Top Reasons for Wound Claim Denial

Proper documentation is required for the coverage of wound claims. Let’s review the top reasons for denial in order to see common areas of inadequate documentation.

Lack of sufficient information on beneficiary condition to determine medical necessity (38.6%) Lack of confirmation that a wound was caused by, or treated by, a surgical procedure, or treatment/dressings required after debridement of a wound. (28.6%) Lack of confirmation for dressing as a primary or secondary dressing or for non-covered use (17.1%) Lack of documentation to support frequency of the dressing changes (14.3%) The documented size of the wound in the medical record does not support the code billed (11.4%) More than a one-month supply of dressings was provided at one time without justification documentation (10.0%) The documentation does not include a detailed written order (DWO) (8.6%) The supplier indicates the item(s) were billed in error (5.7%) Lack of monthly evaluation documentation (4.3%) Item(s) were returned by the beneficiary (2.9%)

 

A review of Medicare claims was completed in 2016 (with an update in 2019). This review suggested that up to 82% of claims were not properly paid. The reasons stated included nearly 40% lacked information about the patient’s condition, so that the medical necessity for coverage could not be determined. Nearly 30% were denied because the medical record did not justify surgical dressings as a part of treatment for wounds caused by a surgical procedure, treated by a surgical procedure, or required after debridement. More than 17% of dressing claims were denied because the medical record didn’t confirm whether the dressing was used in a primary, secondary, or non-covered use (an example of a non-covered use may be wound cleansing). More than 14% were denied because the frequency of dressing changes was not adequately supported in the documentation and more than 11% because the size of the wound didn’t justify the size of the dressing used.

In general, a month’s worth of supplies may be covered for wound care. If more than a month’s supply is provided, there should be documentation to support the necessity of additional quantities in the home setting. Inadequate documentation led to the denial of 10% of these claims.

Close to 9% of claims were denied because of a lack of a Detailed Written Order. Supplier documentation that the items were billed in error resulted in nearly 6% of the denied claims. A monthly evaluation is required, and more than 4% of claims were denied because of the lack of documentation for the type of each wound, its location, size and depth, drainage, or other relevant information. Finally, about 3% of claims were denied because of documentation that the items were returned by the patient.

 

"Document the Wound"

Let’s take a look at what it means to “document the wound”. (American Medical Technologies, 2018)

While we will cover this in more detail in a few minutes, there are a few categories of items that should be routinely documented. Physical characteristics include location, stages, thickness, size, drainage/exudate, and odor.

Wound etiology and cause should be included in documentation. Common etiologies/causes include a description of the type of wound as pressure, venous, arterial, neurotrophic, surgical, or something else.

Other documentation should include:

Indicators of infection, such as fever, redness, drainage, odor, or other.

Complaints of pain such as location, causes, intensity, quality, duration, alleviating factors, patterns, interventions, and others.

Conditions that adversely affect healing such as impaired mobility, malnutrition, abnormal lab test results, infection, non-compliance, and others

Anticipated wound outcomes including healing, maintenance, or palliative and based on co-morbid conditions, medications, circulation, and patient preferences.

 

Physical characteristics Other items: cause, indicators of infection, pain Treatment plan Monthly reassessment -Weekly reassessment in skilled nursing facilities -Heavy drainage, or infection

 

A treatment plan should include documentation of interventions to promote healing, such as dietary supplements, lab tests, turning/repositioning schedules, support surfaces, padding, pillows, elevation, offloading, skin care, and others.

Reassessment is generally completed according to facility protocols. Also, the submission of new orders and reimbursement requests generally require reassessment. Thus, if dressings and supplies are provided on a monthly basis, documentation on monthly reassessment will be required. Reassessment may be required more frequently if the patient is in a skilled nursing facility, or in cases of heavy drainage or infection.

 

Treatment Plan

Interventions should also be documented appropriately and may include methods to increase the potential for wound healing. These may include procedures, additional assessments, and equipment or other supplies.

Plans for turning or repositioning the patient to minimize circulation problems, elevation, and incontinence management may be included in methods for enhancing wound healing. Devices or equipment may be required to provide heel and skin protection, and support surfaces or cushions to reduce barriers to healing--or risk for additional complications. Dietary supplements may be used to enhance nutritional status and the body’s ability to heal. Lab tests and referrals may be required for both monitoring status and providing additional interventions.

Interventions to promote healing Conditions that affect healing Anticipated wound outcome Dressing and supplies Type -Frequency of change -Expected duration of need Referrals for additional assessment and interventions