Surgical Dressings
Overview
Surgical dressings are sterile materials that are used to promote wound healing. Surgical dressings include a primary dressing, which is used as a protective covering applied directly to the wound or lesion. A secondary dressing may be applied to secure a primary dressing in place.
Eligible Providers
The following providers are eligible to provider surgical dressings:
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, or to treat pressure ulcers.
Covered Services
Codes: A6010, A6011, A6021-A6025, A6154, A6196-A6199, A6203-A6224, A6228-A6248, A6251-A6259, A6261, A6262, A6266, A6402-A6404
MHCP covers the following types of surgical dressings:
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 and wound cavities. 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. 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. Up to three dressing changes per week are considered medically necessary, unless the medical necessity of more frequent changes is documented.
Contact layers (A6206-A6208)
Contact layers 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 used to line the entire wound; they are not intended to be changed with each dressing change. One change per week is considered medically necessary, unless the medical necessity of more frequent changes is documented.
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. Usual dressing change for a foam wound cover used as a primary dressing is up to three dressing changes per week. When a foam wound cover 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. 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. 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. 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.
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. 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. 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
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.
Surgical Dressings
Type of Dressing | Minimal Exudate | Moderate Exudate | Heavy Exudate | Usual Dressing Change |
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.
When composite, foam, and hydrocolloid dressings and transparent film 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.
Tape is considered medically necessary to hold on a wound cover or gauze. Additional tape is not considered medically necessary when a wound cover with an adhesive border is used. Document the medical necessity of the number of units of tape being dispensed.
Noncovered Services
MHCP does not cover the following:
Authorization
Authorization is required for quantities over MHCP monthly quantity limits.
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.
MHCP requires that providers bill surgical dressings with modifiers A1 to A9 to indicate the number of wounds on which the dressing is being used. Document the medical necessity of the number of units of dressings being dispensed. Documentation must be less than 30 days old. 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 the following:
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