I got an email from a fantastic wound clinic manager who is worried about the less than stellar documentation she’s noted on the part of her advanced practitioners. She’s trying to raise the bar on wound care documentation and asked me how best to do that. That’s a common and an awkward request. I often feel that I need to issue a global apology on behalf of all physicians when it comes to our infamous unwillingness to modify behavior – even in the face of clear evidence that we need to do so.

A year before the start of the COVID pandemic, I got an email from a physician who told me that his group had paid back 100% of their reimbursement for cellular and/or tissue-based products (CTPs) due to poor documentation. What was really shocking was that their response to the audit was to stop using CTPs entirely – because the doctors were not willing to correct their documentation issues! I have to admit I was surprised. Not only were they willing to sacrifice optimal patient care, they were willing to give up future revenue – because the doctors did not want to change their behavior regarding clinical documentation. Remember, this was before Covid so it’s not a “Pandemic burn out” issue.

As a physician, I totally understand how beleaguered a doctor can get with all the competing demands on time. It feels like everyone and their dog has assigned me some inane task. However, if I can keep the patient’s needs foremost in my mind, I can usually figure out how to navigate the “stupid stuff.” But, truthfully, I am not sure what to say if a practitioner is not motivated EITHER by quality of patient care OR by revenue. It sounds like it’s time for a  new career. At any rate, I gave the excellent clinic manager some guidance about the documentation requirements of her Medicare Administrative Contractor (MAC) – which happens to be Palmetto. I am providing my message below as an FYI.

The truth is, figuring out what you need to document is tedious but not hard. I don’t have a solution to the problem of getting practitioners to do it. I’d love to hear from anyone who has a solution for that.


Dear [Clinic Manager],

The first thing you might want to do is help you staff understand the WHY behind your request to have better documentation. It would be nice if it were about patient care but it’s mostly about Medicare audits (and prior authorization for private payers and MA plans).

Your MAC is Palmetto. (Mine is Novitas). With my own staff, I started by explaining my MACs requirement for debridement documentation (I blogged about that here: The Novitas Wound Care LCD, Debridement Services, and Real World Data – Part 4), just so they understood what would be required and why.

I went to the Palmetto website and searched for LCDs relevant to wound care and hyperbaric oxygen therapy. These are the first two that I came upon – one a hyperbaric oxygen checklist and the other the requirements to order surgical dressings for patients. I have pasted the list of required documentation elements underneath both. If Palmetto does not have a specific policy for debridement, then use the Novitas one linked above because in the absence of an LCD for your region, we use the most demanding LCD knowing that if a note meets the requirements of the toughest one then it will work for all the others.

An important overarching point is that all the MACs now require that the chart contain a Plan of Care and that practitioners explain how any given advanced treatment is related to treatment goals for the wound which are stated in the plan of care.

It’s obvious that simply identifying the required documentation elements is a DAUNTING task. However, even if you know exactly what a note needs to contain, you still have to get all the staff on board with doing it!

Here are resources from Palmetto.

Hyperbaric Oxygen Checklist:

  • Is the documentation provided for the correct beneficiary?
  • Is the documentation provided for the correct dates of service?
  • Is there a valid order for services provided?
  • Are the number and length of HBO treatments to be administered documented?
  • Does the documentation provided support the medical necessity for HBOT?
  • Does the medical record include measurable goals related to the treatment of the indication for HBO or HBO therapy?
  • Does the medical record include progress updates that support the patient’s response to therapy and measurable signs of healing?
  • Is the indicated diagnosis being treated with HBO covered by the NCD?
  • Are there radiology, pathology, or lab reports to confirm the diagnosis of Chronic Refractory Osteomyelitis?
  • Does the documentation support the patient has type I or II Diabetes and/or a lower extremity wound related to Diabetes as required per NCD 20.29 for the use of HBO to treat Diabetic Ulcers?
  • Is there documentation of failed wound care prior to beginning HBO for the treatment of the diabetic wound as required by NCD 20.29?
  • Does the documentation provided support a history of radiation exposure?
  • Does the documentation support HBO was used in combination with conventional treatment as required in NCD 20.29?

For Physicians Ordering Surgical Dressings.

For initial wound evaluations, the treating practitioner’s medical record, nursing home, or home care nursing records must specify:

  • The type of qualifying wound (see above);
    1. A wound caused by a surgical procedure
    2. After the debridement of a wound
  • Information regarding the location, number, and size of qualifying wounds being treated with a dressing; and
  • Whether the dressing is being used as a primary or secondary dressing or for some noncovered use (e.g., wound cleansing); and
  • Amount of drainage; and
  • The type of dressing (e.g., hydrocolloid wound cover, hydrogel wound filler, etc.); and
  • The size of the dressing (if applicable); and
  • The number/amount to be used at one time; and
  • The frequency of dressing change; and
  • Any other relevant clinical information