Many Medicare Administrative Contractors (MACs) have policies currently in place that govern general wound care services in general. I am going to discuss the wound care policy that’s been in effect since 07/23/2020 for the Novitas jurisdiction. This policy specifically excludes topics like “skin substitutes” or hyperbaric oxygen therapy.
Even if you are not in the Novitas jurisdiction, it’s becoming obvious that these regional contractors share their policies and use the same language (sometimes with the same misspellings) from one region to another. I am going to focus on required documentation for wound care current required by Novitas, because it can serve as an example of the documentation that will likely be needed everywhere. There’s a lot on this policy, so you should read it yourself. I can only focus on a few major points. I will quote the policy in italics to distinguish it from my commentary and note that I am providing only portions of the text.
Wound care involves the evaluation and treatment of a wound, including identifying potential causes of delayed wound healing and the modification of treatment when indicated.
While it may seem obvious, some physicians do not want to be bothered with listing the co-morbid conditions, or the various reasons why a patient is compromised. However, it is necessary to explain why the patient needs wound care services by documenting the causes of delayed wound healing.
Medicare coverage for wound care on a continuing basis, for a given wound, in a given patient, is contingent upon evidence documented in the patient’s medical record that the wound is improving in response to the wound care being provided.
The list of things that have to be documented about the wound is no surprise to wound care practitioners. What might get missed is the statement that “Medicare coverage for wound care on a continuing basis… is contingent upon evidence documented… that the wound is IMPROVING [emphasis mine].” The policy does not say over what timeframe the wound has to improve (since many do so at a pace that can only be described as glacial). However, that wording is scary given that perhaps as many as half of our patients do not heal in a year. Thankfully, there is language later to suggest that we can still provide wound care services even when wounds are not objectively “improving.”
The goal of most chronic wound care should be eventual wound closure with or without grafts, skin replacements, or other surgery (such as amputation, wound excision, etc.).
…While complete healing of the wound may be the primary objective; a secondary desired objective is that, with appropriate management, a wound may reach a state at which its care may be performed primarily by the patient and/or the patient’s caregiver with periodic physician assessment and supervision.
In appropriate cases, due to severe underlying debility or other factors such as operability, the goal of wound care provided in outpatient settings may be only to prevent progression of the wound and prevention of prolonged hospitalization.
The take home message here is actually the word “goal.” We need to state the specific goal(s) of therapy. Healing does not have to be the goal, but if not, we had better state goals like, “getting the wound to a state in which the patient and family can care for it with only periodic physician assessment,” or “preventing progression and hospitalization.”