Is Collagen Billable Following Matrixectomy?

Answer: It depends, but probably not.

In 2017 there were significant changes to the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Surgical Dressing Policy Local Coverage Determination (LCD L33831).¹ One of these changes was to remove the wound depth requirement for collagen coverage, and now the Centers for Medicare and Medicaid Services (CMS) says one of the covered indications of collagen dressings is wounds with light to moderate exudate.

Can you bill for collagen for any wounds with light to moderate exudate? No. The need for medical necessity in order for collagen to be billable did not change. As with any service we provide, coverage is dependent upon medical necessity. Durable Medical Equipment is no exception. To substantiate coverage, the nature of the wound and the documentation must support the need for the surgical dressing. A fresh, normal post-matrixectomy site in an uncompromised patient that is progressing as expected does not demonstrate the medical necessity for coverage of collagen surgical dressings.

So when can you bill for collagen after a matrixectomy? Surgical dressings are covered when the criteria outlined under that product in the LCD are met and when medical necessity is present and documented. There is risk in performing a matrixectomy on a compromised patient. However, when performing a matrixectomy, collagen may be indicated immediately postoperatively. In this situation it is important to document the compromised nature of the patient and why his or her healing potential may not be what it should be. Keep in mind it would also be important to document why you decided to perform a matrixectomy on a patient like this.

Another situation when collagen following matrixectomy may be medically necessary is a postoperative site that is not progressing as expected. An example is a patient who is not compromised, where slow progression was not expected, yet a couple weeks after matrixectomy, normal healing has not occurred. If the documentation supports the need for a surgical dressing given these findings, collagen should be covered following matrixectomy.

Reference

1. Centers for Medicare and Medicaid Services. Available at https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33831&ver=14 .

Dr. Lehrman is a consultant to the APMA Health Policy and Practice Department, serves as an expert panelist on Codingline, and is a Fellow of the American Academy of Podiatric Practice Management (AAPPM). Follow him on Twitter @DrLehrman.