HCPCS CODING GUIDANCE
For AmeriGel® Wound Dressing
Download printable PDF here.

FORM 1500 MUST HAVE THE FOLLOWING:
(1) HCPCS code A6248
(2) "A" modifier usage
(3) POS = 12

The Centers for Medicare & Medicaid Services (CMS) have assigned a Medicare billing code for AmeriGel® Wound Dressing effective June 14, 2002: A6248 Hydrogel Dressing, wound filler, gel, per fluid ounce. 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.

Surgical dressings include both primary dressings (i.e., therapeutic or protective coverings applied directly to wounds or lesions either on the skin or caused by an opening to the skin) or secondary dressings (i.e., materials that serve a therapeutic or protective function and that are needed to secure a primary dressing.)

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.

Surgical dressings must be tailored to the specific needs of an individual patient.When surgical dressings are provided in kits, only those components of the kit that meet the definition of a surgical dressing, that are ordered by the physician, and that are medically necessary are covered.

The following are some specific coverage guidelines for a hydrogel dressing when the product itself is 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.) Usual dressing change for hydrogel wound covers without adhesive border or hydrogel wound fillers is up to once per day.

The quantity of hydrogel filler used for each wound must not exceed the amount needed to line the surface of the wound. Additional amounts used to fill a cavity are not medically necessary. Documentation must substantiate the medical necessity for code A6248 billed in excess of 3 units (fluid ounces) per wound in 30 days.

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.

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.