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Understanding Your Documentation Requirements

Hess, Cathy Thomas BSN, RN, CWCN

Advances in Skin & Wound Care: March 2018 - Volume 31 - Issue 3 - p 144
doi: 10.1097/01.ASW.0000530374.61754.a3
Departments: Practice Points

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:

When working in a wound care department, it is the clinician’s responsibility to understand the rules and regulations guiding the department’s documentation and billing processes. These rules are generated from the Fiscal Intermediary, carriers, Medicare Administrative Contractors, National Coverage Determination, respective Local Coverage Decisions (LCD), Centers for Medicare & Medicaid Services, The Joint Commission, American Medical Association, and so on. Below is an example of the documentation requirements based on excerpts from the Novitas Wound Care LCD.1 (For the full list, visit the reference URL at the end of this article.) Do your homework and verify that your documentation complies with the documentation requirements within the LCD governing your department.

  • (1) All documentation must be maintained in the patient’s medical record and made available to the contractor upon request.
  • (2) Every page of the record must be legible and include appropriate patient identification information. The documentation must include the legible signature of the physician or nonphysician practitioner responsible for and providing the care to the patient.
  • (3) The submitted medical record must support the use of the selected International Classification of Diseases code(s). The submitted code must describe the service performed.
  • (4) The most accurate and specific diagnosis code(s) must be submitted on the claim. The patient’s medical record should indicate the specific signs/symptoms and other clinical data supporting the diagnosis code(s) used. 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.
  • (5) The patient’s medical record must contain clearly documented evidence of the progress of the wound’s response to treatment at each physician visit.
  • (6) 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.
  • (7) 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.
  • (8) In addition, except for patients with compromised healing from severe underlying debility or other factors, documentation in the medical record must show:
  • (a) There is an expectation that the treatment will substantially affect tissue healing and viability, reduce or control tissue infection, remove necrotic tissue, or prepare the tissue for surgical management.
  • (b) The extent and duration of wound care treatment must correlate with the patient’s expected restoration potential. If wound closure is not a reasonable goal, then the expectation is to optimize recovery and establish an appropriate non-skilled maintenance program. If it is determined that the goal of care is not wound closure, the patient should be managed following appropriate covered palliative care standards.
    • (9) Service(s) must include an operative note or procedure note for the debridement service(s).
    • (10) 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.
    • (11) 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 medical record at intervals consistent with the nature of the condition or factor.

There are many important reasons to understand the documentation required by your Medicare carrier. This understanding defines what documentation needs to be completed within the medical record, which serves as the source of truth for the patient encounter. In addition, from an audit perspective, knowing the documentation required assists in determining the accuracy of documentation and potentially discovering lost revenues. At the end of the day, the documentation must adequately substantiate the services billed and identify medical necessity for the services rendered. Do you know who your Medicare carrier is and their documentation requirements?

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Centers for Medicare and Medicaid Services. Local Coverage Determination (LCD): Wound Care (L35125): General Information. 2017. Last accessed January 17, 2018.
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