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September 9, 2020

Widespread Post-Pay Service Specific Review Announcement – HCPCS Codes A6196 and A6212

CGS's Medical Review staff will be conducting a complex post-pay service-specific medical review of HCPCS Codes A6196 (Surgical Dressing – Alginate) and A6212 (Surgical Dressing – Foam) claims. This review will be conducted because data analysis revealed that Jurisdiction C's allowed dollars for HCPCS Codes A6196 and A6212 were significantly above expected amounts. Additionally, the Surgical Dressing policy group ranked #5 in total CERT errors.

CGS would like to remind suppliers of the importance of responding to Additional Documentation Request (ADR) letters. Authorization for the collection of this information is included in Federal Law at SSA 1833 (e) and in Federal regulation at 42 CFR 424.5(a)(6).  Suppliers are in violation of Supplier Standard #28 when, upon request, they fail to provide requested documentation to a Medicare contractor. Therefore, the consequences of failure to provide records may not only be a claim denial but also referral to the National Supplier Clearinghouse (NSC).

The ADR letter will contain the following information:

  1. Preliminary dispensing order (if items were dispensed prior to obtaining a detailed written order);
  2. A valid order that includes:
    1. The type of dressing
    2. The size of the dressing
    3. The number/amount to be used at one time
    4. The frequency of dressing change, and
    5. The expected duration of need
  3. Documentation defining the number of wounds being treated with a dressing.
  4. Documentation of evaluation of the wound(s) during the month prior to the date of service on the claim that includes the type of each wound (e.g., surgical wound, pressure ulcer, burn, etc.), location, size (length x width in cm.), depth, amount of drainage, whether the dressing is a primary or secondary dressing and/or any other relevant information. Medical records must document that the LCD criteria has been met for the specific dressing type. These records must be obtained from the physician, nursing home or home care nurse. The source of that information must be documented.
  5. Copy of an Advance Beneficiary Notice (ABN), if one was obtained.
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