Documentation for Surgical Dressings

The Medicare Learning Network provides guidance on required documentation for surgical dressings. 

The following Medicare coverage guidance applies to surgical dressing claims:

• Surgical dressings are covered when a qualifying wound is present. A qualifying wound is defined as either of the following:
  • A wound caused by, or treated by, a surgical procedure
  • A wound that requires debridement, regardless of the debridement technique

• Products that are eligible to be classified as a surgical dressings include both:
  • Primary dressings – Defined as therapeutic or protective coverings applied directly to wounds or lesions either on the skin or caused by an opening to the skin
  • Secondary dressings – Defined as materials that serve a therapeutic or protective function and that are needed to secure a primary dressing

• Dressingsoverapercutaneous catheter or tube are covered as long as the tube or catheter remains in place, and after removal until the wound heals
  • Dressing size must be appropriate to the size of the wound

• Orders
  • The order must specify:
    • Type of dressing (hydrocolloid cover, hydrogel filler)
    • Size of the dressing
    • Number/amount to be used at one time
    • Frequency of the dressing change
    • Expected duration of need

There must be a written, signed, and dated order. This must be received by the supplier before the claim can be submitted

• New order if a new dressing is added or if the quantity of an existing dressing is increased
• New order at least every three months for each dressing being used

• Clinical documentation must include:
  • Number of surgical/debrided wounds treated with a dressing, reason for, and whether the dressing is being used as a primary or secondary dressing (must be obtained from the physician, nursing home, or home care nurse)
  • Clinical information that is up to date and supports the necessity of the type and amount of surgical dressings
  • Documentation of monthly or more frequent wound evaluations (more frequent for those in nursing facilities or with heavily draining/infected wounds).
  Assessments to include:
  • Type of wounds
  • Location
  • Size (Length x Width cm.)
  • Depth
  • Drainage Amount

• Code Specific requirements
  • When codes A4649, A6261 or A6262 are used, there must be a narrative description of the product, manufacturer, brand name/number, and information justifying medical necessity
  • The appropriate modifier (A1 – A9, AW, EY, or GY) must be added when applicable
  • For specific coverage guidelines, please see Surgical Dressings LCD L33831

• For additional guidance on Medical Record Documentation Requirements and Medicare Signature Requirements, please see Complying With Medical Record Documentation Requirements and Complying with Medicare Signature Requirements.

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