Sample Criteria for Alginate of Other Fiber Gelling Dressing

Let’s look at a sample of the criteria for coverage for a particular dressing. In this case, we will look at what is required to determine that an alginate or other fiber gelling dressing is medically necessary. These types of dressings are indicated for wounds that have moderate to high amounts of drainage and are full-thickness--or have wound cavities. These are Stage III-IV wounds and need to be documented as such. These dressings are not indicated in cases of dry wounds or eschar-covered wounds, and they are also not indicated for use in combination with hydrogels.

Dressing change frequency is generally once per day. Any other frequency must be adequately justified in the documentation. One sheet that matches the size of the wound per day or up to two units of wound filler can be allowed for each dressing change.

Example of Alginate Surgical Dressings Denial

Medical necessity must be established for specific dressings, such as alginate surgical dressings. A 2016 review on advances in skin and wound care discussed claim denials due to a lack of adequate and appropriate documentation.  (Schaum, 2016)

We can look at an example from the review that showed 92% of claims for alginate surgical dressings were denied. The lack of documentation for wound debridement, moderate to high drainage of full thickness wounds, or stage III to IV wounds (without supporting documentation) has led to claim denials. Claim denials were issued if the wound evaluation documentation didn’t include type, location, size, depth, and/or drainage amount.

Orders must also specify the quantity or frequency of dressing changes for each category of surgical dressing that the patient may require. And lastly, number five in this top five reasons for a denial of claims was that no medical records were submitted when they were requested by the insurer.

1.Wound debridement not documented 2.Documentation not supportive of moderate-high exudative full-thickness (stage III-IV) wounds 3.Wound evaluation did not include type, location, size, depth, or drainage amount 4.Order did not specify quantity or frequency of dressing change 5.No medical records were submitted when requested

Tips for Improving Documentation and Reimbursement

Now let’s take a look at how we can improve documentation of wounds for more complete communication and to improve accurate coverage. The Scope of Practice and Standards of Practice for nurses can guide us in what, and what not, to do.

A visual inspection of wounds should provide information useful in documenting the wound such as its location, size, stage or depth, color, tissue type, drainage/exudate, erythema, and the condition directly around the wounds. Documentation is not about guessing. If something is not clearly determined, documentation may read something like, “depth cannot be determined” or that the wound is “unstageable”. It can also recommend a consult by a wound care expert.

A pressure injury risk assessment should be completed, such as the Braden Scale, and is usually dictated by the facility guidelines. It is important not to use previous risk assessment scores because they do not reflect the picture at the moment.

Use precise language in the documentation for others to better understand what was done. For example, rather than saying that the physician is aware, documenting the relevant discussion will be more useful.

Include all pertinent information, such as patient condition, wound parameters, pain level, and interventions. Document it in a checklist, when appropriate. Rather than writing “dressing changed” or “dressing dry and intact”, a checklist that is consistent can be used.

Document wound category changes. For instance, note in the record if a skin tear becomes a pressure injury or if a pressure injury becomes a surgical wound after surgical repair, or if a deep tissue injury becomes a stage IV pressure injury. Also, differentiate end-of-life wounds (may be referred to as SCALE or Skin Changes at Life’s End) from pressure injuries and other wounds.

It will also be important to document patient adherence with the plan of care, including conversations, education, and other plans or interventions to improve adherence. Remember that it is not your place to be judgmental, but documentation and even discharge from care may be required in some cases. If care is refused, be sure that you document the details of the refusal and the education and options that were offered. But, it is important to remember that a patient has the right to refuse.

When photographing wounds, it will be important to follow facility guidelines, especially on storing and protecting the photos.

If conditions create an unavoidable circumstance for pressure injuries, note the risk factors, comorbidities, and conditions in the medical record.