1. Hess, Cathy Thomas BSN, RN, CWCN

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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.


• 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 nutrition status or other predisposing conditions) should be addressed in the medical record at intervals consistent with the nature of the condition or factor.


The Utilization Guidelines found within this LCD further define the number of debridements as "only a minority of beneficiaries who undergo debridements for wound care appear to require more than eight 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. Only when medical necessity continues to be met and there is documented evidence of clear benefit from the debridements already provided, should debridement services be continued beyond this frequency or time frame. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient's medical record. When services are performed in excess of anticipated peer norms, based on data analysis, the services may be subject to prepay or post pay medical review."


The work performed within a wound care business operates with specific rules and guidelines. The very root of proving you are working within stated guidelines are the data you capture using your specialty electronic health record. This granularity of information becomes high-value proof of compliance for your facility.




1. Centers for Medicare & Medicaid Services. Local Coverage Determination (LCD): Wound Care (L35125). Last accessed April 23, 2018. [Context Link]


*CPT is a registered trademark of the American Medical Association, Chicago, Illinois. [Context Link]