Does the Documented History Tell the Patient’s Wound Story Accurately?

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Welcome to the second article dedicated to documentation issues in wound care (click here for the first part). The intent of this article is to point out inconsistencies found in the documentation of a patient’s wound care history and provide possible suggestions on how to avoid creating those inconsistencies. Reviewing numerous wound care records has provided me with interesting findings that I would like to share with you.

Documentation provides communication with other providers and also assists in the justification of medical necessity and the diagnosis code(s) that are billed for the services. Most importantly, the history documentation provides the history of the disease, previous treatments that were either successful or unsuccessful, and justification for the current encounter.  

Coincidentally, numerous instances in audits conducted by the Comprehensive Error Rate Testing (CERT) program, Recovery Audit Contractors (RACs), Recovery Auditors (RAs) and Medicare Administrative Contractors (MACs) have shown that available documentation lacks information to establish medical necessity. Many types of audits, both internal and external, have consistently shown that the medical records provided by physicians lack sufficient documentation to support the appropriate code selection. The bottom line: insufficient documentation leads to insufficient payment or no payment!

What to Document

Click here for an MLN Matters guide that discusses what to document.

You need to provide thorough and accurate documentation to support medical necessity for services or items you provide or order. The documentation should paint a thorough picture of what happened during the patient’s visit and why services or items you ordered or provided are medically necessary.

Documentation supporting medical necessity must be complete, legible, and include, at a minimum:
•    Name of person providing the services or items
•    Date of services or items
•    Patient’s signs and symptoms supporting the need for the services or items
•    Details of the services provided, or items supplied
•    Where you provided services or items
•    Signed orders for services or items and the clinical rationale for the orders
•    Rationale for the level of care given
•    Intensity, frequency, duration, and scope of services
•    Legible signature of the person providing the service and the physician ordering and approving treatment plans. (If signature isn’t legible, include a signature log showing the name in print and signature.)

History of present illness (HPI): Should describe the nature and severity of the patient’s presenting problem(s) and will no longer be scored for evaluation and management (E/M) documentation. In wound cases, there should be a detailed history of every wound with a description of the wound at each visit, and documentation of previous therapies as well as their outcomes. Hopefully one would see improvement and reduction of size of the wound week to week.

Review of systems (ROS): Should specify whether organ systems are or are not impacted. This portion of the documentation will no longer be scored for E/M documentation.

Past, family, social, history (PFSH): Used to capture medically appropriate historical information but no longer scored for E/M.

Exam: Medically necessary as set by provider of care but no longer scored for determining the E/M level. The most common problem with the review of systems in a wound case is that next to integumentary, there is nothing listed about the wound! If the patient is being treated for a wound, one would not expect to see the term negative, non-contributory, etc.

NOTE: While these elements are not used for scoring E/M, it is recommended that these areas be covered in the medical record as they are used to pick up status codes like status post cancer or status post amputation, wheelchair bound, etc.

Documentation requirements for medical necessity of cellular- and/or tissue-based products (CTPs) for skin wounds:

•    Document prior therapies which may include the following:
–    Control of edema, venous hypertension, or lymphedema
–    Control of infection or colonization with bacterial or fungal elements
–    Elimination of underlying cellulitis, osteomyelitis, foreign body, or malignant process
–    Appropriate debridement of necrotic tissue or foreign body (exposed bone or tendon) for at least 30 days with conventional therapies. Exact type of debridement must be documented.
–    For diabetic foot ulcers, appropriate offloading
–    For venous ulcers, compression therapy provided with documented use of multilayer dressings, compression stockings of > 20 mmHg pressure.
–    Provision of wound environment to promote healing.
–    Smoking cessation treatment plan.

In addition to the above suggestions for quality documentation, I wanted to give our readers some practical issues that are preventable and should be checked to ensure they do not happen to you!

• Previous history of treatment and exact modalities used are not documented most of the time. No records received from referring physicians. (These records help to meet requirements for standard of care wound care prior to the application of a CTP). No documentation of treatment outcome present.
• Records contain photos and descriptions of exact sites of ulcers; however, unspecified ICD-10 codes are utilized. Charts should at least document laterality. Pictures must include the date the picture was taken.
• Type 1 or Type 2 diabetes consistently not documented.
• No documentation of management of underlying cause by physician. There should be documentation in the record regarding who is monitoring and treating the underlying causes of wounds.  
• In electronic records, it can be very difficult to determine which progress notes applied to the current encounter as many notes were automatically carried forward from previous encounters. These notes are sometimes not dated or listed in the past medical history section. If notes are pulled forward from previous encounters, they should list the dates of each encounter note. The lack of dates makes it almost impossible to track the history of the wounds and the outcomes. Each record should clearly document the diagnoses pertinent to the current encounter. All other notes should be included in the history section. If a patient was referred, a copy of the records from the referring physician should be included to document treatment prior to the arrival at the wound department or office.
• Diagnosis codes, even if resolved or have no impact on the current encounter, are often brought forward to the current record. The record should reflect only those diagnoses codes addressed for that encounter and any relevant past history or status codes to describe the patient’s condition such as status amputations. As discussed earlier, status codes are very important to document existing patient problems such as wheelchair bound, status post amputation, homelessness, etc.
• Documentation does not reflect complete story and is fragmented. For example, on some visits a wound is examined and sometimes it is not. There should also be documentation of wound closure if that occurs or status of the wound such as percent granulation.
• Results of any previous treatment may not be well-documented in the records if the patient is an established patient. If the patient is referred from another practitioner, there should be records from the referring provider that outlines what treatment has been rendered thus far. It is important to document previous wound interventions on the same wound. There should also be an explanation as to the outcomes of previous treatments. Wound progress notes should be documented at each encounter. Medicare will not continue to reimburse a therapy if it does not seem to be improving the wound.
• The most troubling issues involve cases that have multiple wounds. Often, these records will identify wounds as Wound #1, Wound #2, etc. It is extremely important to be consistent in the numbering process from visit to visit to track the status of each individual wound as well as its history. Documentation for each wound should have included size, previous treatment with outcome of the treatment modality as well as any procedures performed on each wound. These records can get quite lengthy, so it is vital to be able to track each wound over time. Payers will utilize this information to determine medical necessity for each wound’s intervention.

As a homework assignment, please print some sample records that you would send to a payer and see if it is easy to follow each wound’s treatment(s) over time. You may be surprised, and maybe unhappy, with how your electronic record reads when it is printed! Some defaults in the programming may yield information that you did not mean to have in the record. If that is the case, review your electronic record templates to be sure you know how each piece of data is generated. If it is a template issue, work with your vendor to fix any problem areas in the template.

Donna Cartwright is senior director of health policy and reimbursement at Integra LifeSciences Corp., Plainsboro, NJ. She is an AHIMA-approved ICD-10-CM/PCS trainer, and she has been designated as a fellow of the American Health Information Management Association.

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