Monthly Hyperbaric Compliance Series
July 2008
Medicare Wound Documentation Guidelines
Medicare’s National and Local Coverage Determinations mandate that ‘The medical record must include, at a minimum, a wound evaluation at least every 30 days during administration of HBO therapy’.
Failure to comply with this requirement is a common cause for repayment demands. When Medicare does undertake post-payment claim reviews (commonly involving claims for diabetic foot wounds) their expectations are as follows:
‘A patient’s medical record must contain clearly documented evidence of the progress of the wound’s response to treatment’. Documentation should include, at a minimum:
- Current wound volume (surface dimensions and depth)
- Presence (and extent of) or absence of obvious signs of infection
- Presence (and extent of) or absence of necrotic, devitalized or non-viable tissue
- Other material in the wound that is expected to inhibit healing or promote adjacent tissue breakdown
It is recommended that the above evaluation take place on a weekly basis, and is documented accordingly. Serial wound photo documentation is particularly valuable from both clinical and compliance perspectives.
Previous Monthly Compliance Series:
