Surgical Dressings
Overview
Surgical dressings are sterile materials that are used to promote wound healing. Surgical dressings include a primary dressing, which is protective or therapeutic and used as a protective covering applied directly to the wound or lesion. A secondary dressing may serve a protective or therapeutic function and are applied to secure a primary dressing in place.
Eligible Providers
The following providers are eligible to provide surgical dressings:
TPL and Medicare
Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare to assist members for whom Minnesota Health Care Programs (MHCP) is not the primary payer.
MHCP quantity limits and thresholds apply to all members unless only Medicare coinsurance or deductible is requested.
Refer to the Medicare and Other Insurance section of the MHCP Provider Manual for more information.
Eligible Members
Surgical dressings are covered for eligible Medical Assistance and MinnesotaCare members to treat a wound or opening in the skin, to remove dead or infected material from a wound or lesion, to treat pressure ulcers, or to promote skin integrity from physical trauma, chemical or pressure injuries, infections, and thermal factors.
Covered Services
Codes: A6010, A6011, A6021-A6025, A6154, A6196-A6199, A6203-A6224, A6228-A6248, A6251-A6259, A6261, A6262, A6266, A6402-A6404, A6407, A6410-A6412, A6441-A6457
Minnesota Health Care Programs (MHCP) covers the following types of surgical dressings:
Review the following categories of surgical dressings, bandages, and other supplies for specific coverage criteria.
Alginate dressings (A6196-A6198)
Alginate dressings provide a moist cover to prevent wounds from drying out and expedite healing. Alginate dressings are considered medically necessary for treatment of moderate to heavy exudative full-thickness wounds, diabetic foot ulcers, partial thickness burns, surgical incisions, and wound cavities.
Alginate dressings may be used as primary dressings. One dressing change per day is considered medically necessary, unless the medical necessity of more frequent changes is documented. These dressings are of no proven benefit on dry wounds or wounds covered with eschar. These dressings are not appropriate for wounds that are bleeding heavily. It is usually inappropriate to use alginates in combination with hydrogels.
Collagen dressings (A6021-A6023)
Collagen dressings are composed of collagen fibers, which target specific defects in the wound healing environment. Collagen dressings are considered medically necessary for treatment of minimal to moderate exudative full-thickness wounds, donor sites, skin grafts, and surgical wounds.
Collagen dressings may be used as primary dressings. Up to two dressing changes per week are considered medically necessary, unless the medical necessity of more frequent changes is documented. These dressings are contraindicated for members with allergies to collagen or bovine products and typically for dry wounds.
Composite dressings (A6203-A6205)
Composite dressings combine physically distinct components into a single dressing that provide multiple functions. Composite dressings are considered medically necessary for treatment of minimal to heavy exudative wounds.
Composite dressings may be used as primary or secondary dressings. Up to three dressing changes per week are considered medically necessary, unless the medical necessity of more frequent changes is documented.
Compression bandages (A6448-A6452)
Compression bandages are elastic, made of knitted or woven material, and used to support wraps. Compression bandages are considered medically necessary for treatment of medical conditions such as sprains, strains, and venous ulcers. Compression bandages are available in a variety of types, including light, moderate, and heavy compression. Most compression bandages are reusable. These bandages are commonly included in multi-layer compression bandage systems.
Compression bandages may be used as secondary dressings. Two units per week is the usual dressing change for most members without a multi-layer compression bandage system. For members with a multi-layer system, more units may be medically necessary.
Conforming bandages (A6442-A6447)
Conforming bandages are nonelastic, made of crocheted, knitted, or woven material, nonsterile or sterile, and used to wrap wounds. Conforming bandages are considered medically necessary for treatment of wounds, lesions, ulcers, and other medical conditions. Sterile conforming bandages have medicated substances added that are intended to heal and provide moisture to the wound. Nonsterile conforming bandages do not have medicated substances added.
Conforming bandages may be used as secondary dressings. Two units per week is the usual dressing change for most members without a multi-layer compression bandage system. For members with a multi-layer system, more units may be medically necessary.
Contact layers (A6206-A6208)
Contact layer dressings are thin nonadherent sheets applied directly on the open wound bed to protect the wound tissue from direct contact with other agents or dressings. Contact layers are considered medically necessary for treatment of open wounds, donor sites, and split-thickness skin grafts.
