Checklist: Wound debridement
This checklist is intended to provide health care providers with a reference for use when responding to additional documentation requests for wound care. Healthcare providers retain responsibility to submit complete and accurate documentation.
| Check | Documentation description |
|---|---|
| Documentation is for the correct beneficiary. | |
| Documentation is for the correct date of service. | |
| Documentation contains a valid and legible signature of the MD or DO performing the service. | |
| Please submit a mandatory Advanced Beneficiary Notice (ABN) if issued | |
| 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 |
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.