Regardless of other elements of documentation in the note, the wound type must be clearly identified. Common options include diabetic foot ulcer, pressure ulcer, arterial ulcer, venous stasis ulcer, and surgical dehiscence.
The exact anatomic location of the wound must be documented. Be sure to include laterality, if appropriate. Be as specific as possible. For example, if a wound is on a toe, document the exact location on the toe.
The Medicare policy above requires length, width, and depth to be documented. Some make the mistake of documenting the length and width, but excluding the depth.
Amount of Draining
In documenting the amount of drainage, it is recommended that providers use the terms that the DMEMACs use in determining coverage requirements for surgical dressings. These include “none, light, minimal, moderate, and heavy.”
Coverage for some surgical dressings depends on whether the wound being treated is full thickness or partial thickness. Therefore, in addition to the measurement of depth, the documentation should indicate whether the ulcer is partial thickness or full thickness.
Some non-Medicare third-party payers may default to the guidelines provided by the DMEMAC policies while others may have their own guidelines. It is always best to check with each payer to determine their requirements.
DISCLAIMER: The information provided here is intended to educate health care providers regarding compliance with ICD, CPT, and HCPCS coding. The information provided does not guarantee reimbursement and is accurate to the best of our knowledge at the time of this publication. Coding guidelines can change and we encourage you to stay up to date. The existence of a code does not guarantee payment.