Today's Wound Clinic - Spring 2008 - (Page 38)

instruction as a wound or an ulcer in the ICD-9 coding system. Ironically, using the term wound and ulcer interchangeably in clinic notes can be cause of confusion and even lead to coding errors and should be avoided in clinic documentation. In addition to determining a diagnosis, usually done by an advanced practitioner, documentation is needed as to the details of the wound appearance. The visit-byvisit wound evaluation is typically carried out by the clinic therapy or nursing staff. This provides the comparative data that, over time, details the progression (or lack thereof) of the wound. It is this ongoing evaluation and the documentation of such that provides the necessary data to support the advanced and ancillary treatment modalities which may be required. Thus, this documentation is vitally important to the patient and the clinic. Phrases such as, in my medical opinion are meaningless without objective data to substantiate medical necessity. Wounds are dynamic and change over time. The evaluation of the status of the wound at each encounter enables us to set goals for management. If the goals are based on an accurate and complete evaluation of the wound, and the treatment is chosen based on that evaluation, then the clinical decisions should be appropriate for that patient. Regardless of whether one uses paper or electronic data collection tools, information should be gathered in a systematic way to allow comparison from visit to visit.The following documentation points may provide guidance. Capturing the Essence of the Wound Evaluation PAM UNGER PT, CWS; CAROLINE FIFE, MD, FAAFP, CWS; AND DOT WEIR, RN, CWON, CWS D ocumentation in wound care is critical for reimbursement. To ensure payment, a comprehensive individualized plan, indicating the wound problem and goal of treatment must be in the medical record. The American Physical Therapy Association’s (APTA) “Guide to Physical Therapist Practice” recommends the five-stage management system; examination, evaluation, diagnosis, prognosis, and intervention. Wound care is usually best performed by a team of experts.Your team may consist of any combination of diabetic educators, dieticians, nurses, nurse practitioners, occupational therapists, orthotists, pedorthists, physical therapists, physicians, physician assistants, and podiatrists. The physician or advanced practice nurse will function as the coordinator of care, utilizing the expertise of other team members to accomplish the wound care goals. The team members conduct evaluations within their specific scope of clinical practice. The examination phase of a wound consultation is assumed to be the most 38 Spring 2008 Today’s Wound Clinic important aspect, particularly identifying any pre-existing signs or symptoms, relevant systems review and tests and measures. It is very important to identify all risk factors (see Table 1). Crucial to the evaluation of the wound is identifying the cause of the wound to establish a diagnosis and prognosis. This allows the clinician to identify the class and severity of the wound by stage, thickness, or colors (see Table 2). In broad terms, wounds are lesions caused by trauma or surgical interventions, and all other lesions would fall into some sort of ulcer classification. However, the ICD-9 diagnosis coding system is a poor one when it comes to proper coding of ulcerations. Using ICD-9, it is not possible to properly designate mixed arterial/venous or inflammatory ulcerations, for example. In addition, a lesion, which began traumatically but persists in a non-healing state for many months, could be classified as a chronic ulcer. Medicare provides no guidance as to how to deal with these issues. For the rest of this article, the term wound to refer generically to all skin lesions, whether they would be classified COMPONENTS OF THE WOUND EVALUATION Wound Etiology. Should be documented with each encounter. Location. Documentation of the location can also support the etiology. For example, an ulcer documented over a bony prominence is indicative of a pressure ulcer, one at the medial ankle suggests venous, and plantar foot, of course a diabetic foot ulcer. In most settings, wounds are generally assigned a

Table of Contents Feed for the Digital Edition of Today's Wound Clinic - Spring 2008

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

For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.