If you are involved in wound care, you need to read this in its entirety. However, here is one small excerpt of the many documentation requirements to justify the medical necessity of wound care services:
The medical record must include a plan of care containing treatment goals and physician follow-up. The record must document complicating factors for wound healing as well as measures taken to control complicating factors when debridement is part of the plan. Appropriate modification of treatment plans, when necessitated by failure of wounds to heal, must be demonstrated. A wound that shows no improvement after 30 days requires a new approach. Documentation of such cases may include a physician reassessment of underlying infection, metabolic, nutritional, or vascular problems inhibiting wound healing, or a new treatment approach.
Novitas also has expanded its “pre payment review” of hyperbaric oxygen therapy to the following states: AR, CO, LA, MS, NM, OK, TX. In the release below (see link) Novitas has specified the documentation needed to support HBOT.
The requirements are extensive and detailed and include (among many other things):
- Signed physician orders.
- History of present illness to include clinical documentation of diagnosis; symptoms supporting the medical necessity of services (including, if applicable, wound grade classification per Wagner Scale).
- HBO progress notes (including measurable signs of healing).
- HBO Treatment Log with documented length of treatment time.
- Results of all testing/services billed.
- Documentation of physician attendance and supervision of HBO therapy.
- Itemized Bill.
It is more important than ever to have the right electronic health record system, and to commit to reporting relevant quality measures as a mechanism to ensure that appropriate conservative care is being performed.