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Improve your wound care documentation

HIM Connection, August 8, 2005

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Proper documentation and ease of coding always go hand-in-hand, and outpatient wound care is no different.

"Providers should document what they did with the patient, what they saw, and what the details of the wound were," says Gloryanne Bryant, BS, RHIA, RHIT, CCS, corporate director of coding/HIM compliance for Catholic Healthcare West (CHW).

"Given that there are many wound care choices and that wounds often heal at slow rates, careful documentation of changes can help the clinician decide what treatment approach is providing the best results," she says, adding that proper documentation also leads to accurate and compliant coding.

Bryant addressed the topic of wound care documentation during a June 30 HCPro audioconference, Outpatient wound care coding: Strategies for charge capture and compliance. Ensure complete capture of these services and develop a standardized physician order form to improve wound care documentation.

A physician order form is a written document on which the physician indicates a primary diagnosis or reason for the wound care services and provides his or her signature to authenticate that diagnosis. But the physician order form needs to be specific. When designed properly, a standardized order form will capture all necessary diagnostic information, including any related diseases, secondary diagnoses, or comorbid conditions.

For example, Bryant says it's a good idea to capture the relationship of the wound to the diabetes on your order form because of the general assumption that a wound results from a trauma, injury, or cut. "Wounds aren't always due to injuries or cuts," she says. "Sometimes it's systemic or related to a disease."

If you don't provide specific details, the word 'wound' can be misleading, she says. "The insurance carrier might think there was an accident and it will direct it to a third-party carrier, which will hold up the claim payment process." She says it's helpful to provide physicians with check-off boxes that prompt them to specify "due to diabetes mellitus," "due to atherosclerotic peripheral vascular tissue," or "due to other underlying disease process."

Editor's note: This article was adapted from the audioconference Outpatient wound care coding: Strategies for charge capture and compliance.

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