Foam Dressings Probe Shows Close to 100 Percent Denial Rate

COLUMBIA, S.C.–TriCenturion announced on Thursday that it has
completed a widespread prepayment review of foam dressings billed
with the A1 modifier that showed close to a 100 percent denial rate
for the claims in both Jurisdictions A and B.

The probe was initiated as a result of data analysis that
identified “a significant number” of beneficiaries who received
excessive dressings compared to the LCD allowable number of
services, the DME PSC said.

The denial rate for HCPCS A6209-A6214 was 99.25 percent for
Region A and 98.77 percent for Region B. In Jurisdiction A, 71
percent of the claims were denied as not medically necessary, and
28 percent were denied for no response. In Jurisdiction B, 65
percent were denied as not medically necessary with 34 percent
denied for no response.

According to results of the probe, some denials resulted from
missing physician orders and lack of documentation for frequency of
change, the amount and size of the dressing and duration of need.
TriCenturion said other information lacking in medical records
showed that:

–Wound measurements were not documented;
–The amount of drainage documented did not support the need for
the dressing;
–Wound depth measurement did not indicate full thickness
involvement;
–Supplier-created forms were submitted as a substitution for the
medical record; and
–Monthly wound measurements were not submitted.

To view the probe results in full, click here.