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Know How to Code and Document Wound Debridement

Know How to Code and Document Wound Debridement

Sometimes a wound gets worse before it gets better and knowing how to properly code it will enable your office to get the maximum reimbursements on your medical billing instead of having the treatment bundled.

Debrided ulcers are not uncommon and knowing how to correctly document the staging and coding on the MDS is most of the problem. It is difficult to assign a stage to a wound you can’t see and the MDS does not allow you to bill for a wound you can’t stage. A good rule of thumb to use is to stage the wound at stage 4 (necrotic eschar is present) until the exact stage can be determined either surgically or mechanically as advised in the RAI manual.

After you debride the wound, follow the RAI manual definitions to stage and code the wound. The manual describes a stage 3 wound as one where the “full thickness of the skin” has been lost, “exposing the subcutaneous tissues.” The wound “presents as a deep crater with or without undermining adjacent tissue.”

Additionally, make sure you provide a detailed documentation of a debridement as it can make a wound look bigger and deeper. Documentation on how much necrotic tissue was removed is the key to showing the wound hasn’t actually worsened by what was debrided and has had dead tissue removed. Showing wound dimensions before and after debridement will help back this up.

When the wound is improving, describe how the edges of the wound are red and healthy looking and granulation tissue is appearing at the bottom of the wound showing signs of healing. Documentation is key to getting reimbursed on these claims. Be very detailed and show medical necessity for each procedure and you should be able to document a time line showing the wound looked worse after debridement but it was actually part of the healing process.

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