Today's Wound Clinic - Spring 2008 - (Page 11)

inbusiness TABLE 2. Example: Chronic Wound Care and Debridement Documentation Guidance • Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record, and made available to Medicare upon request. • 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. • The 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: o Current wound volume (surface dimensions and depth). o Presence (and extent of) or absence of obvious signs of infection. o Presence (and extent of) or absence of necrotic, devitalized or non-viable tissue. o Other material in the wound that is expected to inhibit healing or promote adjacent tissue breakdown. • When debridements are reported, the debridement procedure notes must demonstrate tissue removal (ie, skin, full or partial thickness, subcutaneous tissue, muscle, and/or bone), the method used to debride (ie, hydrostatic, sharp, abrasion), and the character of the wound (including dimensions, description of necrotic material present, description of tissue removed, degree of epitheliazation, etc.) before and after debridement. • 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 record at intervals consistent with the nature of the condition or factor. • 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 skin and subcutaneous tissue) per wound. • When ES or ET is used, wounds must be evaluated periodically (no less than every 30 days) by the treating physician. Clear documentation of this must be present in the patient’s medical record. • Debridements of the wound(s), if indicated, must be performed judiciously and at appropriate intervals. Medicare expects that, with appropriate care, wound volume or surface dimension should decrease by at least 10% per month or wounds will demonstrate margin advancement of no less than 1 mm/week. Medicare expects the wound care treatment plan to be modified in the event that appropriate healing is not achieved. • Persons who report debridement services to Medicare must pay close attention to CPT code definitions for debridements. The following coding guideline found in the associated LCD article is repeated here for emphasis: o CPT codes 11040–11044 are used to report surgical removal (debridement) of devitalized tissue from wounds. CPT codes 11040–11044 are payable to physicians and qualified non-physician practitioners licensed by the state to perform the services. o CPT codes 97597–97598 are used to report selective (including sharp) and non-selective debridement of devitalized tissue and are payable to physicians and qualified non-physician practitioners, licensed physical therapists, and licensed occupational therapists. o Removal of non tissue-integrated fibrin exudates, crusts, biofilms or other materials from a wound without removal of tissue does not meet the definition of any debridement code and may not be reported as such. • With appropriate management, it is expected that, in most cases, a wound will reach a state at which its care should be performed primarily by the patient and/or the patient's caregiver with periodic physician assessment and supervision. Wound care that can be performed by the patient or the patient's caregiver will be considered as maintenance care. • Payment for prolonged, repetitive debridement services requires adequate documentation of complicating circumstances that reasonably necessitated additional services. Medicare expects fewer than five debridements involving removal of muscle and/or bone debridements to be required for management of most wounds. number and amounts of repayments that the facility and the physicians may incur. Remember that above all, documentation is essential for correct payment and clean claims. Kathleen D. Schaum, MS, is President of Kathleen D. Schaum & Associates, Inc., Lake Worth, Fla. Schaum can be reached for questions and consultations by calling (561) 9642470 or through her email address: kathleendschaum@bellsouth.net. Information regarding coding, coverage, and payment is provided as a service to TWC readers. Every effort has been made to ensure the accuracy of the information. However, HMP Communications and the author do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received.The ultimate responsibility for verifying coding, coverage, and payment information accuracy lies at the discretion of the reader. Today’s Wound Clinic Spring 2008 11

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Today's Wound Clinic - Spring 2008 Contents InTroduction InBusiness Documentation: The 30,000-Foot View Documentation: Clearing Up the Role of Compliance InTech InPhotography InFluence InStruction InNews InCentive Ad Index

Today's Wound Clinic - Spring 2008

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