of providers, and though most clinics have companies that they utilize frequently, the patient must be informed that they have a choice. As tempting as it is to allow personnel from the company access to the patient’s chart to assist in placing the order, there is much more health information found in the chart outside of the wound and dressing needs that still should remain protected.

  • Consider the fact that wounds are dynamic and change, particularly in the early part of the treatment, and document the duration of time that the dressings will be needed when ordering so that an appropriate amount will be sent and not wasted.

  • There are utilization guidelines within the policy outlining frequency of use based on averages (see attached chart) established in the policy. There may be deviations necessary due to particular patient factors which would allow for dressings in excess of the guidelines. The medical necessity reason for the deviation must be documented in the medical record and in the information given to the Part B provider. An example of this is the patient who requires calcium alginate dressings, gauze and ABD pads due to copious amounts of exudate requiring daily dressing changes. Providing this information allows for an increase over the product usage guidelines until the exudate becomes more manageable.

  • Beware and be diligent in the use of company provided “starter packs.” While very helpful to allow a patient to have dressings on hand until their shipment arrives, these must be documented and considered as part of the patient’s order and utilization amount so as not to be “giving” dressings away. If ordered early enough in the day most companies can ship overnight in the case of a need. This obviously adds to their cost so try to avoid if possible. Instruct the patient to be aware of their dressing needs to call for additional supplies before they run out completely. Lastly, these starter packs should be segregated from the clinic’s own supplies and not utilized for patients outside of the program.

  • Compression stockings, oddly enough, are also allowable under the surgical dressing policy. The allowable is for one pair per month, allowing for reduction in edema as treatment progresses, and they must be at least 30-40 mmHg. While tempting to “stockpile” for use after the patient heals, the intent is that they are used as part of the treatment program during healing.

  • Each company has a formulary and specific brands of products that they provide, so be prepared for possible substitution of the brand that you may use in your practice. It is important to be flexible on this point.Just as our hospitals have company contracts and thereby better pricing based on these contracts, the same can apply to the Part B Provider. The caveat, of course, is the patient who has specific needs due to allergies or skin sensitivities. In this case, speaking to the Part B Provider about obtaining specialized supplies may enable the patient to get what they need. Additionally, knowing the formulary of products for a few Providers may help in the decision making process.

  While there may seem to be lot of rules to remember and to follow, it is really an easy program to work within and provide benefit to our patients. Again, those patients who are not covered by Medicare Part B may still be eligible for dressing coverage. Patients covered by state Medicaid programs may also be eligible, though choices are more limited, and coverage is different state by state. For example, in Florida, patients aren’t covered for gauze and tape, but are covered for collagen dressings. The provider companies are knowledgeable on coverage and can provide assistance in understanding the minutia involved in getting our patients what they need.

Dot Weir, RN, CWON, CWS is the Clinical Coordinator for Wound Care at Osceola Regional Medical Center in Kissimmee, Florida and co-editor of Today’s Wound Clinic.

Ms. Scarborough is currently the Director of Public Relations and Education for American Medical Technologies, headquartered in Irvine, California. Her clinical career spans over 30 years having practiced a variety of setting including acute, outpatient, home health and long-term care. Her clinical experience has included traditional physical therapy, orthopedics and sports medicine, cardiac rehabilitation, and wound care. She considers herself a physical therapist generalist with specialty interests and board certifications in both diabetes education and wound care. Pamela has published book chapters, articles, and monographs on the topics of diabetes and wound care, in addition to frequently being invited to present at conferences and educational activities around the country on these and related subjects. She is actively licensed as a physical therapist in the state of Texas and is certified by two ­­­nationally accredited boards, the National Certification Board of Diabetes Educators, where she has held the credential of Certified Diabetes Educator for the past 20 years and the American Academy of Wound Management where she has held the Certified Wound Specialist credential since 2000. She is on the board of directors for the Association for the Advancement of Wound Care and has served on numerous symposium planning panels and association boards over her extensive career.