Contact layer dressings may be used as primary dressings. One change per week is considered medically necessary, unless the medical necessity of more frequent changes is documented. Contact layers are used to line the entire wound; they are not intended to be changed with each dressing change.
Foam dressings (A6209-A6214)
Foam dressings are composed of semipermeable polymers, with a contact area that is nonadherent and repels lint. Foam dressings are considered medically necessary for treatment of moderate to heavy exudative full-thickness wounds. Foam dressings are medically necessary to cover abrasions, diabetic foot ulcers, IV sites, lacerations, and skin grafts, protect skin in friction areas of feeding tubes and infusion pumps, and secure catheters.
Foam dressings may be used as primary or secondary dressings. Usual dressing change for a foam dressing used as a primary dressing is up to three dressing changes per week. When a foam dressing is used as a secondary dressing for wounds with heavy exudate, dressing changes may be medically necessary up to three per week. One dressing change per day is considered medically necessary, unless the medical necessity of more frequent changes is documented. These dressings are typically inappropriate for wounds with minimal exudate and third-degree burns.
Impregnated gauze (A6222-A6224, A6228-A6230)
Impregnated gauzes have medicated substances added that are intended to heal and provide moisture to the wound. Gauzes are considered medically necessary for treatment of minimal to heavy exudative wounds or other medical conditions. One dressing change per day is considered medically necessary, unless the medical necessity of more frequent changes is documented.
Nonimpregnated gauze (A6216-A6221, A6402-A6404)
Nonimpregnated gauzes do not have medicated substances added and are intended to cover and secure wounds. Up to three dressing changes per day are considered medically necessary for nonimpregnated gauzes without a border, unless the medical necessity of more frequent changes is documented. One dressing change per day is considered medically necessary for nonimpregnated gauzes with a border. It is usually not considered medically necessary to apply two gauze pads on top of each other in one area.
Gel sheets (A6025)
Gel sheets are considered medically necessary for treatment of wounds with little to no drainage. Up to two dressing changes per week are considered medically necessary, unless the medical necessity of more frequent changes is documented.
Hydrocolloid dressings (A6234-A6239)
Hydrocolloid dressings provide a moist and insulating healing environment for uninfected wounds. Hydrocolloid dressings are considered medically necessary for treatment of minimal to moderate exudative wounds, diabetic foot ulcers, lacerations, skin tears, and wounds with necrosis.
Hydrocolloid dressings may be used as primary or secondary dressings. Up to three dressing changes per week are considered medically necessary, unless the medical necessity of more frequent changes is documented. These dressings are contraindicated for wounds with heavy exudate and infected wounds.
Hydrogel dressings (A6242-A6247)
Hydrogel dressings are composed of hydrogels, which absorb wound exudates and permit oxygen diffusion to expedite healing. Hydrogel dressings are considered medically necessary for treatment of minimal exudative full-thickness wounds, donor sites, minor burns, radiation dermatitis, skin tears, and wounds with necrosis.
Hydrogel dressings may be used as primary dressings. One dressing change per day is considered medically necessary for hydrogel dressings without a border, unless the medical necessity of more frequent changes is documented. Up to three dressing changes per week are considered medically necessary for hydrogel dressings with a border, unless the medical necessity of more frequent changes is documented. These dressings are contraindicated for wounds with heavy exudate.
Hydrogel filler used for each wound should not exceed the amount needed to line the surface of the wound. Documentation must demonstrate the medical necessity for filler. Use of both a hydrogel filler and cover on the same wound simultaneously is not considered medically necessary.
Padding bandages (A6441)
Padding bandages are nonelastic, made of nonknitted or nonwoven material, and used to pad and protect the surface of wounds. Padding bandages are considered medically necessary for treatment of wounds, lesions, and ulcers.
Padding bandages may be used as secondary dressings. Two units per week is the usual dressing change for most members without a multi-layer compression bandage system. For members with a multi-layer system, more units may be medically necessary.
Self-adherent bandages (A6453-A6455)
Self-adherent bandages are elastic, made of nonknitted or nonwoven material, and used to support wraps. Self-adherent bandages are considered medically necessary for treatment of medical conditions such as sprains, strains, and venous ulcers. Self-adherent bandages stick to themselves but not to other materials or the skin.
Self-adherent bandages may be used as secondary dressings. Two units per week is the usual dressing change for most members without a multi-layer compression bandage system. For members with a multi-layer system, more units may be medically necessary.
