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Medicare Documentation Guidelines for Wound Care Nurses

Schaum, Kathleen D. MS

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Advances in Skin & Wound Care: May-June 2002 - Volume 15 - Issue 3 - p 142

Q: Can you clarify the appropriate way a wound, ostomy, and continence nurse (WOCN) and nurse practitioner (NP) should document in a patient’s medical record in order to bill Medicare for their services?— BM, MO

A: The key to documentation is to always thoroughly document the patient’s medical history, physical examination, wound assessment, laboratory and radiology test results, wound photographs, wound management, impressions, plan of care, and related items. Nurse practitioners who have a Medicare provider number and are billing Medicare under that number must follow the American Medical Association’s (AMA) and the Center for Medicare and Medicaid Services’ (CMS) guidelines for documentation of evaluation and management services. These documentation guidelines are not mandatory for WOCNs and NPs who are not billing Medicare directly for their professional services. The documentation required by the facility where WOCNs or NPs work dictates the level of documentation they must provide in order to meet Medicare’s requirements for the facility to prove medical necessity and to receive payment.

The question of who should bill Medicare for their services is quite clear. WOCN nurses cannot bill Medicare directly for their services. Hospitals bill Medicare for inpatients according to the patient’s diagnosis and receive payment via the Diagnosis Related Group (DRG) payment system. Skilled nursing facilities bill Medicare according to the resources necessary to care for each patient at day 5, 14, 30, 60, and 90 and receive payment via the Resource Utilization Group (RUG) payment system for up to 100 days. Home health agencies bill Medicare according to the resources necessary to care for each patient for 60-day periods and receive payment via the Home Health Resource Group (HHRG) payment system. Physician offices bill according to the level of work performed during each office visit and receive payment via the Resource Based Relative Value System (RBRVS) payment system. Hospital outpatient departments bill Medicare for the clinic visit level and/or procedures provided at each wound care visit and receive payment via the Ambulatory Payment Classification (APC) payment system.

The APC payment system is based on the AMA’s Current Procedural Terminology (CPT) * codes for procedures and clinic visits. The Federal Register Final Rule for Hospital Outpatient Departments instructs each hospital to specify their own method of determining the parameters that identify the 5 levels of evaluation and management services that can be provided during patient clinic visits. The physician’s and nurse’s documentation of the work performed at each outpatient visit should be mapped, according to their own parameters, to the appropriate level of clinic visit. The hospital then bills for that level of clinic visit.

Hospital outpatient department billing can be confusing. It helps to remember that the hospital is not billing for the WOCN and NP services. Instead, the hospital is billing for all the resources used to provide wound management services in the hospital outpatient department. This includes use of the facility, dressings, supplies, medications, nursing staff, overhead, and so on. In all cases, Medicare requires a physician to provide the initial examination, plan the care, and periodically examine the patient.

Often, WOCNs and NPs think that use of the CPT codes for clinic visits in hospital outpatient departments automatically requires them to follow the same AMA and CMS documentation guidelines as physicians and nonphysician practitioners who are billing under their own Medicare provider number. This is not the case.

The next time you are confused by documentation requirements, first identify your place of employment. Then, identify and follow the Medicare guidelines required by the facility where you work. Remember, WOCNs are never paid directly by Medicare for their services. Nurse practitioners can be paid directly for their services, but only when they are not included in a facility’s Medicare cost report.

Additional Readings

Schaum KD. Unscramble the alphabet soup of Medicare payment systems. Adv Skin Wound Care 2001; 14:176–8.
Schaum KD. Will payers cover nursing services for wound care? Adv Skin Wound Care 2001; 14:290–1.


*CPT is a trademark of the American Medical Association.
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© 2002 Lippincott Williams & Wilkins, Inc.