Wound care is one of the top paying clinical groups under PDGM, but documentation is critical to prevent compliance and audit issues that could put your payment at risk.
Good documentation starts at the beginning of the admission process. The discharge summaries and office notes from visits must address the wounds. If high blood pressure was the reason a patient was in the ER, you can’t use that as the documentation justifying wound care.
Face-to-face documentation, a frequent challenge for compliant documentation, must go beyond referencing wound care. Here is an example:
- Insufficient face to face: Patient unable to do wound care
- Appropriate face to face: Wound care completed to left great toe. No s/s of infection, but patient remains at risk due to diabetic status. Skilled nurse visits to perform wound care and assess wound status. Patient on bed to chair activities only.
Remember home health requirements
The Medicare Benefit Policy Manual goes into more detail on documentation requirements specific to wound care in Chapter 7 § 40.1.2.8.
“The size, depth, nature of drainage (color, odor, consistency, and quantity), and condition and appearance of the skin surrounding the wound must be documented in the clinical findings so that an assessment of the need for skilled nursing care can be made,” according to CMS, which also notes the plan of care must contain the specific instructions for treatment.
Consider these tips:
Not every wound qualifies. Chronic wound care is a particular concern for medical reviewers. Assess whether there is a realistic finite and predictable endpoint to the need for daily skilled nursing visits for wound care.
The MACs expect home health agencies to focus on wound care to get patients back to the level they were functioning in before they got sick. However, if this is a chronic issue, for instance, diabetic wounds that aren’t infected, CMS says they don’t qualify.
Always assess homebound status. Recent audits by the Department of Health and Human Services Office of Inspector General have referenced wound claims when questioning ongoing homebound status.
Assessing homebound status is a best practice for all cases at every visit. Assessment can include asking the patient about their activity and using their own words in the documentation.
Make compliance count to clinicians. Beyond the start of care, CMS requirements put extra focus on how clinicians monitor wounds and whether they’re carefully documenting treatment.
You must document any kind of change in status. If you’re treating a wound and there is no change, that in itself is a change of status if the wound is not healing.
Clinicians must use objective measurements whenever possible. Document the record to include the type of wound and cause, including information about size, color, drainage, and any undermining. In addition, clinicians must document how they manage the wound, including dressings used, any debridement, and other aspects of the patient care they modified to promote wound healing.
Stay consistent. Be consistent in documenting the etiology of the wound — whether it is a pressure ulcer, stasis, diabetic ulcer, for example. Wound care is documented in multiple places — face-to-face, visit notes, plan of care, etc. — so being consistent in the descriptions is essential.
Having the same clinician documenting wound care is helpful, but it has been difficult during the pandemic. If you’re going to have someone stepping in to help, they need to know the state of the wound.
Train, train, train. Clinicians should have their competency tested annually and more often if deficits are recognized.
Take advantage of educational opportunities, including medical suppliers that often provide in-person education with a certified wound care nurse.
Have help standing by. It’s not practical to expect that every clinician will be wound-care certified. However, many agencies have a certified wound care nurse under contract and accessible for questions — someone that nurses in the field can call and ask about complex wounds.
Dietitians are also an asset for clinicians facing tough cases. For example, when you’re trying to heal wounds, a dietitian can help with nutrients and proteins that you’d like so that you can make sure the patients are well-nourished to help them heal.