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Wound/ulcer management professionals typically perform a high volume of a few specific procedures. Therefore, they often cannot prevent prepayment and postpayment audits. However, these professionals may prevent most prepayment claim denials and repayments after postpayment audits by painting a detailed picture of each patient’s condition at each encounter and thoroughly documenting the where, when, who, why, and what that the provider performed at each encounter. 

Remember that you are a wound/ulcer management professional, not a hyperbaric oxygen professional, not a cellular and/or tissue-based product (CTP) for skin wounds application professional, not an autologous platelet-rich plasma or other blood-derived products professional, etc. Therefore, you should follow: 

1) published clinical practice guidelines for conservative wound/ulcer management; 

2) your Medicare Administrative Contractor’s (MAC’s) documentation guidelines, which are found in pertinent Local Coverage Determinations (LCDs)and Local Coverage Articles (LCAs);¹ and 

3) your MAC’s documentation checklists. For example: CGS Medicare created a documentation checklist for physicians and QHPs who order surgical dressings for their patients to use at home.²

These documents should assist providers in creating templates they can use to thoroughly document all the services and procedures they perform. However, these templates should be customizable. Because wounds/ulcers “morph” over their lifetime, documentation should capture all these positive and negative changes at each encounter. Additionally, the documentation for each service and procedure performed at each encounter should be unique. This means no cloning, no copying, and no pasting from previous notes.

In my reimbursement education and consulting work, one of the most frequently asked questions I receive is, “What should I include in my documentation?” Following are some, but not all, of the pearls that I share with providers to assist them in refining their wound/ulcer management documentation.

Documentation Pearls for Conservative Wound/Ulcer Management

• For new patients, include the referral and documentation from previous treatment(s) provided, including types of conventional therapy, dates, and results.

• If the patient has more than one wound/ulcer, identify and describe each wound/ulcer separately; use that same identification to describe the wound’s/ulcer’s progress from encounter to encounter.

• Perform and document a complete wound/ulcer assessment at every encounter. The minimum requirements are:

• Measure the wound/ulcer (length, width, depth) and take photos at every encounter, and before and after every procedure.

• Document the specific anatomic location and side (right, left).

• Describe the wound/ulcer [eg, color; odor; amount of exudate; percent of granulation; percent of necrotic tissue; edema; exposed tendon, muscle, joint capsule, or bone; presence (and extent of) or absence of obvious signs of infection; culture results and interpretation; antibiotics prescribed]. If complete, document date of completion.

• Document your overall assessment of the wound/ulcer (eg, stable, improved, worsening).

• Document your clinical impression or diagnosis. Use specific ICD-10-CM codes.

• Create and document a plan of care for each wound/ulcer, to include:

• Goals (specific, measurable, attainable, relevant, and time-bound)

• Potential to heal

• Expected frequency and duration of the conservative management

• Description of how the wound/ulcer should look when the goal is reached

• Document progress towards goal.

• Modify the plan of care as the wound/ulcer morphs. Note: If the goals are not met, and the plan of care is not adjusted or modified, payment for the service, procedure, and/or product may be denied after an audit.

• Legibly sign the plan of care.

• Document additional conservative management work [eg, diagnostic tests, evaluation of factors that affect the course of healing (nutritional status, activity level, smoking, etc), dressings applied and reason for the dressing selection, debridement performed, negative pressure wound therapy applied, offloading or compression, medications ordered, devices and/or dressings ordered from a durable medical equipment supplier, orders for home health agency care, etc].

• Document follow-up orders and reason(s) for next visit.

• Legibly sign orders, your work, and changes to the plan of care.

• When managing a wound/ulcer on a continuing basis, the documentation at every encounter should:
  
  
  • 1) describe that the wound/ulcer is improving, or not improving, in response to the management provided, and

  • 2) prove that quality care (based on clinical practice guidelines, payer’s coverage policies, etc) was provided.

The evidence of improvement should include measurable changes (decreases) of drainage (color, amount, consistency), inflammation, swelling, pain, wound dimensions (diameter, depth, tunneling), and necrotic tissue/slough. 

Note: Most clinical practice guidelines and payer coverage policies state that a wound/ulcer that shows no improvement after 30 days requires a different approach (which may include physician reassessment of underlying infection; metabolic, nutritional, or vascular problems inhibiting wound healing; or a new treatment).

Documentation Pearls for Procedures Performed

Even though wound/ulcer management procedures are not always performed in an operating room, many of them are considered surgical procedures, such as debridement and application of CTPs.³ Therefore, the documentation of these and other surgical procedures should include the typical components of an operative note: 

• Date, time, and place of service

• Physician or other qualified healthcare professionals (QHPs) (who is/are appropriately trained and operating within her/his/their scope of practice)

• Preoperative and postoperative diagnoses

• Wound/ulcer assessment (including measurement and photos preop and postop)

• Reason for the procedure
  
  
  • If a repeat procedure, document its medical necessity.

  • If a CTP, document the medical necessity for the specific brand of CTP.

• Timeout documentation

• Full description of steps in procedure
  
  
  • If a CTP application:
    
    
    • Wound bed preparation (estimated blood loss, hemostasis, complications)

    • CTP preparation and application (amount applied and wasted and reason for wastage, method of fixation, primary and secondary dressings, offloading or compression)

• Patient tolerance

• Patient/caregiver instructions

• Follow-up orders

Summary 

As a wound care professional, this article should motivate you to 1) immediately compare your existing documentation of conservative wound/ulcer management and of all procedures to published clinical practice guidelines/LCDs/LCAs/your MAC’s documentation checklists, and 2) to make documentation refinements that align with all the conservative wound/ulcer management and procedure requirements. Keep in mind that the auditors make their audit checklists from the same documentation guidelines. Do not give them a reason to recoup payments. By taking the time to create customizable documentation templates correctly and to document each unique encounter, providers can prevent claim denials and repayments after audits. Reminder: Just because payment occurred does not mean that payment will remain after an audit of the in a postpayment review. You are in control of and responsible for the quality and accuracy of your documentation.

Kathleen D. Schaum oversees her own consulting business and is a member of the WoundSource editorial advisory board. She can be reached for consultation and questions at kathleendschaum@gmail.com and at 561-670-7176.

Reference:

1.Centers for Medicare & Medicaid Services. Medicare Coverage Database. https://www.cms.gov/medicare-coverage-database/search.aspx. Accessed June 2, 2024. 

2.Centers for Medicare & Medicaid Services. Documentation Checklist: Surgical Dressings. https://cgsmedicare.com/jc/checklists/surg_dress.pdf. Accessed June 18, 2024.

3.Centers for Medicare & Medicaid Services. Billing and Coding: Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities. https://www.cms.gov/medicare-coverage-database/view/article.aspx?articl…;. Accessed June 18, 2024.