Detailed wound care documentation is a critical part of day-to-day operations in any wound care facility. Complete documentation will not only ensure high-quality patient care but also protect the practice from litigation. Unfortunately, lawsuits tied to wound care are incredibly common. One of the best ways to protect yourself is to ensure that everyone working at your facility knows how to document wound care effectively. In this article, we discussed common wound care documentation errors and basic guidelines to eliminate them.
To share common wound care documentation errors we referred to Medicare claim data. Most of the claims used two HCPCS codes, A6197 (Alginate or other fiber gelling dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each dressing) and A6199 (Alginate or other fiber gelling dressing, wound filler, sterile, per 6 inches). The common wound care documentation errors are as follows:
Debridement, either mechanical or chemical must be documented as a part of the wound treatment regimen. Those in podiatric medicine, especially those who dispense wound dressings, always document debridement. If you are treating wounds routinely without debridement, this falls below the standard of care for wound treatment.
Wound evaluation missing type, location, size, depth, and/or drainage amount. These simple and obvious findings should be recorded whether you are dispensing dressings or not. The simple wound template can assure that these basic clinical findings are recorded. As it is the case that wound/surgical dressings are reimbursable only if the wound is a full-thickness wound, it goes without saying that the depth and staging must be recorded.
In the era of EHR, there is simply no excuse for not templating and documenting the characteristics of the wounds. In some podiatry practices, paper templates are still used in the treatment rooms which are partially completed by staff and partially by the physician. These templates are then shared with a documentation scribe who then converts the templates into the medical record. If the characteristics of the wound or if the size, depth, and staging are missing for some reason, the scribe hands the template back to the physician to complete.
The order did not specify a quantity to be used at one time. This is information that should be recorded both in the patient’s medical record and in the detailed written order (DWO) and is no different than what is required in writing a prescription for an antibiotic or any other prescription product. Simply recording the information in a detailed written order and not having identical information documented in the medical record will undoubtedly result in a claim rejection if your claims are subject to a complex medical review. The bottom line is, insurance carriers want you to simply document how many wound dressings you think the patient needs.
This information should be recorded in the patient’s medical record and in the detailed written wound dressing prescription order described above. In most cases, the order should indicate that the patient is to change the dressing 1 time per day (collagen powder/alginate) or 1 time every 3 days (foam). Again, this should be templated on the detailed written order form embedded into your EHR.
Use the body as a clock when documenting the length, width, and depth of a wound using the linear method. In all instances of the linear (or clock) method, the head is at 12:00 and the feet are at 6:00. When measuring length, the ruler will be placed between the longest portion of the wound between 12:00 and 6:00. The width is measured at the widest part of the wound between 3:00 and 9:00. Measuring depth is a little more challenging. This can be accomplished by gently placing a cotton-tip applicator into the deepest part of the wound, then holding the applicator up to a ruler. This same applicator can be used to measure tunneling and undermining. Because undermining spreads in many directions, the linear method should be used to document multiple measurements. For example, a nurse may describe the wound’s undermining as ‘0.5 cm between 1:00 and 2:00 and 1.5 cm between 2:00 and 5:00.’
Always be specific while documenting and use exact keywords explaining the clinician’s treatment. The term ‘packed’ is a common example of a wound assessment documentation term often used in healthcare facilities and in the courthouse. If a wound gets worse or fails to heal, lawyers may argue that the clinician packed the wound too tightly, causing additional damage. Instead of using the word ‘packed,’ a more accurate wound care charting sample would say, ‘filled the wound loosely.’ This type of specificity leaves less room for misinterpretation and accusations of wrongdoing.
Edema, or swelling, can vary in severity depending on the patient and the wound. Some will experience significant swelling, while others may have little or none. Edema can be documented using a simple, yet effective, grading system that rates its severity on a scale of one to four. To use this system, healthcare professionals must apply pressure to the affected area for five seconds, then release it. The grade of the edema is determined by the depth of the depression that is left: grade one indicates a 2-mm depression that rebounds quickly, grade two describes a 4-mm depression that takes a few seconds to rebound, grade three pertains to a 6-mm depression that lasts for 10 to 12 seconds, and grade four signifies an 8-mm depression that lasts for 20 seconds.
Wound care documentation has the power to elevate your practice’s standard of care and protect your team from undue legal charges. Medical Billers and Coders (MBC) is a leading medical billing company providing complete billing and coding services. For provider education, we shared common wound care documentation errors and guidelines to eliminate them. If you are looking for medical billing assistance for your wound care practice, email us at: firstname.lastname@example.org or call us at: 888-357-3226.