CERT: $126.9 million in improper payments for insufficient documentation of surgical dressings

CMS had a 71.3% improper payment rate for surgical dressings in 2017, accounting for 0.3% of the overall Medicare Fee-for-Service improper payment rate that year, according a Comprehensive Error Rate Test (CERT) report in the most recent Medicare Quarterly Provider Compliance Newsletter.

Surgical dressings are required for the treatment of a wound caused by, or treated by, a surgical procedure that was performed by a physician or other healthcare professional. They are also required after the debridement of a wound, according to Chapter 20 of the Medicare Claims Processing Manual.  

The July report issued by CMS pulls numbers from 2017 Medicare FFS Supplemental Improper Payment Data, which lists an improper payment amount of $126.9 million for surgical dressings billed during the 2017 reporting period.

The majority improper payments for surgical dressings were due to insufficient documentation errors, including one or both of the following:  

• A valid physician or NPP order that includes all elements required by regulation, Medicare guidelines, and MAC-specific guidelines. Examples of required elements include a physician signature or date, the type of dressing, frequency of dressing change, and/or expected duration of need.
• Clinical documentation for a wound evaluation as required by a Local Coverage Determinant (LCD). LCDs may require documentation of the type of wound, wound location, and/or amount of drainage.

For example, a physician bills HCPCS code A6021 (collagen dressing, sterile, 16 sq. in. or less per dressing) for a surgical dressing. In response to a CERT review contractor’s request for further documentation, the physician submits the treating physician’s clinical records documenting a debrided sacral wound with wound measurements, the treating physician’s written order that is missing required elements such as the frequency of dressing change, and proof of delivery.

A CERT review contractor determines the documentation to be insufficient to support the claim, per LCD and Medicare requirements. The provider ignores further requests from the CERT review contractor for documentation to support the billed item.

According to CMS, due to the lack of insufficient documentation and corrective action from the billing provider, the claim would be scored as an insufficient documentation error and payment would be recovered from the provider.

More detailed information from CMS on the accurate reporting and billing of surgical dressings can be found here.