Standard written order template for surgical dressings

What a standard written order must include

Medicare's regulation on orders for durable medical equipment, prosthetics, orthotics and supplies, 42 CFR 410.38(d)(1)(i), lists six elements. The DME MACs' Standard Documentation Requirements article, A55426, lists the same six for the claims they process, surgical dressings included:

1. Beneficiary Name or Medicare Beneficiary Identifier (MBI)
2. General Description of the item
3. Quantity to be dispensed, if applicable
4. Order Date
5. Treating Practitioner Name or National Provider Identifier (NPI)
6. Treating Practitioner Signature

The description can be a general description, a HCPCS code, a HCPCS code narrative or a brand name/model number (Program Integrity Manual, Ch. 5 §5.2.2). An order may include all concurrently ordered supplies that are separately billed; A55426 says to “List each separately.”

You can add details such as change frequency or length of need. The same section of the manual adds: “This additional information shall be corroborated by information in the medical record.”

When the supplier needs the order

CMS keeps a Required Face-to-Face Encounter and Written Order Prior to Delivery List. The version effective October 28, 2026 has 105 HCPCS codes for items such as wheelchairs, beds, oxygen equipment, ventilators and orthoses — and no surgical dressing codes. For items that aren't on the list, 42 CFR 410.38(d)(1)(ii)(B) says “the written order/prescription must be communicated to the supplier prior to claim submission.”

LCD L33831 spells out the consequence: if the supplier bills for a dressing without first receiving a completed order, “the claim shall be denied as not reasonable and necessary.” CMS can add items to the list with at least 60 days' notice, so check the current version when you set up your process.

Order rules specific to surgical dressings

• Every 3 months. Policy Article A54563: “A new order is required every 3 months for each dressing being used.”
• When something changes. “A new order is needed if a new dressing is added or if the quantity of an existing dressing to be used is increased.”
• Quantities. Write an amount per week or per month, such as “30 per month.” The LCD limits a delivery to one month's supply at a time, unless the record documents why an individual patient needs more in the home setting.
• The record carries medical necessity. CMS's Program Integrity Manual says an order by itself doesn't provide sufficient documentation of medical necessity. That comes from the medical record: the wound evaluation, updated monthly — or weekly for nursing-facility patients and heavily draining or infected wounds.
• Home health and hospice. While a patient is under a Medicare home health plan of care, the home health agency supplies dressings and is the only entity that can bill for medical supplies (Benefit Policy Manual, Ch. 7 §10.10). Dressings for a hospice patient's terminal illness or related conditions come from the hospice (42 CFR 418.202(f)).

Want to check the rest of your dressing documentation? Try the 10-question documentation self-check or read the surgical dressing documentation checklist.

Signature rules

• The named practitioner signs. Office staff or the supplier may fill in parts of the order “so long as the treating practitioner identified in the order, via their name or national provider identifier (NPI), signs the document” (Program Integrity Manual, Ch. 5 §5.2.3).
• By hand or electronically. Signature and date stamps aren't accepted under A55426. CMS's manual says “Stamped signatures are not typically acceptable,” with one narrow exception: a rubber stamp used by an author with a physical disability who can provide proof, under the Rehabilitation Act of 1973.
• Illegible signatures. A signature log or an attestation from the author can resolve them during review (Program Integrity Manual, Ch. 3 §3.3.2.4). An attestation must be “signed and dated by the author of the medical record entry.”

Sources

Checked on October 6, 2026. The notes printed on the form are PCSS's plain-English summary of these sources — general information, not CMS text, and not billing, coding or legal advice.