HCPCS CODING GUIDANCE
For AmeriGel® Hydrogel Saturated Gauze Dressing
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FORM 1500 MUST HAVE THE FOLLOWING:
(1) HCPCS code A6231
(2) "A" modifier usage
(3) POS = 12

The Centers for Medicare & Medicaid Services (CMS) have assigned a Medicare billing code for AmeriGel® Hydrogel Saturated Gauze Dressing effective July 8, 2004: A6231 (2x2) Gauze, impregnated, hydrogel, for direct wound contact, pad size 16 square inches or less, each dressing. The following information is cited from and found in Chapter 58 – Surgical Dressings Region C DMEPOS Supplier Manual.

COVERAGE AND PAYMENT RULES:
For any item to be covered by Medicare, it must (1) be eligible for a defined Medicare benefit category, (2) be reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member, and (3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this medical policy, the criteria for "reasonable and necessary" are defined by the following indications and limitations of coverage and/or medical necessity.

The surgical procedure or debridement must be performed by a physician or other healthcare professional to the extent permissible under State law. Debridement of a wound may be any type of debridement (examples given are not all-inclusive): surgical (e.g., sharp instrument or laser), mechanical (e.g., irrigation or wet-to-dry dressings), chemical (e.g., topical application of enzymes), or autolytic (e.g., application of occlusive dressings to an open wound.) Dressings used for mechanical debridement, to cover chemical debriding agents, or to cover wounds to allow for autolytic debridement are covered although the agents themselves are non-covered.

Surgical dressings are covered for as long as they are medically necessary.

Surgical dressing codes billed without modifiers A1-A9 (see Coding Guidelines) are non-covered under the Surgical Dressings benefit.

Modifiers A1 – A9 have been established to indicate that a particular item is being used as a primary or secondary dressing on a surgical or debrided wound and also to indicate the number of wounds on which that dressing is being used.The modifier number must correspond to the number of wounds on which the dressing is being used, not the total number of wounds treated. For example, if the patient has four (4) wounds but a particular dressing is only used on two (2) of them, the A2 modifier must be used with that HCPCS code.

HCPCS MODIFIERS:

A1	Dressing for one wound
A2	Dressing for two wounds
A3	Dressing for three wounds
A4	Dressing for four wounds
A5	Dressing for five wounds
A6	Dressing for six wounds
A7	Dressing for seven wounds
A8	Dressing for eight wounds
A9	Dressing for nine wounds
AW	Item furnished in conjunction with a surgical dressing
EY	No physician or other licensed healthcare provider order for this item or service
GY	Item or service statutorily non-covered or does not meet the definition of any Medicare benefit
LT	Left side
RT	Right side

If dressing changes are sent home with the patient, claims for these dressings may be submitted to the DMERC. In this situation, use the place of service corresponding to the patient's residence (POS=12); Place of Service Office (POS=11) must not be used.

Dressing size must be based on and appropriate to the size of the wound. For wound covers, the pad size is usually about 2 inches greater than the dimensions of the wound. For example, a 5 cm x 5 cm (2 in. x 2 in.) wound requires a 4 in. x 4 in. pad size.

Gauze or gauze-like products are typically manufactured as a single piece of material folded into a several ply gauze pad. Coding must be based on the functional size of the pad as it is commonly used in clinical practice. For all dressings, if a single dressing is divided into multiple portion/pieces, the code and quantity billed must represent the originally manufactured size and quantity.

Dressing needs may change frequently (e.g.,weekly) in the early phases of wound treatment and/or with heavily draining wounds. Suppliers are also expected to have a mechanism for determining the quantity of dressings that the patient is actually using and to adjust their provision of dressings accordingly. No more than a one month's supply of dressings may be provided at one time, unless there is documentation to support the necessity of greater quantities in the home setting in an individual case. An even smaller quantity may be appropriate in the situations described above.

The following are some specific coverage guidelines for individual products when the products themselves are necessary in the individual patient.The medical necessity for more frequent change of dressing must be documented in the patient's medical record and submitted with the claim to the DMERC (see Documentation section.)

HYDROGEL DRESSING (A6231-A6233,A6242-A6248):
Hydrogel dressings are covered when used on full thickness wounds with minimal or no exudate (e.g., stage III or IV ulcers.) Hydrogel dressings are not usually medically necessary for stage II ulcers. Documentation must substantiate the medical necessity for use of hydrogel dressings for stage II ulcers (e.g., location of ulcer is sacro-coccygeal area.)

Use of more than one type of hydrogel dressing (filler, cover, or impregnated gauze) on the same wound at the same time is not medically necessary.

The maximum allowable of AmeriGel® Hydrogel Saturated Gauze Dressings that can be provided to a patient is 30 each, per 30 days, per wound.

DISCLAIMER:
This information does not guarantee reimbursement, but provides guidance for accurate documentation and appropriate usage for a hydrogel wound filler. Should you need further technical assistance or have specific coding questions, please contact your regional DMERC or intermediary. It is the manufacturers intent to share this information with healthcare professionals to highlight awareness of the reimbursement process.