Debridement Audits: Expert Insights and Required Documentation

Medicare’s increased focus on wound care audits has revealed numerous errors among providers, leading to financial repercussions as they recover funds. Therefore, understanding the necessary documentation is vital to protecting your practice from costly mistakes.

That’s why we’re excited to share an insightful article by expert Caroline Fife, MD.  In her post, she sheds light on the essential documentation required for debridement, providing valuable insights for healthcare professionals. Caroline is a highly respected authority in the field of wound care. So join us as we explore the expertise of Caroline Fife and discover why her post is a must-read for anyone involved in wound care.

Our in office expert coders have highlighted a couple of key takeaways from Caroline’s post:

  • From her section on “Documentation among EACH physician visits”: “The patient’s medical record must contain clearly documented evidence of the progress on the wound’s response to treatment at each physicians visit.”
  • From her section on the “Big 15” parts of your document note: “When debridements are reported, the debridement operating notes must demonstrate tissue removal (i.e., skin, full press partial thickness; subcutaneous tissue; muscle and/or bone), the methodology applied go debride (i.e., hydrostatic, sharp, abrasion, etc.) and the character of the wound (including dimensions, description of necrotic material presentation, description of tissue removed, degree of epithelialization, etc.) before and after debridement. Pressure Ulcers: Prevention, Evaluation, and Executive”

To view the full article from Caroline follow the link below.