Last month’s column discussed the importance of workflows needing to be defined, reviewed, and refined. In this column, we will review how wound care regulations tie to your workflow.
Within the wound care department, procedures are common. The type of procedure varies based on the patient’s wound chronicity and healing trajectory. In an outpatient wound care setting, both the facility and the professional receive payment from Medicare for the services rendered. It is prudent to be familiar with the payer agreements and limitations. Medical necessity guidelines can be payer specific, but most often payers follow the National or Local Coverage Determinations (LCDs).
In this column, we will review specific portions of the Novitas Solutions, Inc, Wound Care LCD (L35125)1 to further highlight the importance of understanding regulations tied to your documentation and clinical decision making for proper payment based on your workflow. Take your time to review the entire LCD.
When you review the documentation requirements, ask yourself, does my documentation reflect the LCD requirements, such as those excerpted here1:
- The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT*/HCPCS code must describe the service performed.
- The most accurate and specific diagnosis code(s) must be submitted on the claim. 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.
- The patient’s medical record must contain clearly documented evidence of the progress of the wound’s response to treatment at each physician visit.
- 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. This may be of particular benefit for documentation as an adjunct to written documentation of reasonable and necessary services, which require prolonged or repetitive debridement (especially those that exceed 5 debridements per wound).
- 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.
- The medical record must include a plan of care containing treatment goals and physician follow-up. The record must document complicating factors for wound healing as well as measures taken to control complicating factors when debridement is part of the plan. Appropriate modification of treatment plans, when necessitated by failure of wounds to heal, must be demonstrated.
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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.