Setting of care dictates requirements for wound care documentation

Improving your wound care documentation is the key to boosting your reimbursement rate, but the trick is knowing what documentation is needed. Often the type of documentation that Medicare and managed care companies demand is affected by the setting of care.

In one chapter of their 50-page booklet, Defensive Wound Management, co-authors Glenda Motta, BSN, MPH, ET, and Kathi Whitaker, BSN, MSN, CETN, spell out wound documentation strategies based on whether the care is provided in the hospital, subacute facilities, skilled nursing facilities, or home.1 Here are some highlights:

All non-home settings

• Documentation of pertinent observations and nursing actions is crucial to reimbursement for all payers, especially Medicare.

• Providing accurate, pertinent information on a patient admitted to a hospital, subacute care facility, or skilled nursing facility reinforces the determination that the admission meets Medicare or other third-party payer requirements.

• Focus on the nursing process when documenting.

• Assess the patient/resident, identify problems (use nursing diagnosis), plan goals, implement the care plan, and evaluate the effectiveness of the care provided.

• Documentation in care plans, nurses’ notes, and physicians’ and nurses’ orders is required to substantiate a patient’s need for the health care setting they are in (acute care, subacute care, nursing facility).

• Wound documentation guidelines:

— location and measurement of pressure ulcers (including width, length, depth in cm) and of all ulcers (on admission and daily);

— assessment of wound healing progress;

— turning and positioning schedule;

— assessment and documentation of general skin condition;

— evaluation and documentation of nutritional intake;

— use of protective or pressure-reducing devices;

— topical treatment of wounds;

— skilled nursing care provided.

Skilled nursing facility

• Documentation must prove that the care provided is skilled and can only be performed by, or under, the supervision of licensed nurses.

• State the reason a patient is certified as a Medicare resident. Include records of vital signs, other conditions being monitored, treatment regimen, expected results, and progress or decline actually observed.

• Medicare policy for wound care coverage in skilled nursing facilities:

— sterile dressing changes;

— care of extensive pressure ulcers;

— monitoring an unstable condition;

— pain control for terminal malignancy patients;

— whirlpool treatment for open wounds.

Home health care

Observation and assessment.

Observation and assessment for wound care is reasonable and necessary when the likelihood of change in a patient’s condition requires skilled nursing personnel to identify and evaluate the need for:

— possible modification of treatment;

— initiation of additional medical procedures until the treatment regimen is stabilized.

Direct, hands-on skilled nursing care.

According to the Regional Home Health Intermediary Manual, direct, hands-on skilled nursing care, including any necessary dressing changes, is reasonable and necessary for:

— open wounds draining purulent or colored exudate or emitting a foul odor and/or for which the beneficiary is receiving antibiotic therapy;

— wounds with a drain or t-tube that requires shortening or movement;

— wounds requiring irrigation or instillation of a sterile cleansing or medication solution in several layers of tissue and/or packing with sterile gauze;

— recently debrided ulcers;

— pressure ulcers with partial thickness tissue loss and signs of infection;

— pressure ulcers with full thickness tissue loss that involves exposure of fat or invasion of other tissues, such as muscle or bone;

— wounds with exposed internal vessels or a mass that may hemorrhage with dressing change;

— open wounds or widespread skin complications following radiation therapy, immune deficiencies, or vascular insufficiencies;

— postoperative wounds with complications or underlying disease with potential to adversely affect healing (such as diabetes);

— third-degree burns and second-degree burns in which the size of the burn or presence of complications causes the need for skilled nursing care;

— other open or complex wounds that require treatment that can be safely and effectively provided only by a licensed nurse.

Teaching and training activities.

Teaching and training activities are reasonable and necessary to:

— teach a beneficiary, the family, or caregivers how to manage the wound treatment regimen;

— reinforce teaching previously provided in an institution or in the home;

— provide initial instructions for wound care;

— teach proper application of a specialized dressing.

Medicare Part B

• Claims for wound care supplies are submitted to the Durable Medical Equipment Regional Carrier (DMERC).

• Only dressings used on surgical wounds are covered under Part B.

• Primary and secondary dressings are covered.

• Debridement such as mechanical, enzymatic, and autolytic, as well as surgical or sharp debridement qualifies a wound for surgical dressings if the debridement is reasonable and medically necessary.

• Debridement may be performed by any health care professional, as permitted by state law.

• Always follow the documentation requirement listed in the DMERC Supplier Manual.

• Use the appropriate ICD-9-CM diagnosis code for the type of wound.

• Information may be requested by the DMERC during a pre- or post-payment review of selected patients or suppliers with significantly high supply utilization.

• Suppliers must keep a certificate of information on file for post-payment review.

• Maintain current clinical information that includes at least:

— number of wounds;

— size (including depth) of wounds;

— frequency of dressing changes;

— number of dressings per wound to support reasonableness and necessity of the type and quantity of surgical dressings provided.

• Document any acute problems such as increase in drainage, amount of necrosis, infection, and development of additional wounds.

• Suppliers should obtain extra documentation or have the patient sign an advance notice of possible denial on assigned claims for high utilization.

• Always contact the DMERC for clarification on problem cases and keep current bulletins and newsletters from the DMERC.

• The DMERC has developed an appendix to the surgical dressing policy that lists dressings by category. Contact the Statistical Analysis DME Regional Carrier to obtain a copy. (See Sources, below.)


1. Motta GJ, Whitaker KT, Defensive Wound Management. Mitchellville, MD. Pathways to Empowerment, LLC; 1994:24-29.