Specialty absorptive dressings (A6251-A6256)
Specialty absorptive dressings are multilayer wound covers that provide a nonadherent layer combined with highly absorptive layers of fibers. Specialty absorptive dressings are considered medically necessary for treatment of moderate to heavy exudative full-thickness wounds, abrasions, donor sites, lacerations, skin grafts, surgical incisions, and any exudating wound.
Specialty absorptive dressings may be used as primary or secondary dressings. One dressing change per day is considered medically necessary for specialty absorptive dressings without a border, unless the medical necessity of more frequent changes is documented. One dressing change every other day is considered medically necessary for specialty absorptive dressings with a border, unless the medical necessity of more frequent changes is documented.
Transparent films (A6257-A6259)
Transparent film dressings are composed of polymer membranes that are impermeable to liquids and bacteria but permeable to moisture. Transparent film dressings are considered medically necessary for treatment of open partial-thickness wounds with minimal exudate or closed wounds and wounds with necrosis. Transparent film dressings are medically necessary to cover abrasions, donor sites, IV sites, lacerations, second-degree burns, and surgical incisions, protect skin in friction areas of feeding tubes and infusion pumps, and secure catheters.
Transparent film dressings may be used as primary or secondary dressings. Up to three dressing changes per week is considered medically necessary, unless the medical necessity of more frequent changes is documented. These dressings are inappropriate for wounds with moderate to heavy exudate.
Tubular dressings (A6457)
Tubular dressings are secondary dressings used to secure primary dressings. Tubular dressings are considered medically necessary for treatment of wounds, lesions, ulcers, and other medical conditions. Tubular dressings are available in a variety of materials, including natural or synthetic materials. Tubular dressings are used as an alternative to other secondary dressings such as gauze or adhesive tape. Some dressings are used with a metal cage device, while others are placed by hand.
Wound fillers (A6010, A6011, A6024, A6199, A6215, A6240, A6241, A6248)
Wound fillers are nonadherent formulations that fill the wound, maintain a moist environment, and absorb the exudate. Wound fillers come in hydrated forms, dry forms, or other forms. One dressing change per day is considered medically necessary, unless the medical necessity of more frequent changes is documented.
Wound pouches (A6154)
Wound pouches are waterproof collection devices with drainable ports that adhere to the skin around a wound. Up to three dressing changes per week are considered medically necessary for wound pouches, unless the medical necessity of more frequent changes is documented.
Zinc impregnated bandages (A6456)
Zinc impregnated bandages are nonelastic, made of knitted or woven material, and used to promote healing. Zinc impregnated bandages dressings are considered medically necessary for treatment of wounds, lesions, ulcers, venous insufficiency, and other medical conditions requiring zinc oxide paste.
Miscellaneous surgical supplies
Adhesive tape (A4450, A4452) is considered medically necessary to hold on a surgical dressing or gauze without an adhesive border. Tape is not considered medically necessary when a surgical dressing with an adhesive border is used. Tape may be waterproof or nonwaterproof. Document the medical necessity of the number of units of tape being dispensed. Quantities of tape should reasonably indicate the size of the surgical dressing being used.
Eye pads (E6410, A6411) are considered medically necessary to protect an injured eye from further injury. Pads are usually made of soft absorbent cotton covered by fine mesh gauze and formed to fit the eye. They may be sterile or nonsterile.
Eye patches (A6412) are considered medically necessary to protect an eye from damage due to light or for treatment of other medical conditions such as amblyopia. Light occlusive eye patches have an outer surface film that obstruct specific light wavelengths.
Packing strips (A6407) are nonimpregnated sterile strips that are placed in open wounds and are often used in wet-to-dry wound treatment. Packing strips are considered medically necessary for members who require wet-to-dry treatment. Packing strips are usually made of fine mesh cotton gauze, and some are impregnated with antiseptics.
First-aid adhesive bandages (A6413) are noncovered. Skin sealants, protectants, moisturizers, and ointments (A6250) of any type are noncovered, unless dispensed by an approved dialysis equipment provider for members receiving dialysis for end-stage renal disease (ESRD). For non-dialysis indications, HCPCS code A6250 must be billed by a pharmacy as a drug.
