Article - Billing and Coding: Wound and Ulcer Care (A58567)

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.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.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.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 patients 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.Service(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.The medical record must include 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. 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.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.Documentation must support the use of skilled personnel with the use of jet therapy and wound irrigation for wound debridement.Documentation for low frequency, non-contact, non-thermal ultrasound services (Mist Therapy) 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 providers documentation of a medical evaluation of the patient's condition, diagnosis, and plan.When the documentation, or lack thereof, does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.Utilization Guidelines:In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.Wound care must be performed in accordance with accepted standards for medical and surgical treatment of wounds. The appropriate interval and frequency of debridement depends on the individual clinical characteristics of the patient and the extent of the wound. The extent and number of services provided should be medically necessary and reasonable based on the documented medical evaluation of the patient's condition, diagnosis, and plan.With the above in mind, only a minority of beneficiaries who undergo debridements for wound care appear to require more than twelve total surgical excisional debridement services involving subcutaneous tissue, muscle/fascia, or bone in a 360 day period, (five debridements of which involve removal of muscle/fascia, and/or bone) in order to accomplish the desired objective of the treatment plan of the wound. When medical necessity continues to be met and there is documented evidence of clear benefit from the debridements already provided, debridement services may be continued beyond this frequency or time frame. It is similarly unlikely that more than four debridements are needed in a month, i.e. 30 days, and again, continuance of care would depend on evidence of benefit to the patient.