Dig into the details of wound care documentation

Association of Clinical Documentation Improvement Specialists, September 6, 2011

Documentation is central to accurate coding and reimbursement. It justifies treatment, supports the diagnosis, and captures patient severity and acuity. None of that comes as a surprise to coders, who often have to deal with documentation shortcomings.

Some patient information, such as age, address, and insurance carrier, is simple and easy to find. The clinical information, documentation, and data, however, can be very complex, says Gloryanne Bryant, RHIA, RHIT, CCS, CCDS, regional managing director of health information management (Northern California Revenue Cycle) for Kaiser Permanente in Oakland, CA. "Lots of different rules and caveats surround that information," Bryant says.

Templates, in paper or electronic form, can help ensure complete documentation. If your facility does not already have a template, consider creating one.

To support services provided, coding, and reimbursement, providers should include in the medical record information that shows an assessment of the patient, the condition, and what the provider observed on that date.


What should providers document and coders look for in order to accurately code for wound care?

Documentation should describe the following, in detail:

  • Patient's condition, using terminology that includes specific diagnoses, symptoms, and reasons for the visit
  • Observed condition and wound
  • Treatment or procedure provided

Let's take a closer look at wound care documentation.

Wound characteristics

First, there should be specific details regarding the wound(s). Coders should look for documentation of the following:

Onset and duration: Knowing whether a wound is chronic or acute will help with treatment and outcome planning. It will also become more important after the switch to ICD-10-CM because coders will need additional detail to select the appropriate code.
Size: All wounds must be measured in centimeters for length (vertical), width (horizontal), and depth. Be sure the documentation indicates whether a wound has increased in size. If so, the provider may decide to reevaluate the wound, and the documentation should reflect that.
Edema: The presence of edema can indicate underlying diseases and signify infection.
Peri-wound: Assessment must include inspection of the surrounding tissues.
Undermining: Undermining indicates the presence of a cavity under the peri-wound that is caused by shearing forces.
Tunneling: A tunnel is a tract or sinus extending into the underlying tissues from any point in the wound bed.
Exudate: Record the amount (e.g., none, minimal, moderate, copious), color (e.g., red, greenish-blue, yellow-clear), and odor.
Necrotic tissue: Document whether nonviable tissue is present and, if so, whether it is a particular color, such as black-brown (eschar) or yellow (slough).
Granulation tissue: The development of granulation tissue is the goal for full-thickness wounds. This area of the wound will look red and beefy and should increase in size with each wound reevaluation.

For ongoing wounds, look for documentation of improvement—or lack of improvement—in the wound over time, Bryant says. This is great information to bring to the attention of providers to ensure specifics are within the medical record.

"As healthcare providers, auditors, and professional coders, you want these characteristics to be present in the record," she says.

Treatment choices

Providers can choose from a wide range of treatment options, including debridement and excision. In some cases, excision can be performed down to the bone. When a physician performs a debridement or excision, documentation should include the size of the wound, the level of debridement performed, and the type of debridement. For example, was it a surgical debridement? Was anesthesia used? The documentation should answer these questions.

If the provider is treating an infection, coders should look in the documentation for the type of infection and the specific type of treatment. Practitioners may apply a topical treatment, such as a wound dressing. Look for details about the type of dressing and any other topical treatments the provider used.

For diabetic patients with foot ulcers, providers will often use off-loading with casts, which is the process of preventing, reducing, or eliminating mechanical insults to skin and underlying tissue. Make sure the provider documents not only the characteristics of the ulcer, but also the type of ulcer and off-loading performed.

Healing process

Documentation of the healing process is important because it shows that what the provider is doing is working—it medically justifies continuing treatment. Many providers do not document the patient's improvement, Bryant says.

"This is a very important piece of documentation when we are audited to show that we are continuing care because the wound is healing and the treatment is working," Bryant says. "Showing the progress of the healing wound can be key for ongoing coverage."

Wounds heal slowly, so don't expect to see documentation of improvement from one day to the next. However, providers should see improvement over time and they should include that improvement in their documentation.

Other important documentation

The documentation requirements don't stop there. Make sure the documentation contains a physician order that includes a diagnosis, signature, and date. The provider should also document the initial evaluation and a reevaluation at least every 30 days. If something changes drastically within 30 days, the provider may decide to reevaluate the patient sooner. The documentation must be labeled as a reevaluation and should include the reason for the reevaluation and details similar to the initial evaluation.

Daily treatment notes should include:

  • Indications and impression
  • Changes in condition, improvements, etc.
  • Wound size and details
  • Procedure details, including how the wound looked before and after the procedure

Make sure the notes are signed, dated, and timed. "The notes are often too short and lack detail," Bryant says.

Know common wound care terminology

Review some terms coders are likely to see for wound care, Bryant says:

Debridement: Removal of devitalized tissue and foreign matter from a wound. Various methods can be used for this purpose:
Autolytic debridement: The use of synthetic dressings to cover a wound and allow eschar to self-digest by the action of enzymes present in wound fluids.
Enzymatic (chemical) debridement: The topical application of proteolytic substances (enzymes) to break down devitalized tissue.
Mechanical debridement: Removal of foreign material and devitalized or contaminated tissue from a wound by physical forces rather than by chemical (enzymatic) or natural (autolytic) forces. Examples are wet-to-dry dressings, wound irrigation, whirlpool, and dextranomers.
Sharp debridement: Removal of foreign material or devitalized tissue by a sharp instrument such as a scalpel. Laser debridement is also considered a type of sharp debridement.
Full-thickness tissue loss: The absence of epidermis and dermis.
Granulation tissue: The pink/red, moist tissue that contains new blood vessels, collagen, fibroblasts, and inflammatory cells, which fills an open, previously deep wound when it starts to heal.
Infection: The presence of bacteria or other microorganisms in sufficient quantity to damage tissue or impair healing. Clinical experience has indicated that wounds can be classified as infected when the wound tissue contains 105 or more microorganisms per gram of tissue. Clinical signs of infection may not be present, especially in immunocompromised patients or patients with a chronic wound.
Infection (clinical): The presence of bacteria or other microorganisms in sufficient quantity to overwhelm tissue defenses and produce the inflammatory signs of infection (i.e., purulent exudate, odor, erythema, warmth, tenderness, edema, pain, fever, and elevated white cell count).
Local clinical infection: A clinical infection confined to the wound and within a few millimeters of its margins.
Systemic clinical infection: A clinical infection that extends beyond the margins of the wound. Some systemic infectious complications of pressure ulcers include cellulitus, advancing cellulitus, osteomyelitis, meningitis, endocarditis, septic arthritis, bacteremia, and sepsis.
Necrotic tissue: Tissue that has died and has therefore lost its usual physical properties and biological activity. Also called "devitalized tissue."
Partial-thickness tissue loss: Wounds that involve the epidermis and can extend into, but not through, the dermis. These wounds heal mainly by epithelialization from the wound edges and from epithelial cells in the remaining hair follicles and glands.
Peri-wound: The area surrounding the wound. Assessment of the edges may help to identify undermining (blue-gray or blanched appearance), infection (erythema), or maceration (white margins).
Undermining: A closed passageway under the surface of the skin that is open only at the skin surface. Generally it appears as an area of skin ulceration at the margins of the ulcer with skin overlying the area. Undermining often develops from shearing forces.

Editor’s Note: This article was originally published in the May issue of Briefings on APCs. E-mail your questions to Senior Managing Editor Michelle Leppert, CPC-A.

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