Miscellaneous surgical supplies (A4649) require authorization if the submitted combined charges are over $400. HCPCS code A4649 should only be used when a surgical supply is not described by a more specific HCPCS code mentioned in this MHCP Provider Manual section. Documentation must clearly indicate member’s diagnosis, medical necessity, description of the item, and pricing information.
Surgical dressings table
Refer to the Surgical dressings coverage and usual dressing change frequency table to review surgical dressings coverage guidelines for wounds, lesions, and ulcers and the frequency of dressing changes that is considered medically necessary for most members.
Surgical dressings coverage and usual dressing change frequency
Type of Dressing | Minimal Exudate | Moderate Exudate | Heavy Exudate | Usual Dressing Change Frequency |
Alginate | Not covered | Full thickness | Full thickness | Once per day |
Collagen | Full thickness | Full thickness | Not covered | Up to two times per week |
Composite | Any | Any | Any | Up to three times per week |
Contact layer | Any | Any | Any | Once per week |
Foam | Not covered | Full thickness | Full thickness | Up to three times per week |
Impregnated gauze | Any | Any | Any | Once per day |
Nonimpregnated gauze (no border) | Any | Any | Any | Up to three times per day |
Nonimpregnated gauze (border) | Any | Any | Any | Once per day |
Gel sheets | Any | Any | Not covered | Up to two times per week |
Hydrocolloid | Any | Any | Not covered | Up to three times per week |
Hydrogel (no border) | Full thickness | Not covered | Not covered | Once per day |
Hydrogel (border) | Full thickness | Not covered | Not covered | Up to three times per week |
Specialty absorptive (no border) | Not covered | Full thickness | Full thickness | Once per day |
Specialty absorptive (border) | Not covered | Full thickness | Full thickness | Up to once every other day |
Transparent film | Partial thickness or closed | Not covered | Not covered | Up to three times per week |
Wound filler | Any | Any | Any | Once per day |
Wound pouch | Any | Any | Any | Up to three times per week |
Refer to the Medical Supply Coverage Guide (PDF) for quantity limits.
Surgical dressing size should be based on the approximate size of the wound, lesion, ulcer, or other medical condition. When a surgical dressing with an adhesive border is used, appropriate clinical judgment should be used as these dressings are more binding and are typically changed at frequencies less than daily.
When composite, foam, hydrocolloid, and transparent film dressings are used as secondary dressings, appropriate clinical judgment should be used as these dressings are typically changed at frequencies less than daily. While a heavy exudative wound may require such a combination initially, the wound should continue to heal with proper management, and appropriate selection of dressings should result in less frequent dressing changes.
Noncovered Services
MHCP does not cover the following:
Authorization
Authorization is required for the following:
Submit authorization to the Medical Review Agent.
Billing
Providers are responsible to coordinate services. Refer to the Billing Policy Overview section of the MHCP Provider Manual for general billing information.
Bill surgical dressings using MN–ITS 837P Professional. Refer to the Billing for Durable Medical Equipment, Medical Supplies, Prosthetics, Orthotics, and Augmentative Devices MN–ITS user manual for general billing requirements and guidance when submitting claims.
Surgical dressings are purchase items only. MHCP requires that providers bill surgical dressings with modifiers A1 to A9 to indicate the number of wounds, lesions, or ulcers on which the dressing is being used. Modifiers A1 to A9 are not required if dressings are not being used to treat wounds, lesions, or ulcers. Document the medical necessity of the number of units of dressings being dispensed. MHCP per-wound quantity limits apply if A HCPCS codes are not billed with modifiers A1 to A9 for covered indications other than wounds, lesions, or ulcers.
Providers must contact the MHCP Provider Resource Center after submitting claims using modifiers A6 to A9 to start a work order to pay the MHCP per-wound quantity limit.
The original documentation must be less than 30 days old. A new order or ongoing supporting documentation explaining a change in required number of units is required only if there is a major change in the member’s condition. No more than one month’s supply of dressings may be provided at one time, unless the medical necessity of greater quantities is documented.
Documentation must include:
Dressings used with feeding tubes, infusion pumps, and parenteral nutrition are included in payment for the kit. MHCP pays for additional dressings if the dressings from kits are exhausted. Document the medical necessity of the number of units of dressings being dispensed beyond the quantity included in the kit.
When multi-layer compression bandage systems are used, each part is billed using the specific HCPCS code for the component or item.
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