Currentpriority healthPolicy N/A

SURGICAL DRESSINGS

Defines coverage, quantity limits, billing modifiers, and documentation expectations for surgical and wound care dressings for Priority Health commercial products.

Policy Summary

Payerpriority health

PolicySURGICAL DRESSINGS

Policy CodePolicy N/A

Change TypeMultiple revisions (code removals, limit updates, clarifications)

Effective DateJun 19, 2025

Next Review DateNov 1, 2024

Key ActionObtain and document authorization/medical necessity where required; authorization is not a guarantee of payment.

SourceLink

POLICY UPDATE CHANGES

Added 'Place of service' section.

Removed code A4649 from list of codes that would be rejected when billed without modifiers A1-A9.

Limits for specified HCPCS codes will be effective June 16, 2025.

Removed frequency limits for general supplies A4450 and A4452 and moved them to the Miscellaneous DME Supplies billing policy with an MDHHS limit of 240 per month.

Added clarifying information under the 'Quantity of surgical dressings' section.

1 monthusual maximum medically necessary supply interval

A4364 = 4per-month usual maximum (example)

A6216-A6221codes with updated limits

A1-A9 / AW

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Coverage criteria for surgical dressings

Covered when ALL of the following are met:

ALL of the following

ALL of the following
- ALL of the following
  - ALL of the following
    A qualifying wound is defined as either: (1) a wound caused by, or treated by, a surgical procedure; or (2) a wound after debridement, regardless of debridement technique.
- ALL of the following
  - The surgical procedure or debridement must be performed by a treating practitioner or other health care professional to the extent permissible under State law.
ALL of the following
- Product must be an eligible surgical dressing: a primary dressing (therapeutic or protective covering applied directly to wounds or lesions) or a secondary dressing (materials to secure a primary dressing such as adhesive tape, roll gauze, bandages, disposable compression material).
ALL of the following
- No more than a one-month supply is considered medically necessary at one time unless documentation supports greater quantities for the individual case; smaller quantities may be appropriate depending on wound status.
- Units are billed as 1 gram, 1 fluid ounce, 6-inch length, or one yard depending on product; when packaged in fractional units, multiply number dispensed by product size and round to the nearest whole unit (example: eleven 1/2‑oz tubes = 11 x 0.5 = 5.5 -> bill 6 units).
- Claims with overlapping dates of service will be denied; supplies billed for a date span must follow 'From'/'To' date guidelines; a Calendar Month runs from a day of one month to the corresponding day of the next month.
- To receive separate reimbursement for bilateral items, submit appropriate RT/LT modifiers on separate lines; up to one unit per side with a maximum of two rental rates within the same calendar month.

Representative HCPCS codes, modifiers, and quantity limits

Representative HCPCS dressing codesHCPCS

A4364	Surgical dressing example with per-month max
A4402	Surgical dressing
A4450	Adhesive tape (when used with surgical dressings; requires AW modifier; billed without AW and A1-A9 will be rejected)
A4452	Adhesive tape (when used with surgical dressings; requires AW modifier; billed without AW and A1-A9 will be rejected)
A4456	Surgical dressing
A4481	Surgical dressing
A4623	Surgical dressing
A4625	Surgical dressing
A4626	Surgical dressing
A4629	Surgical dressing

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Codes requiring AW modifier (when applicable)HCPCSCovered

A6531	Gradient compression stocking (requires AW modifier for open venous stasis ulcer; A1-A9 not used)
A6532	Gradient compression stocking (requires AW modifier for open venous stasis ulcer; A1-A9 not used)
A6545	Gradient compression wrap (requires AW modifier for open venous stasis ulcer)
A4450	Adhesive tape (must be billed with AW when used with surgical dressings)
A4452	Adhesive tape (must be billed with AW when used with surgical dressings)

Codes noted for modifier A1-A9 requirementsHCPCS

A6010	Modifier A1-A9 usage described; billed without required A1-A9 will be rejected
A6011	Modifier A1-A9 usage described; billed without required A1-A9 will be rejected
A6021	Modifier A1-A9 usage described; billed without required A1-A9 will be rejected
A6022	Modifier A1-A9 usage described; billed without required A1-A9 will be rejected
A6023	Modifier A1-A9 usage described; billed without required A1-A9 will be rejected
A6024	Modifier A1-A9 usage described; billed without required A1-A9 will be rejected
A6154	Modifier A1-A9 usage described; billed without required A1-A9 will be rejected
A6196	Modifier A1-A9 usage described; billed without required A1-A9 will be rejected
A6197	Modifier A1-A9 usage described; billed without required A1-A9 will be rejected
A6198	Modifier A1-A9 usage described; billed without required A1-A9 will be rejected

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Per-code monthly quantity limits — selected HCPCS

A43644 per month (unless noted)

A6216 - A6221200 per month (limits effective 6/16/2025)

A6010 - A602430 per month for A6010-A6024 (limits effective 6/16/2025)

A5120150 per month (unless noted)

A445650 per month (unless noted)

A6402 - A6404200 per month (limits effective 6/16/2025)

Authorization, documentation, and billing guidance

Documentation Required

Authorization, documentation and billing requirements (authorization not a payment guarantee)

Obtain and document authorization and medical necessity when required; note that an authorization is not a guarantee of payment and claims may be rejected or denied if billing, coding, or documentation requirements are not met. Maintain medical record documentation that supports the service, procedure, diagnosis, quantity and frequency billed; failure to document services or items supplied will result in denial or recoupment. Follow units-of-service rules (e.g., wound fillers billed in grams, fluid ounces, 6-inch length or yards; round aggregated product size to the nearest whole unit) and ensure dates of service do not overlap and span dates follow From/To guidelines.

Authorization/medical necessity must be obtained and documented where required; authorization does not guarantee payment (Priority Health may still reject, deny or recover payment if coding/billing or policy rules are not followed).
Document that the dressing treats a qualifying wound and support the quantity/frequency billed; failure to document services/items supplied will result in denial.
Bill wound fillers using the specified units of service (1 gram, 1 fluid ounce, 6-inch length or one yard) and round aggregated product sizes to the nearest whole unit (example: eleven ½ oz. tubes billed as 6 units).
Avoid overlapping dates of service and follow 'From'/'To' date span guidelines; use appropriate laterality modifiers for bilateral reimbursement and separate lines for RT/LT when applicable.

Key definitions

Qualifying wound; Surgical dressing — definitions

Qualifying wound — definitionA wound caused by, or treated by, a surgical procedure; or a wound after debridement (any debridement technique). The procedure or debridement must be performed by a treating practitioner or other health care professional as permitted by State law.

Purpose of surgical/wound dressingsUsed after surgery to help control bleeding, prevent infection and promote healing; dressings for mechanical, chemical, or autolytic debridement are covered though debriding agents themselves are not covered.

Coverage requirementSurgical dressings are covered only when required to treat a qualifying wound and when other coverage criteria (e.g., practitioner-performed procedure, documentation) are met.

Primary and secondary dressings — definitions

Primary dressingTherapeutic or protective coverings applied directly to wounds or lesions on the skin or caused by an opening to the skin.