Important Ulcer Debridement Documentation Update
Thorough documentation for debridement of ulcerations is essential for medical records and to ensure proper payment. Insurance companies will request documentation for these procedures and will request refunds if certain criteria is not reported.
Please remember to include the following when documenting ulcer debridements:
- Decision to perform excisional ulcer debridement
- Pre- and post-debridement measurements
- Location and description of wound bed
- Type and amount of tissue removed
- Depth of procedure (subcutaneous layer, muscle layer, etc)
- Amount of bleeding and how hemostasis was achieved
- Instrumentation used
- Patient tolerance
- Dressings applied
- Follow up
Additionally, when applying skin substitute grafts, ensure documentation of the percentage of graft applied to the wound bed v. discarded.
Doctors are directed to their local coverage determinations for further information.
Patrick J. Sanchez, DPM
