Avoiding Improper Medicare Payments for Surgical Dressings

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Improper Payment Reasons

Durable Medical Equipment (DME) suppliers of surgical dressings and physicians submit claims for surgical dressings and CMS covers it under the surgical dressings benefit i.e., SSA Section 1861[s][5]. CMS recently published Medicare Fee-for-Service (FFS) improper Medicare payments rate for surgical dressings for the 2020 reporting period. For this reporting period, the improper payment rate for surgical dressings was 67.3 percent, with a projected improper payment amount of over $194.9 million. For the 2020 reporting period, insufficient documentation accounted for 82.4 percent of improper Medicare payments for surgical dressings. Additional types of errors for surgical dressings in the 2020 reporting period were no documentation (1.9 percent), medical necessity (1.7 percent), incorrect coding (1.9 percent), and other (12.2 percent). 

Avoiding Improper Medicare Payments

All claims billed to Medicare require a written order or prescription from the treating practitioner as a condition for payment. The written order or prescription must meet the requirements outlined for the Standard Written Order (SWO). Billing guidelines would require you to communicate an SWO to the supplier before claim submission. Certain items of Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS), require a Written Order Prior to Delivery (WOPD) of the item(s) to the patient.

Billing guidelines for surgical dressings would require an SWO containing all the following elements:

• Patient’s name or Medicare Beneficiary Identifier (MBI)
• Order Date
• General description of item:
  • Description can be either a general description (for example, wheelchair or hospital bed), an HCPCS code, an HCPCS code narrative, or a brand name and model number
  • For equipment: Besides the description of the base item, the SWO may include all concurrently ordered options, accessories, or other features separately billed or require an upgraded code (list each separately)
  • For supplies: Besides a description of the base item, the DMEPOS order or prescription may include all concurrently ordered supplies separately billed (list each separately)
• Dispensed quantity, if applicable
• Treating practitioner name or National Provider Identifier (NPI)
• Treating practitioner’s signature