Understanding Your Wound Documentation Requirements

When working in a wound care department, it is the clinician’s responsibility to understand the rules and regulations guiding the department’s wound documentation and billing processes.

These rules are generated from the Fiscal Intermediary, carriers, Medicare Administrative Contractors, National Coverage Determination, respective Local Coverage Decisions (LCD), Centers for Medicare & Medicaid Services, The Joint Commission, American Medical Association, and so on.

Below is an example of the documentation requirements based on excerpts from the Novitas Wound Care LCD.¹ (For the full list, visit the reference URL at the end of this article.)

Do your homework and verify that your wound documentation complies with the documentation requirements within the LCD governing your department.

• (1) All documentation must be maintained in the patient’s medical record and made available to the contractor upon request.
• (2) Every page of the record must be legible and include appropriate patient identification information. The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
• (3) The submitted medical record must support the use of the selected International Classification of Diseases code(s). The submitted code must describe the service performed.
• (4) The most accurate and specific diagnosis code(s) must be submitted on the claim. The patient’s medical record should indicate the specific signs/symptoms and other clinical data supporting the diagnosis code(s) used. It is expected that the physician will document the current status of the wound in the patient’s medical record and the patient’s response to the current treatment.
• (5) The patient’s medical record must contain clearly documented evidence of the progress of the wound’s response to treatment at each physician visit.
• (6) Identification of the wound location, size, depth, and stage by description must be documented and may be supported by a drawing or photograph of the wound. Photographic documentation of wounds at initiation of treatment, as well as either immediately before or immediately after debridement, is recommended.
• (7) Medical record documentation for debridement services must include the type of tissue removed during the procedure, as well as the depth, size, or other characteristics of the wound, and must correspond to the debridement service submitted. A pathology report substantiating depth of debridement is encouraged when billing for the debridement procedures involving deep tissue or bone.
• (8) In addition, except for patients with compromised healing from severe underlying debility or other factors, documentation in the medical record must show:

Cathy is Chief Clinical Officer for WoundExpert® and Vice President at Net Health, and in addition to being the MIPS Clinical Consultant for WoundExpert. She gained over 30 years of expertise in various acute care, long-term care, sub-acute care facilities, home-health agencies, and outpatient wound care department settings. Cathy is the author of Clinical Guide to Skin and Wound Care (also translated into Italian and Portuguese) – Eighth Edition published in September of 2018.