Checklist: Wound debridement / care
This checklist is intended to provide health care providers with a reference for use when responding to additional documentation requests for wound debridement / care services. It is not intended to replace the published guidelines. Health care providers retain responsibility to submit complete and accurate documentation.
| Check | Documentation description |
|---|---|
| Documentation is for the correct beneficiary and date of service. | |
| Documentation is complete, legible, signed, and dated by the physician or clinician. | |
| Signed physician order for wound care / treatment | |
|
History & physical (H&P) with the initial wound description, location and measurements and response to prior treatment if applicable.
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| Clinical documentation of diagnosis or symptoms to justify services | |
|
Current progress notes (including measurable signs of healing as well as causes of delayed wound healing or modification to the treatment plan).
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| Operative note or procedure note for the debridement services including description of tissue debrided, instrumentation used, pre and post wound measurements. | |
| Plan of care (POC) containing treatment goals and physician follow -up | |
| Consult reports as applicable | |
| Reports of all testing / services billed | |
| Advanced Beneficiary Notice (ABN), if applicable | |
| Itemized bill |
Disclaimer
This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or the CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.