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Documentation Requirements of Wound Care Treatment

The patient’s medical record should indicate the specific signs/symptoms and other clinical data supporting the diagnosis code(s) used. It is expected that the physician will document the current status of the wound in the patient’s medical record and the patient’s response to the current treatment.

The patient’s medical record must contain clearly documented evidence of the progress of the wound’s response to treatment at each physician visit. This documentation must include, at a minimum:

  • Current wound volume (surface dimensions and depth).
  • Presence (and extent of) or absence of obvious signs of infection.
  • Presence (and extent of) or absence of necrotic, devitalized, or non-viable tissue.
  • Other material in the wound that is expected to inhibit healing or promote adjacent tissue breakdown.

    Identification of the wound location, size, depth, and stage by description must be documented and may be supported by a drawing or photograph of the wound. Photographic documentation of wounds at initiation of treatment as well as either immediately before or immediately after debridement, is recommended.

    This may be of particular benefit for documentation as an adjunct to written documentation of reasonable and necessary services, which require prolonged or repetitive debridement (especially those that exceed 5 debridements per wound).

    The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.

    Please click on the Local Coverage Determination (LCD) for the Florida Medicare MAC for complete billing and coverage of wound care services.

    Local Coverage Determination (LCD): Wound Care (L37166)