All documentation must be maintained in the patient’s medical record and made available to the contractor upon request.

  1. 1Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)).
  2. 2The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. 3The 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.
  4. 4The 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. 5The patient’s medical record must contain clearly documented evidence of the progress of the wound’s response to treatment at each physician visit. This documentation must include, at a minimum:
    • Current wound volume (surface dimensions and depth).
    • Presence (and extent of) or absence of obvious signs of infection.
    • Presence (and extent of) or absence of necrotic, devitalized, or non-viable tissue.
    • Other material in the wound that is expected to inhibit healing or promote adjacent tissue breakdown.
  6. 6 Identification of the wound location, size, depth, and stage by description and may be supported by a drawing or photograph. Photographic documentation of wounds immediately before and after debridement is recommended for prolonged or repetitive debridement services (especially those that exceed five debridements per wound). Photographic documentation is required for payment of more than five extensive debridements (beyond the skin and subcutaneous tissue) per wound.
  7. 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. 8 In addition, except for patients with compromised healing due to severe underlying debility or other factors, documentation in the medical record must show:
    • There is an expectation that the treatment will substantially affect tissue healing and viability, reduce or control tissue infection, remove necrotic tissue, or prepare the tissue for surgical management.
    • The extent and duration of wound care treatment must correlate with the patient’s expected restoration potential. If wound closure is not a reasonable goal, then the expectation is to optimize recovery and establish an appropriate non-skilled maintenance program. Alternatively, palliative care of the patient and wound may be provided to diminish the probability of prolonged hospitalization, etc. If it is determined that the goal of care is not wound closure, the patient should be managed following appropriate covered palliative care standards.
  9. 9Service(s) must include an operative note or procedure note for the debridement service(s). This note should include the following:
    • Medical diagnosis.
    • Indication(s) and medical necessity for the debridement.
    • Type of anesthesia used, if and when used.
    • Wound characteristics such as diameter, depth, undermining or tunneling, color, presence of exudates or necrotic tissue.
    • Level/depth of tissue debrided and a description of the types(s) of tissue involved and the tissue(s) removed.
    • Vascular status, infection, or evidence of reduced circulation.
    • Narrative of the procedure to include the instruments used. When debridements are reported, the debridement procedure notes must demonstrate tissue removal (i.e., skin, full or partial thickness; subcutaneous tissue; muscle and/or bone), the method used to debride (i.e., hydrostatic, sharp, abrasion, etc.), and the character of the wound (including dimensions, description of necrotic material present, description of tissue removed, degree of epithelialization, etc.) before and after debridement.
    • Patient-specific goals and/or response to treatment.
    • Immediate post-op care and follow-up instructions.
    • The presence or absence of necrotic, devitalized, fibrotic, or other tissue or foreign matter must be documented in the medical record when wound debridement is performed.
  10. 10 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 the failure of wounds to heal, must be demonstrated. A wound that shows no improvement after 30 days may require a new approach. Documentation of such cases may include a physician reassessment of underlying infection, metabolic, nutritional, or vascular problems inhibiting wound healing, or a new treatment approach.
  11. 11 Appropriate evaluation and management of contributory medical conditions or other factors affecting the course of wound healing (such as nutritional status or other predisposing conditions) should be addressed in the medical record at intervals consistent with the nature of the condition or factor.
  12. 12 Documentation must support the use of skilled personnel with the use of jet therapy and wound irrigation for wound debridement.
  13. 13 Documentation for low frequency, non-contact, non-thermal ultrasound (MIST Therapy) services should include documented improvements of pain reduction, reduction in wound size, improved and increased granulation tissue, or reduction in necrotic tissue. The services should be medically necessary based on the provider’s documentation of a medical evaluation of the patient’s condition, diagnosis, and plan.

Reference:  LCD – Wound Care (L37166)