Medical Necessity Documentation

Suggested Documentation

The following should be documented in the patient’s medical record based on current wound care standards:

• Duration of wound (# of days or weeks)
• Prior conservative treatments that have failed to induce significant wound healing
• Wound diagnosis (e.g. DFU, VLU, etc.); ICD-10 code(s) should support diagnosis
• Baseline wound measurements (L x W x D) at least twice in past 30 days and before first treatment; specify exact location of wound (use specific ICD-10 code for location)
• Wound is free of infection and osteomyelitis (noted at each visit); any past history of osteomyelitis has been treated successfully and is not active
• Adequate treatment of the underlying disease(s) contributing to the nonhealing wound
• Describe wound dressings applied and frequency of wound dressing changes
• Appropriate off-loading or compression (if applicable), and patient compliance with treatment
• Adequate blood flow / perfusion; documentation of tests used to assess perfusion
• Patient’s nutritional status is adequate for healing
• If patient is a smoker, document patient was counselled that smoking inhibits wound healing, and resources for smoking cessation were provided
• Measurement of the wound progression at each visit (length x width x depth)
• Wound appearance at each visit: amount of granulation tissue, amount and description of exudate and slough, appearance of wound edge
• Was debridement performed? If not, explain why? If yes, describe level of debridement and tissue removed at each visit
• Record application number and improvement since last treatment at each visit
• Product lot & unit #, graft size used, and amount discarded, if any (wastage)
• Type of fixation, types of wound dressings applied, and frequency of dressing changes