Understanding Your Documentation Requirements

Understanding Your Documentation Requirements Practice Points Cathy Thomas Hess, BSN, RN, CWCN When working in a wound care department, it is the clinician’s of debridement is encouraged when billing for the debride- responsibility to understand the rules and regulations guid- ment procedures involving deep tissue or bone. ing the department’s documentation and billing processes. (8) In addition, except for patients with compromised healing These rules are generated from the Fiscal Intermediary, from severe underlying debility or other factors, documentation carriers, Medicare Administrative Contractors, National Cov- in the medical record must show: erage Determination, respective Local Coverage Decisions (a) There is an expectation that the treatment will substan- (LCD), Centers for Medicare & Medicaid Services, The Joint tially affect tissue healing and viability, reduce or control Commission, American Medical Association, and so on. Below tissue infection, remove necrotic tissue, or prepare the tissue is an example of the documentation requirements based on for surgical management. excerpts from the Novitas Wound Care LCD. (For the full list, (b) The extent and duration of wound care treatment must visit the reference URL at the end of this article.) Do your correlate with the patient’s expected restoration potential. If homework and verify that your documentation complies with wound closure is not a reasonable goal, then the expectation the documentation requirements within the LCD governing is to optimize recovery and establish an appropriate non- your department. skilled maintenance program. If it is determined that the goal of care is not wound closure, the patient should be managed (1) All documentation must be maintained in the patient’s medical record and made available to the contractor upon following appropriate covered palliative care standards. request. (9) Service(s) must include an operative note or procedure (2) Every page of the record must be legible and include note for the debridement service(s). appropriate patient identification information. The documen- (10) The medical record must include a plan of care containing tation must include the legible signature of the physician or treatment goals and physician follow-up. The record must nonphysician practitioner responsible for and providing the document complicating factors for wound healing, as well as care to the patient. measures taken to control complicating factors when debride- (3) The submitted medical record must support the use of ment is part of the plan. Appropriate modification of treatment the selected International Classification of Diseases code(s). The plans, when necessitated by failure of wounds to heal, must be submitted code must describe the service performed. demonstrated. (4) The most accurate and specific diagnosis code(s) must be (11) Appropriate evaluation and management of contrib- submitted on the claim. The patient’s medical record should utory medical conditions or other factors affecting the course indicate the specific signs/symptoms and other clinical data of wound healing (such as nutritional status or other pre- supporting the diagnosis code(s) used. It is expected that the disposing conditions) should be addressed in the medical record physician will document the current status of the wound in the at intervals consistent with the nature of the condition or factor. patient’s medical record and the patient’s response to the cur- There are many important reasons to understand the docu- rent treatment. mentation required by your Medicare carrier. This under- (5) The patient’s medical record must contain clearly docu- standing defines what documentation needs to be completed mented evidence of the progress of the wound’s response to within the medical record, which serves as the source of truth treatment at each physician visit. for the patient encounter. In addition, from an audit perspec- (6) Identification of the wound location, size, depth, and tive, knowing the documentation required assists in determin- stage by description must be documented and may be sup- ing the accuracy of documentation and potentially discovering ported by a drawing or photograph of the wound. Photo- lost revenues. At the end of the day, the documentation must graphic documentation of wounds at initiation of treatment, as adequately substantiate the services billed and identify medical well as either immediately before or immediately after debride- necessity for the services rendered. Do you know who your ment, is recommended. Medicare carrier is and their documentation requirements? (7) Medical record documentation for debridement ser- vices must include the type of tissue removed during the Reference procedure, as well as the depth, size, or other characteristics 1. Centers for Medicare and Medicaid Services. Local Coverage Determination (LCD): Wound of the wound, and must correspond to the debridement Care (L35125): General Information. 2017. www.cms.gov/medicare-coverage-database/ service submitted. A pathology report substantiating depth details/lcd-details.aspx?LCDId=35125. Last accessed January 17, 2018. Cathy Thomas Hess, BSN, RN, CWCN, is Vice President and Chief Clinical Officer for Wound Care, Net Health. Ms Hess presides over Net Health 360 WoundExpert Professional Services, which offers products and solutions to optimize process and workflows. Address correspondence to Ms Hess via e-mail: chess@nethealth.com. ADVANCES IN SKIN & WOUND CARE & VOL. 31 NO. 3 144 WWW.WOUNDCAREJOURNAL.COM Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Advances in Skin & Wound Care Wolters Kluwer Health

