Documentation for Supplies Coverage (Medicare)

Surgical Dressing Materials

Take a moment to look at the list below of qualifying wound, treatments and dressings. Medicare coverage guidelines require documentation of these five areas to assure medical necessity and that the treatment and supplies are matched to wound characteristics. For instance, to qualify for coverage, the documentation must state that the wound was surgically created, modified or debrided, regardless of the debridement method.

Qualifying Wounds, Treatments and Dressings 1. Surgically created/modified or debrided 2. Surgical dressing materials 3. Type of debridement 4. Characteristics of the wound 5. Treatment plan

Documentation of the dressing materials should be matched to those that are deemed effective with clinical evidence. These may include alginate, collagen, foam, gauze, hydrocolloid, hydrogel, and others. The documentation should note that in multi-component dressings the appropriate materials are the predominant materials. The pad size should be correct. There are three sizes of pads, which include ≤16 square inches, ≥16 square inches but ≤48 square inches, and >48 square inches. Because safety and effectiveness has not been established for some wound care items, such as Balsam of Peru in castor oil, iodine (other than iodoform gauze packing), carbon fiber, charcoal, copper, honey, and silver, these are not covered.

Those deemed effective with clinical evidence Alginate, collagen, foam, gauze, hydrocolloid, hydrogel, etc Safety and effectiveness not established for Balsam of Peru in castor oil, iodine (other than iodoform gauze packing), carbon fiber, charcoal, copper, honey, silver Must be predominant component of multiple components claim Must use correct size pad (three sizes include ≤16 sq in, ≥16 sq in but ≤48 sq in; >48 sq in; be sure to match with DWO) Must match DWO

Types of Debridement

During Deficiency

Debridement is the removal of dead, damaged, or infected tissue or foreign objects from a wound. Debridement is usually done as wounds do not properly heal or for chronic wounds that are infected and getting worse. This procedure helps to restart the healing process, to minimize scarring, and to reduce the complications of infection. The types of debridement conducted should be documented, which includes four categories and may depend on the wound itself, the age of the patient, the overall health of the patient, and their risk for complications.

Surgical debridement may include the use of a sharp instrument or laser to cut off unhealthy tissue. Typically, the procedure will use scalpels, curettes, or scissors for bedside removal that can be done by a number of health care professionals. Surgical sharp debridement uses surgical instruments and may include some healthy tissue around the wound. This type of debridement can be used for large, deep, or very painful wounds and is done with anesthesia by a surgeon.

Mechanical debridement is appropriate for both infected and non-infected wounds and accomplished through a number of methods, including hydrotherapy, wet-to-dry dressing, or monofilament debridement pads. In hydrotherapy, running water is used to wash away old tissue. Wet-to-dry dressings involve the application of a wet gauze to the wound, which dries and sticks to the dead tissue that is removed when the gauze is lifted. Monofilament debridement pads are soft polyester pads that are gently brushed over the wound to remove bad tissue and debris.

Surgical (eg, sharp instrument or laser) Mechanical (eg, irrigation or wet-to-dry dressings) Chemical/enzymatic (eg, topical application of enzymes) Autolytic (eg, application of occlusive dressings to an open wound).

 

Chemical or enzymatic debridement uses an ointment or gel with enzymes applied once or twice daily, which are then covered. This method softens unhealthy tissue for removal as the dressing is removed. While not recommended for large or severely infected wounds, they are useful if there is a high risk for surgical complications (or bleeding).

Autolytic debridement involves the use of a moisture-retaining dressing that uses the patient’s enzymes and natural fluids to soften tissue for removal. As moisture accumulates the bad tissue swells and separates from the wound. Used in non-infected wounds and pressure sores, it may be used with other forms of debridement in infected wounds. 

There is also a category of biological debridement called larval therapy or biosurgery which uses sterile maggots. The maggots consume old tissue and release antibacterial substances while consuming bacteria. These maggots are usually placed on a wound or in a mesh bag under a dressing and left for 24-72 hours. They can then be replaced twice per week. This form of debridement may be used for large or antibiotic resistant infections, or in place of surgery when contraindications exist.

 

Documentation Guidelines

For wound dressings and supplies, the guidelines for documentation are clear and specific. Before delivery of any products, a written order is required (this will include the patient’s and physician’s name, date of the order, start date, and detailed description of the items ordered). These orders must include the prescribing practitioner’s National Provider Identifier, physician signature, date of signature, and a date stamp for the supplier’s date of receipt (which must be on or before the date of delivery).

The medical records need to show a detailed written order (or DWO). This also includes the patient’s and physician’s name, date of the order and start date (if the start date is different from the date of the order), a detailed description of the items ordered, and the physician’s signature and date of signature.

A dispensing order comes with a description of the items ordered, patient’s and physician’s name, date of the order and start date, physician signature for a written order or the supplier signature for a verbal order.

Written order and detailed written order (DWO) Dispensing order Periodic DWO Rationale

Beyond the initial order and delivery, periodic DWOs are required to continue dispensing the supplies. These periodic orders should have the items to be dispensed, dosage and concentration (if appropriate), frequency of use, duration of any infusions, quantities to dispense, and number of refills (if applicable).

 

Documentation of rationale will include signed and dated orders that are kept on file by the supplier with a source of the information, order, and date. The documentation of supplies will include dressing type (eg hydrocolloid wound cover, hydrogel wound filler), dressing size (if appropriate), number and amount to be used at one time (if more than one), change frequency, and expected duration of need. In addition, orders should be documented at least every three months for each dressing used, even if the orders remain the same--or are for a decreased amount of supplies. New orders must be documented if a new dressing is added or the quantity of dressings is increased. And it should be noted that new orders are not necessary if the quantity of dressings is decreased.

Documentation for medical supplies used to treat wounds may appear in several records including those from the physician’s office, the hospital, nursing home, homehealth agency or other healthcare professional records. These records must be made available when requested by the payer, such as Medicare.