Understanding Your Documentation Requirements

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Wolters Kluwer Health
Copyright
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
ISSN
1527-7941
eISSN
1538-8654
D.O.I.
10.1097/01.ASW.0000530374.61754.a3
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Abstract

Practice Points Cathy Thomas Hess, BSN, RN, CWCN When working in a wound care department, it is the clinician’s of debridement is encouraged when billing for the debride- responsibility to understand the rules and regulations guid- ment procedures involving deep tissue or bone. ing the department’s documentation and billing processes. (8) In addition, except for patients with compromised healing These rules are generated from the Fiscal Intermediary, from severe underlying debility or other factors, documentation carriers, Medicare Administrative Contractors, National Cov- in the medical record must show: erage Determination, respective Local Coverage Decisions (a) There is an expectation that the treatment will substan- (LCD), Centers for Medicare & Medicaid Services, The Joint tially affect tissue healing and viability, reduce or control Commission, American Medical Association, and so on. Below tissue infection, remove necrotic tissue, or prepare the tissue is an example of the documentation requirements based on for surgical management. excerpts from the Novitas Wound Care LCD. (For the full list, (b) The extent and duration of wound care treatment must visit the reference URL at the end of this article.) Do your correlate with the patient’s expected restoration potential. If homework and verify that your documentation complies with wound closure is not a reasonable goal, then the expectation the documentation requirements within the LCD governing is to optimize recovery and establish an appropriate non- your department. skilled maintenance program. If it is determined that the goal of care is not wound closure, the patient should be managed (1) All documentation must be maintained in the patient’s medical record and made available to the contractor upon following appropriate covered palliative care standards. request. (9) Service(s) must include an operative note or procedure (2) Every page of the record must be legible and include note for the debridement service(s). appropriate patient identification information. The documen- (10) The medical record must include a plan of care containing tation must include the legible signature of the physician or treatment goals and physician follow-up. The record must nonphysician practitioner responsible for and providing the document complicating factors for wound healing, as well as care to the patient. measures taken to control complicating factors when debride- (3) The submitted medical record must support the use of ment is part of the plan. Appropriate modification of treatment the selected International Classification of Diseases code(s). The plans, when necessitated by failure of wounds to heal, must be submitted code must describe the service performed. demonstrated. (4) The most accurate and specific diagnosis code(s) must be (11) Appropriate evaluation and management of contrib- submitted on the claim. The patient’s medical record should utory medical conditions or other factors affecting the course indicate the specific signs/symptoms and other clinical data of wound healing (such as nutritional status or other pre- supporting the diagnosis code(s) used. It is expected that the disposing conditions) should be addressed in the medical record physician will document the current status of the wound in the at intervals consistent with the nature of the condition or factor. patient’s medical record and the patient’s response to the cur- There are many important reasons to understand the docu- rent treatment. mentation required by your Medicare carrier. This under- (5) The patient’s medical record must contain clearly docu- standing defines what documentation needs to be completed mented evidence of the progress of the wound’s response to within the medical record, which serves as the source of truth treatment at each physician visit. for the patient encounter. In addition, from an audit perspec- (6) Identification of the wound location, size, depth, and tive, knowing the documentation required assists in determin- stage by description must be documented and may be sup- ing the accuracy of documentation and potentially discovering ported by a drawing or photograph of the wound. Photo- lost revenues. At the end of the day, the documentation must graphic documentation of wounds at initiation of treatment, as adequately substantiate the services billed and identify medical well as either immediately before or immediately after debride- necessity for the services rendered. Do you know who your ment, is recommended. Medicare carrier is and their documentation requirements? (7) Medical record documentation for debridement ser- vices must include the type of tissue removed during the Reference procedure, as well as the depth, size, or other characteristics 1. Centers for Medicare and Medicaid Services. Local Coverage Determination (LCD): Wound of the wound, and must correspond to the debridement Care (L35125): General Information. 2017. www.cms.gov/medicare-coverage-database/ service submitted. A pathology report substantiating depth details/lcd-details.aspx?LCDId=35125. Last accessed January 17, 2018. Cathy Thomas Hess, BSN, RN, CWCN, is Vice President and Chief Clinical Officer for Wound Care, Net Health. Ms Hess presides over Net Health 360 WoundExpert Professional Services, which offers products and solutions to optimize process and workflows. Address correspondence to Ms Hess via e-mail: chess@nethealth.com. ADVANCES IN SKIN & WOUND CARE & VOL. 31 NO. 3 144 WWW.WOUNDCAREJOURNAL.COM Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

Journal

Advances in Skin & Wound CareWolters Kluwer Health

Published: Jan 1, 2018

References

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